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What are the consequences of using a non-DSP for medical procedures?



In an effort to ensure quality service in the face of medical inflation, many Medical Aid Schemes have implemented networks of Designated Service Providers (DSPs). This helps control costs and means Medical Aids can offer discounted plans that restrict members to these networks. For members of the Medical Aid Scheme, this means that should you make use of a DSP, your treatment will generally be covered in full, especially for Prescribed Minimum Benefit (PMB) conditions. However, there are often penalties involved with making use of a non-DSP. Understanding how DSPs work and how gap cover can help is critical to making the most of your medical aid coverage.

So, what is a DSP really?

DSPs are healthcare providers, including hospitals, doctors and pharmacies, contracted within your Medical Aid Scheme as preferred service providers with the agreement to charge agreed rates for services. This is designed to be a beneficial arrangement for all parties.

Members of the medical scheme have access to medical care that is fully covered, while healthcare providers benefit from increased patient volumes. They also often have a direct payment arrangement with the Medical Aid which means the patient does not have to pay the medical provider upfront. Moreover, service providers receive prompt payment, which is beneficial for them and reduces instances of non-payment of accounts.

DSP networks also extend to out of hospital treatment or care at pharmacies for chronic medication, where members need to make use of specific pharmacies to obtain medication for registered chronic conditions. Members can be penalised financially for obtaining formulary chronic medication from a non-DSP pharmacy. By making use of DSPs you can avoid medical expense shortfalls for PMB conditions and avoid significant penalties and co-payments for treatment and medication.

When will a non-DSP be covered?

There are certain very specific instances where your Medical Aid will fund the use of a non-DSP in full for PMB conditions, as regulated and required by the Medical Schemes Act (131 of 1998). For example, if a DSP is not available to assist within a reasonable time frame, such as if a patient requires a heart bypass in hospital and the DSP (A.K.A the cardiologist) for the medical aid is away, then a non-DSP will be covered due to the urgency of treatment required.

The Act also states that if immediate medical or surgical treatment for a PMB condition is required under circumstances or at locations where the beneficiary cannot obtain treatment from a DSP, this will be covered. Furthermore, as per the Act, if there is no DSP within reasonable proximity to the beneficiary’s ordinary place of business or personal residence then a PMB will be covered in full at a non-DSP.

While these circumstances will be covered, it is important to remember that once your condition has stabilised or a DSP becomes available, your medical scheme may request you to make use of a DSP for further treatment. If you choose not to move to the services of the DSP your admission may no longer be covered in full at cost, making you liable for medical expense shortfalls.

Where does Gap Cover come in?

When you require a medical procedure, you may do all of the required work to ensure you make use of a DSP specialist at a DSP hospital only to find on the day of your surgery, for example, that the anaesthetist preferred by your surgeon is not a DSP. This means that you will be liable for the medical expense shortfall in payment to this doctor. Gap Cover can help to minimise this additional medical expense shortfall.

Your preference can also play a huge role in determining your choice of provider. For example you might have a gynaecologist who has treated you for years and when you fall pregnant you would like the same gynaecologist to deliver your baby. However, this doctor might not be a DSP of your medical scheme. You might choose to stay with a DSP due to your existing relationship with them, which means that you will be liable for any medical expense shortfalls, which can be significant, if you do not have Gap Cover in place. 

For a non-PMB condition, making use of a non-DSP can incur significant penalties. Most specialists charge . above the scheme rate and without gap cover you will have to pay the . medical expense shortfalls not covered out of your own pocket.

It is important to discuss your medical aid and gap cover needs with your financial advisor to make sure you know who falls within your DSP network and how to access them. Cover for non-DSPs is not a standard Gap Cover benefit and non-DSP hospital penalty cover is often a limited benefit. Having a Gap Cover provider who understands that it is not always possible to make use of DSPs is essential. Your financial advisor can ensure that you have the most appropriate Medical Aid and Gap Cover options in place to ensure you maximise your coverage.