SOME medical aid members will have to make fewer co-payments to specialists or for hospital admissions as the country`s two biggest open schemes seek to maximise direct payment arrangements with doctors. The absence of guideline tariffs for medical specialists has prompted Bonitas to establish a specialists` network and Discovery Health Medical Scheme is looking to make payment arrangements with more specialists. Much finger pointing has taken place in the private health sector about who is to blame for shrinking medical aid benefits. At the last health funders` gathering, it emerged that some medical specialists were charging as much as 700 percent above what medical schemes covered, while most charged two to three times more than medical schemes` tariffs. Even Parliament was asked to intervene in the interpretation of regulation 8 of the Medical Schemes Act, which deals with prescribed minimum benefits (PMBs), as medical schemes alleged that the cost of treating these conditions had shot up.

The obscure billing structure experienced in the private health industry has more often than not left members footing the bill where their medical schemes could not. Bonitas announced the creation of a medical specialists` network towards the end of last year and Discovery said it had made payment arrangements with 89 percent of the country`s medical specialists to date. Both schemes have undertaken to pay a tariff that is higher than their normal rates to specialists with an agreement that no co-payments will be levied on their members when they use these designated service providers. Alain Peddle, Discovery Health`s head of research and development, said the scheme had initiated these payment arrangements in 2007 and now, about 88 percent of its members were seen by specialists participating in these agreements.

He said with this arrangement in place, Discovery Health had experienced fewer billing problems and the debate about the guideline tariffs for specialists was less of a concern to it. Peddle said that, in the past, the scheme had experienced huge amounts of in-hospital billing by specialists and this had driven the decision to contract with doctors. He said the arrangement had protected the medical scheme from the crazy billing structure when doctors shot up their rates for PMBs. Discovery Health Medical Scheme paid specialists between 140 percent and 216 percent of its tariff, he said.

However, a small percentage of doctors were still not willing to contract with the schemes even if they paid more than twice the usual medical aid tariffs. Bonitas`s principal executive officer, Bobby Ramasia, said the scheme started contracting with specialists in mid-2012 even though the specialist network went live in September. The scheme now had more than 1 800 specialists contracted onto its network and it was expecting to increase this number to about 2 300 by the end of March.

Ramasia said because of the open-ended financial liability that the absence of guideline tariffs and PMBs created, medical schemes and their members became the price takers in an environment where clinical outcomes measures were not easily available. The cost was passed on to members in the form of high contributions. Now that Bonitas had contracted with specialists, the scheme would realise significant savings which would ultimately translate into more favourable contribution increases for Bonitas members.