Anaesthetic Fee and your Account
There is widespread misunderstanding at present about how medical fees are determined and billed so we wish to give you some background information to explain the current situation.
The fees charged by this practice are derived from the recommendations of the South African Medical Association fee schedule - which was last revised and published in 2006. The fees we currently charge have allowed for annual inflation adjustments. We are a private practice and are not contracted to any Medical Aid or Insurance Scheme. You are personally responsible for the payment of your account even if you are a member of a medical aid scheme.
Since 2006, after a ruling by the Competition Commission abolishing the “Medical Aid Rate”, each of the medical aid schemes has been free to set its own tariffs. Almost all medical aid schemes offer different levels of reimbursement - according to the amount of cover you have contracted from them. There can be a three-fold difference between the amount paid on a full cover option and that reimbursed by the same scheme on a low cover option.
Many medical aid schemes have chosen the National Health Reference Price List (NHRPL) as the reimbursement rate for their lower cover options. This was a fee set out by government and is the rate at which the state pays for services to people who are without medical aid who are injured on duty. This rate bears no relationship at all to the actual cost of providing the service. A successful court action in 2010 led to a judge ordering the withdrawal of this tariff as it bore no relationship to the actual cost of services. Nevertheless, many medical aid schemes have continued to use the NHRPL rate as the basis for their reimbursement rates, particularly on low cover options.
Although your scheme may offer you “100%” (or even more) cover, please understand that this scheme rate may cover only as little as one-third of the actual invoiced amount. The rates charged by this practice might not be similar to the rate covered by your particular medical aid scheme or option. If you are on a lower cover option you will note that there will be a significant shortfall between the cost of your procedures and the reimbursement amount you receive from your medical aid. Some higher plans pay up to 300% cover.
Allowing for inflationary adjustments since the 2006 published rates our fees are currently at about 275% NHRPL – that is, they are less than the amount some medical aid plans are prepared to pay. Furthermore, we encourage all our patients to consider purchasing Gap Cover – an additional product that is available to cover shortfalls from your medical aid cover.
Please take note of the following:
You will receive a completely separate account from the anaesthesiologist. There will also be other accounts from the surgeon, radiologists, physiotherapist, pharmacist and hospital.
The anaesthesiologist does not deal with your medical aid re account payment. You are responsible for settling the anaesthetic account with the anaesthesiologist and claiming from your medical aid.
An account may be sent to your medical aid to help with your claim, but you are still responsible for payment of your anaesthetic account to your anaesthesiologist and interest and all legal fees that arise from any accounts that are not paid in full within 60 days.
Further explanations of the codes on anaesthetic accounts can seen in the article “Explaining you medical bill” on the website or may be obtained from The Board of Health Funders (011-537-0200).
Explaining the Anesthetic Bill
Please take careful note of the following information regarding billing and anaesthesia accounts. When you receive your account for your anaesthetic it could seem confusing to understand. This will attempt to clarify how they are formulated:
An anaesthetic account is made up of 4 parts consisting of time factors and risk modifiers
The Preoperative Assessment (or premed) fee: This is a basic consultation of less than 10 minutes during which your anaesthetist reviews your medical history, medications, anaesthetic history, conducts a physical examination, discusses your anaesthetic and post-operative pain relief plan and answers any questions you may have. This fee also includes the preparation of the anaesthetic part of theatre including drawing up drugs, preparing equipment and monitors.
The Procedure fee: Is determined by the type and complexity of your surgery and your anaesthetic. This fee forms a small portion of your bill. This fee is higher for more complex surgeries and is calculated by the procedural code rating for your surgery (and ranges from 3 to 15 units).
Anaesthetic Time fee: This will form the biggest single component of your account. This fee is calculated per 15 minute intervals and the hospital will carefully measure the time spent in theatre. The anaesthetist may charge additional time for dealing with problems or time spent with you in the recovery area.
Additional “Modifier” fees: These are risk-related fees that apply to certain patients and special anaesthetic techniques. Examples include modifiers for bone and joint surgery, morbid obesity (BMI >35kg/m2), very old (>70yr) or young patients (<1 yr), where techniques for the deliberate control of blood pressure are required, surgery above the shoulders or when special operating positions are required. There are procedural modifiers for the placement of invasive monitoring lines (often using ultrasound to optimise safety) or specific pain control procedures.
An emergency or unscheduled procedure will incur a charge for a set of emergency modifiers as this increases the risks and skills needed to perform the anaesthetic.
All the above time and risk modifiers are allocated specific unit values and each unit is then given a Rand value. These values are added together to determine the final anaesthetic cost.
ICU or High Care charges: Should you be admitted to a specialised post-operative care unit your anaesthetist will charge you additional amounts for this special level of care - which may include charges for life support (such as ventilation or blood pressure control).
As the anaesthetic time will form the largest component of your fee, it is difficult to give accurate quotations as surgical time has so many independent variables.
As a rough guide, for 2023, your fee (excluding possible additional modifiers) will be
calculated as follows:
Surgery Type 1st hr (+ pre-op assessment) per 15 min thereafter
Least Complex R 5 116.00 +R 1 047.00
Moderately Complex R 6 163.00 +R 1 047.00
High Complexity R 8 257.00 + R 1 047.00
Should you require a more accurate quotation you will need the following details from your surgeon: 1. the procedural code (4-digit code) and 2. an estimate on how long he anticipates the surgery will take
Please then contact us on 033-345-4054. We will generate the quote that is appropriate for your estimated time and procedure codes. Please be aware that should you or the procedure qualify for any of the above modifier or ICU charges your fee can, in some circumstances, be up to 100% more than those quoted above.
Conditions of Credit
The anaesthetic practice of Drs Jones, Bhagwan & Partners Inc. is not contracted to any Medical Aid Scheme. The patient and/or person(s) responsible for payment of the account must pay such account within 60 days of surgery.
For your benefit, the following is brought to your attention.
a) The benefits offered by Medical Aid Schemes vary according to which Medical Aid Scheme you belong to and which particular package within that scheme you have chosen.
b) Even if a Medical Aid Scheme assures a patient and/or the person(s) responsible for the payment of the account that they will cover 100% of the medical costs, it may be misleading. What is often meant is that the scheme will cover 100% of their own scale of repayment.
c) Some Medical Aid Schemes offer a higher rate of cover than others.
d) The benefit paid by a Medical Aid Scheme frequently does not match the fees charged by Drs Jones, Bhagwan & Partners Inc. and an additional co-payment is likely to be payable.
e) Anaesthetic fees are largely based on the time spent in theatre, which varies depending on the complexity of the surgery and any surgical and/or anaesthetic difficulties encountered during the surgery.
f) There are additional costs involved in the event of a patient being transferred to the High Care and/or ICU units after surgery.
3. By signing below, the patient and/or the person(s) responsible for payment of the account acknowledges the following:
That all the patient information recorded herein is both true and correct, and he/she/they hereby undertake to notify Drs Jones, Bhagwan & Partners Inc. immediately of any change in his/her/their personal particulars, especially details relating to his/her/their residential address(s) and place(s) of employment.
That the patient and/or the person(s) responsible for the payment of the account shall be jointly and severally liable for payment of any account, irrespective of whether he/she/they belong to a Medical Aid Scheme.
That the patient and/or the person(s) responsible for payment of the account nominate the above physical/residential address as his/her/their domicilium citandi et executandi.
That should the patient and/or person(s) responsible for settlement of the account fail to make payment of any account, and such account is handed over to attorneys for collection, the patient and/or person(s) responsible for the account shall be liable for costs on the scale as between attorney and client including collection commission and tracing fees.