History and current situation:
Since the intervention of the Competition Commission there is no national recommended or fixed tariff for medical services. To comply with the law of the country, there is no medical aid rate or “contracted in” fee, neither is there a “contracted out” or S A Medical Association rate.
The North Gauteng High Court ruling of 2010 made the Reference Price List of 2009 and 2010 unlawful. Therefore, there has been NO reference price list or “medical aid rate” since 2011.
This means that doctors have to determine their own professional fees in a market related environment. Every medical scheme, on the other hand, will determine the level of benefits they are prepared to pay. The consequence of this is that there is a confusing number of widely varying rates, many of them referred to by their commercial underwriters as the “scheme rate” which is really the rate they are adhering to.
To complicate matters further, there is an ongoing Market Enquiry into the Private Healthcare Sector by the Competition Commission of South Africa.
There is a lot of confusion around rates and benefits and even experts are often in disagreement!
The reality of Modern Healthcare
All over the world people are getting older and demand more healthcare. There is phenomenal development in the technology of care. All this comes at a cost and medical schemes limit their exposure to costs. This is fair and acceptable as long as you know where you stand as a member of that medical scheme. What this means in practice is that you get what you pay for by way of medical insurance into a pool of money of all the members of that scheme plus a percentage deducted for administration. When they specify what is covered, they invariably refer to the rate they are willing to pay. All of the medical schemes invariably have a set of limitations and exclusions. Nobody can cover all expenses!
You cannot go to your doctor and insist on complete care and just expect your medical aid or other insurer to pay all your accounts. You would not expect to fill your trolley to your heart’s desire at the supermarket and then simply walk out of there and expect your bank to foot the bill regardless of the money in your account. This is not an entirely fair comparison but it does help to explain the point.
This means that patients are ultimately responsible for paying their own accounts or, at least, for expecting an extra payment over and above the amount that the medical aid may agree to pay.
Different medical schemes and their plans
If you have a medical scheme, they may reimburse you the full amount of the doctor’s fee or only part thereof, depending on which medical scheme and which plan you have. The different plans within any specific Medical Scheme offer different benefits and reimburse members differently. Members choose a plan according to the premiums they are able to pay. You should be sure before entering the hospital whether your medical scheme will cover the doctor’s fees or whether you will have to make up any difference. Membership of medical schemes should be seen as an insurance cover and the type of package one chooses will determine the excess payment if there is one. Even after they have pegged the scheme rate in a certain bracket of the market (think of it as where you sit in the aeroplane) they may still decline to pay for certain surgeries, devices, therapies or medicines. Some of this is quite understandable, e.g. cosmetic surgery and sophisticated dental work, others less so e.g. the choice of a modern intervention or endovascular repair as opposed to a traditional operation which may be more dangerous and ultimately more expensive.
The Rand Value per Unit that the medical schemes are prepared to pay for an anaesthetic service varies so much between medical schemes and over time that it is almost impossible to give examples. However you should know that it may be anything between R110.76 to R385.94 in 2024. We sometimes also do not understand the differences… how should we adapt our service for different rates if we want to give every patient our best care? We are not a supermarket that can sell different quantities and qualities. We cannot discount the oxygen percentage or the dose of pain medication down to suite a cheaper plan… However, we do understand that we sometimes have to give a discount to patients with limited financial resources or have to use a cheaper medication that may be proven to be just as effective.
Proper financial preparation for your surgery may make all the difference. It is often difficult to discuss finances with your anaesthesiologist in a busy general ward and it is strongly recommended that you contact our office at the numbers given on this website and discuss any financial concerns prior to the booked elective surgical procedure. Rates and perceptions are changing rapidly and this is an attempt to keep you informed. What has not changed is our commitment to render a quality health service.
The benefits of medical schemes and their plans vary over a large spectrum. You get what you pay for.
Anaesthetic Fee Structure
The total anaesthesia account is a sum of the preoperative consultation, certain “modifiers” or special procedures and a time based anaesthetic procedure fee. This latter anaesthetic unit and time makes up the biggest part of the account as referred to in “medical schemes and their plans”. Anaesthetic time is not the same as theatre time as the anaesthetist often spends extra time with you in the recovery room or intensive care unit.
The consultation or “pre anaesthetic assessment” is needed to evaluate any patient risk factors and to enable planning of the anaesthetic management. This is usually done in the ward for bigger operations if you are admitted in good time, but can also be done in the theatre.
All this is coded according to a structure initially developed by Anaesthesiologists in the then Medical Association of South Africa which has since changed into the South African Medical Association. There are ongoing plans to modernise this structure but this is the current norm for medical accounts.
If your procedure has not been planned and booked as part of the routine list, or in case of an emergency, an additional “emergency fee” will be added irrespective of the time of day. If the attending Anaesthesiologist needs to make a special trip to the venue where your procedure is booked this will attract an additional “emergency travel fee”. These fees are included to remunerate Anaesthesiologists for the disruption to their planned workday and to encourage timeous attendance at any emergency.
The anaesthetic account is mainly determined by the time, the type of operation and the health of the patient.
