Frequently Asked Questions - Family practitioner nomination

Tuesday, 17 February 2015

GEMS always has its members' health at heart, and continually strives to ensure that members receive the very best care and get the most out of their benefits. As part of a coordinated healthcare approach, GEMS is placing a heavy emphasis on disease management and care coordination between providers. Your GP or family practitioner (FP) is at the heart of this process and members will be required to nominate a primary treating doctor from the GEMS Network by 02 April 2015 for their day-to-day consultations.

Why do I need to have a nominated family practitioner (FP)?
By consulting the same FP you will help to ensure that:

• your doctor develops a good understanding of your health and treatment history so that he/she can make informed decisions about your health;
• no duplicate diagnostic tests are done - this will help to preserve your benefits;
• hospital admissions and re-admissions are reduced.

How do I select my nominated FP?

To assist you with the process of FP nomination, GEMS will automatically allocate you and your dependants to the GEMS Network doctor that you currently visit. You and your dependants will receive confirmation from GEMS regarding which Network FP has been allocated to you. If GEMS could not allocate you to a network FP, you will receive communication from GEMS requesting you to nominate your FP.

Sapphire and Beryl (SB) members must select an FP from the SB FP Network. Members on the Ruby, Emerald and Onyx (REO) benefit options must select an FP from the REO FP Network.

What if I want to change my nominated FP?

You can change your nominated FP once every six months by contacting the GEMS Call Centre (0860 004 367).

What if my dependant wants to have different nominated FP?

Because we realise that our members and their dependants have different needs and preferences, each member and each of their dependants may have their own nominated FP. Adult dependants may choose their own nominated FP while the main member will choose the nominated FP for their child dependants younger than 16 years of age.

What happens if my current family practitioner is not on the GEMS Network?

The family practitioner you choose to nominate will have to be on the GEMS Network. If your current FP is not on the GEMS Network, GEMS will actively assist you to get your FP on the Network. Should your FP choose not to join the GEMS Network, you will be notified and given the option to select a Network FP of your choice.

With approximately 10 000 healthcare service providers covering 46 disciplines, the Friends of GEMS network covers every corner of the country. Indeed GEMS has the largest network of healthcare service providers of any medical scheme in South Africa and this is constantly growing. Members therefore have a wide selection of practitioners to choose from and you will be able to decide on one who will best meet the needs of you and your family.

Why must my nominated FP be on the GEMS Network?

The advantage of visiting a GEMS Network doctor is that this doctor has agreed to provide you with high-quality, cost-effective care. A network doctor also agrees to bill at the agreed rate and you therefore have the assurance that your claims will not attract any co-payments and you will not be liable for any out-of-pocket expenses. If we become aware that your preferred doctor is not on the GEMS Network, GEMS will actively engage with your doctor and make every attempt to encourage him/her to join the GEMS Network.

What if I am out of town and cannot see my nominated FP?

If you are on holiday or out of town and need to see an FP, the consultation will be paid from your non-nominated benefit. This benefit allows three visits per family annually to an FP who is not your nominated FP.

What if my nominated FP is not available?

If your nominated FP is not available for consultation, then you can see another FP. The consultation will be paid from your non-nominated benefit which allows three visits per family annually to an FP who is not your nominated FP:

• GEMS Sapphire and Beryl members can only see other FPs within the GEMS Network
• GEMS Ruby, Emerald and Onyx members can see other FPs within or outside the GEMS Network

What if my non-nominated benefit is depleted?

If your non-nominated benefit is depleted and you visit a non-nominated FP, then:

• Once the FP nomination claims rules are applied, visits to a non-network FP will be paid from the ‘non-nominated' benefit. Once the ‘non-nominated' benefit is depleted:
  SB members - the claim will not be paid
  REO members- the claim will attract a 30% co-payment
  

I am separated from my partner and my child dependants alternate between living with me and staying with my ex. We live in different parts of the city. Are my children allowed to have more than one nominated FP?

Yes, each GEMS beneficiary are allowed to have two nominated FPs.

My daughter studies at a teriary institution in Johannesburg but our home is in Durban. What if her nominated FP is in Durban and she gets sick at university and needs to see a doctor?

If you have children or adult dependants who attend school or university far away from home, they are allowed to have more than one nominated FP.

I live mainly in Cape Town but my job requires that I often stay in Johannesburg for an extended period. May I have more than one nominated FP?

If your work is of such a nature that you are situated at different locations for a period longer than three months at a time, then you may have one nominated FP in each city.

What if I think my medical problem can only be addressed by a specialist and not my nominated FP?

From 02 April 2015 all GEMS members will need to first see their nominated Network FP before consulting a specialist for all out-of-hospital consultations. This is because GEMS encourages the philosophy of one doctor, namely your preferred nominated FP, being your care coordinator and ultimately being responsible for keeping track of your healthcare. Your nominated FP should therefore be aware that you are receiving care from different specialists.

In this way, the specialists can notify your nominated FP of any changes in your treatment and the progress of your treatment. This will help your nominated FP to make informed decisions about your healthcare needs in the future. In addition, this system ensures that no duplicate diagnostic tests are performed by both your FP and your specialist, which protects your benefits.

What happens if I do not first consult my FP before seeing a specialist?

The current Specialist Referral process on SB will continue to apply for 2015 where the Network FP is required to obtain a referral via the Call Centre. For REO, although the Specialist Referral claims rules will not apply in 2015, GEMS REO members are advised to visit their nominated FP to obtain a specialist referral prior to consulting with a specialist in order for their FP to coordinate their care. GEMS will communicate when the Specialist referral rules on REO will apply.

If I am already seeing a specialist regularly, do I still need a referral from my FP?

If you are already seeing a specialist regularly, then you do not need a referral from your FP. However, your nominated FP should ideally be aware that you are seeing the specialist.

The nominated FP's practice number must also be submitted with the specialist's claim in order for it to be paid in full (subject to available benefits). If you need to see a new specialist for a new condition, then you must be referred by your nominated FP.

Can I see the same specialist more than once in a certain period without having to consult my FP each time beforehand?

Yes, the specialist referral is valid for a period of six months.