Patients often have questions regarding co-payments, and the matter recently received a lot of media attention. Whilst it is not a pleasant discussion, the truth is that the rate medical aids reimburse doctors at, is not a fair one. Consider that medical aid rates are based on a list from 2006 (with annual adjustments that are usually BELOW CPI – ie they do not keep up with inflation) – most people would not be happy earning their 2006 salary, in 2019!!! In addition, all payments made to a doctor are before tax and overheads. Thus, it is virtually impossible to maintain a practice at medical aid rates, and most doctors therefore charge a co-payment, or amount over and above this rate. The amount of the co-payment differs from one doctor to another. Obviously, it is unethical for a doctor to charge a rate that is exorbitant, but at the same time, many people begrudge doctors earning a fair living – one that often takes in excess of 32 years of continuous study (including school), to achieve.
Below is a quick guide to co-payments:
1. What is a co-payment?
Why do I have to make an additional payment when I have medical aid?
A co-payment is a portion of your consultation fee that you must pay from your own pocket. The amount of the co-payment depends on a few factors like what medical aid plan you are on, whether you are having a consultation with a specialist, whether it’s an emergency/out of hours visit or if you are having an elective medical procedure. Medical aids decide what rate they will pay for these consultations and often it does not cover the doctors’ rate in full, the balance of which is payable by you – the patient.
2. When is the co-payment due?
Co-payments should be paid in full when settling your invoice after your consultation, unless there are special circumstances that you’d like to discuss with us. In future it’s always advisable to ask whether there is a co-payment due when making your appointment, to avoid any confusion. We will be able to advise if a co-payment is applicable, and the approximate amount. Most procedures are charged at fixed rates, so that the co-payment is always predictable.
3. I can’t make the co-payment now. What can I do?
In this instance it is possible to negotiate a payment plan, which is always interest free. However, any discounts that may be enjoyed for full upfront payment fall away.
4. I have gap cover, does that mean I still have to make a co-payment?
Depending on the type of gap cover, they might pay for some or all of your co-payment. Again it’s advisable to get in touch with them directly. We will give you a copy of your invoice to submit your claim to them if it applies. Most gap covers do not deal directly with the doctor, and will pay the client instead. It is important in these cases to be honest and forward such payment to the doctor.
5. Can I claim the co-payment back from my medical aid?
No, co-payments are over and above the amount your medical aid allows you to claim for. It’s advisable to get in touch with your medical aid’s call centre or your broker directly and ask them to explain your cover in more detail. Ask them what rate they will pay for consultations and under what circumstances. Some medical aids, eg Momentum, will pay the member directly as soon as a rate above the scheme rate is charged. Most doctors view this as a blackmail tactic to force them to charge scheme rates. In these cases, they often reimburse at the rate that the doctor charged ie they pay the scheme rate as well as the co-payment to the member. Again, with a view to honesty and integrity, it is important to pay any funds received, to the doctor.