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Undesirable Practices by Medical Schemes Set Down

April 29, 2021

Department of Health

The selection by medical schemes of healthcare providers to provide diagnosis, treatment and care in respect of one or more prescribed minimum benefit conditions without engaging in a fair procurement process has been declared as an irregular and undesirable practice for all medical schemes.

The health department announced the declaration in Government Gazette 44469 in terms of the Medical Schemes Act.

According to the notice, some medical schemes select dedicated service providers (DSP) “without engaging in a fair procurement process and without considering applications to join their DSP network from all interested and qualified service providers”.

This practice “unfairly limits the number of selected service providers (including pharmacies) available to provide healthcare services to the members”.

The Registrar of Medical Schemes holds the view that this practice has prevented many healthcare service providers, including independent community pharmacies, from joining the DSP network of schemes despite the ability to offer healthcare services at the same fee rate as the selected DSPs.

The Registrar has also declared imposing a co-payment in terms of Regulation 8(2)(b) that exceeds the amount of the difference between that charged by the medical scheme’s DSP and a provider that is not a DSP as an undesirable practice.

“This includes any other co-payments, which are unfair to members or beneficiaries or cannot otherwise be numerically justified.”

The Council for Medical Schemes will publish guidelines on selecting DSPs for medical schemes and co-payments within 180 days of the date of publication.