Since the intervention of the Competition Commission there is no national recommended or fixed tariff for medical services. To comply with the law of the country, there is no medical aid rate or “contracted in” fee, neither is there a “contracted out” or S A Medical Association rate.
The North Gauteng High Court ruling of 2010 made the Reference Price List of 2009 and 2010 unlawful. Therefore, there has been NO reference price list or “medical aid rate” since 2011.
This means that doctors have to determine their own professional fees in a market related environment. Every medical scheme, on the other hand, will determine the level of benefits they are prepared to pay. The consequence of this is that there is a confusing number of widely varying rates, many of them referred to by their commercial underwriters as the “scheme rate” which is really the rate they are adhering to.
To complicate matters further, there is an ongoing Market Enquiry into the Private Healthcare Sector by the Competition Commission of South Africa.
There is a lot of confusion around rates and benefits and even experts are often in disagreement!
The reality of Modern Healthcare
All over the world people are getting older and demand more healthcare. There is phenomenal development in the technology of care. All this comes at a cost and medical schemes limit their exposure to costs. This is fair and acceptable as long as you know where you stand as a member of that medical scheme. What this means in practice is that you get what you pay for by way of medical insurance into a pool of money of all the members of that scheme plus a percentage deducted for administration. When they specify what is covered, they invariably refer to the rate they are willing to pay. All of the medical schemes invariably have a set of limitations and exclusions. Nobody can cover all expenses!
You cannot go to your doctor and insist on complete care and just expect your medical aid or other insurer to pay all your accounts. You would not expect to fill your trolley to your heart’s desire at the supermarket and then simply walk out of there and expect your bank to foot the bill regardless of the money in your account. This is not an entirely fair comparison but it does help to explain the point.
This means that patients are ultimately responsible for paying their own accounts or, at least, for expecting an extra payment over and above the amount that the medical aid may agree to pay.
Different medical schemes and their plans
If you have a medical scheme, they may reimburse you the full amount of the doctor’s fee or only part thereof, depending on which medical scheme and which plan you have. The different plans within any specific Medical Scheme offer different benefits and reimburse members differently. Members choose a plan according to the premiums they are able to pay. You should be sure before entering the hospital whether your medical scheme will cover the doctor’s fees or whether you will have to make up any difference. Membership of medical schemes should be seen as an insurance cover and the type of package one chooses will determine the excess payment if there is one. Even after they have pegged the scheme rate in a certain bracket of the market (think of it as where you sit in the aeroplane) they may still decline to pay for certain surgeries, devices, therapies or medicines. Some of this is quite understandable, e.g. cosmetic surgery and sophisticated dental work, others less so e.g. the choice of a modern intervention or endovascular repair as opposed to a traditional operation which may be more dangerous and ultimately more expensive.
The Rand Value per Unit that the medical schemes are prepared to pay for an anaesthetic service varies so much between medical schemes and over time that it is almost impossible to give examples. However you should know that it may be anything between R110.76 to R385.94 in 2024. We sometimes also do not understand the differences… how should we adapt our service for different rates if we want to give every patient our best care? We are not a supermarket that can sell different quantities and qualities. We cannot discount the oxygen percentage or the dose of pain medication down to suite a cheaper plan… However, we do understand that we sometimes have to give a discount to patients with limited financial resources or have to use a cheaper medication that may be proven to be just as effective.
Proper financial preparation for your surgery may make all the difference. It is often difficult to discuss finances with your anaesthesiologist in a busy general ward and it is strongly recommended that you contact our office at the numbers given on this website and discuss any financial concerns prior to the booked elective surgical procedure. Rates and perceptions are changing rapidly and this is an attempt to keep you informed. What has not changed is our commitment to render a quality health service.
The benefits of medical schemes and their plans vary over a large spectrum. You get what you pay for.
Anaesthetic Fee Structure
The total anaesthesia account is a sum of the preoperative consultation, certain “modifiers” or special procedures and a time based anaesthetic procedure fee. This latter anaesthetic unit and time makes up the biggest part of the account as referred to in “medical schemes and their plans”. Anaesthetic time is not the same as theatre time as the anaesthetist often spends extra time with you in the recovery room or intensive care unit.
The consultation or “pre anaesthetic assessment” is needed to evaluate any patient risk factors and to enable planning of the anaesthetic management. This is usually done in the ward for bigger operations if you are admitted in good time, but can also be done in the theatre.
All this is coded according to a structure initially developed by Anaesthesiologists in the then Medical Association of South Africa which has since changed into the South African Medical Association. There are ongoing plans to modernise this structure but this is the current norm for medical accounts.
If your procedure has not been planned and booked as part of the routine list, or in case of an emergency, an additional “emergency fee” will be added irrespective of the time of day. If the attending Anaesthesiologist needs to make a special trip to the venue where your procedure is booked this will attract an additional “emergency travel fee”. These fees are included to remunerate Anaesthesiologists for the disruption to their planned workday and to encourage timeous attendance at any emergency.
The anaesthetic account is mainly determined by the time, the type of operation and the health of the patient.