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Helping clients manage medical expenses

07 February 2024 Bonitas Medical Fund
Lee Callakoppen

Lee Callakoppen

‘As you and your clients begin 2024 with a clean slate in terms of medical aid benefits, it’s a good time to look at ways to manage medical expenses,’ says Lee Callakoppen, Principal Officer of Bonitas Medical Fund.

Here are 10 tips for you to empower your clients with the ways in which they can manage their medical expenses.

1. Designated Service Providers (DSPs) and networks
Healthcare costs in South Africa are generally unregulated, this means providers are free to charge any tariff.

‘Using DSPs and hospital networks means that favourable tariffs for members have been negotiated,’ explains Callakoppen. ‘Using networks also means you can reduce or eliminate co-payments.’

2. Tariffs and rates of payments
The Scheme Rate is the amount a scheme will pay for specific treatments and procedures. However, 100% of the scheme rate doesn’t necessarily mean 100% of the account will be paid. Advise your clients to ask for a quote from their practitioner and/or hospital ahead of any procedure. If there is a major discrepancy, they can try and negotiate and adjusted fee.

3. The value-add benefits
Encourage clients to make use of the free wellness screening and testing offered by their medical aid. There has been an intensified drive to detect, prevent or manage various chronic conditions as well as vaccinate against potential diseases and conditions.

‘After completing an online wellness questionnaire or a wellness screening, your clients are able to access the ‘Benefit Booster’ providing access of up to R5,000 in additional funds to use for out-of-hospital expenses.’

The Bonitas ‘Be Better Benefit’ includes an annual wellness screening, per beneficiary, to check blood pressure, blood glucose, BMI and cholesterol. It’s about being on the right path to good health and wellness. Other benefits include ‘flu vaccines, HIV tests, lipograms, mammograms, prostate screening, pap smears, pneumococcal vaccines, whooping cough boosters, HPV vaccines, stool tests for colon cancer, dental fissure sealants, online hearing screenings and contraceptives.

4. Ask your pharmacists
Remind clients to ask their pharmacists for over-the-counter medications for less serious illnesses. Pharmacists are able to provide sound medical advice about problems like rashes, colds or illnesses that are not severe. Also use generic medications where possible. A generic’s active ingredient or drug content is identical but is between 30% and 80% cheaper.

5. Managed Care
The prevalence of Non-Communicable Diseases (NCDs) has been increasing year-on-year, so have mental health issues, which is a risk factor for NCDs and vice versa. For this reason, it is important to make full use the Care programmes your medical aid offers.

‘At Bonitas we offer support for NCDs through a range of Care programmes including Audiology, HIV/AIDS, cancer, diabetes, mental health, back and neck, hip and knee replacements as well as hospital-at-home.’

6. Remember to pre-authorise
Pre-authorisation is required for all hospital admissions, out-of-hospital screenings and procedures. Always ask if there are any co-payments or sub-limits that will apply and how to avoid these. For planned procedures, make sure clients use a DSP or check whether the procedure can be in the doctor’s rooms or a day clinic.

7. Be aware of consulting after hours
Caution against using after-hours consultations or emergency rooms unless it’s absolutely necessary. In a bona fide medical emergency one has no choice and this usually results in an admission to hospital.

8. Manage your chronic medicine correctly
The golden rule for chronic illness benefits is to try to use the medication on the scheme’s formulary and to obtain this from a specified pharmacy, either on the network or a DSP.

9. PMBs
Make sure your client understands what is covered under Prescribed Minimum Benefits (PMBs) and to use a DSP to ensure that claims are paid from risk, not from their medical savings account.

10. Gap Cover
Gap Cover is designed to cover the difference or part of the difference between what the medical scheme pays and the service provider charges for in-hospital procedures/treatment and specified outpatient procedures.

Helping your clients ‘work smarter’ with the benefits and medical expenses during the year, is a win-win situation for their health and pocket.

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