02 Feb What is a tariff shortfall on medical aid? (And how to avoid surprise bills)
You’re on medical aid. You’ve got hospital cover. So why do bills arrive after you’ve been discharged?
This common (and frustrating) situation often comes down to a tariff shortfall. In plain terms, your medical aid pays what it thinks the treatment should cost. But the doctor or specialist charged more. You’re then left with the difference to pay.
Let’s break this down and show how you can protect yourself
Tariff shortfall meaning
A tariff shortfall happens when your medical aid pays a fixed rate for a procedure, known as the scheme tariff, but the healthcare provider charges more.
The gap between what your plan pays and what the healthcare provider charges becomes your responsibility. That’s the medical aid shortfall. And unless you’ve got GapCover, it usually comes out of your pocket
A simple example with round numbers
Let’s say the following:
- Your medical aid covers a surgery at R5,000.
- The surgeon charges R10,000.
- The shortfall = R5,000.
You pay that R5,000 unless you have GapCover to pick up the difference for qualifying claims.
Why tariff shortfalls happen (even when you’re covered)
Your scheme pays a rate. Providers can charge more.
Medical schemes don’t pay based on what your doctor charges. They pay based on a pre-set rate which is often called the scheme tariff or medical aid rate.
Some plans say they pay 100% of tariff, or even more. But if a specialist charges 300% of tariff, and your plan only covers 100%, you’ll be responsible for the difference.
Where shortfalls show up most often
Shortfalls often appear in:
- In-hospital procedures
- Specialist bills
- Anaesthetist fees
- Scopes and diagnostics
- Not using a designated service provider
Even when the hospital stay is authorised, these professionals bill separately and may charge well above your plan’s rate.
How to spot a tariff shortfall before it becomes your bill
Most medical aid shortfalls aren’t complete surprises. You can reduce the risk if you know what to ask ahead of time.
Here’s a quick checklist to help you take control before any procedure.
The 5 questions to ask before treatment
1. What tariff percentage does my plan cover for this procedure?
(Is it 100%, 200%, etc. of the medical aid rate?)
2. What will the specialist and anaesthetist charge me?
(Are their rates “above tariff”?)
3. Can I have a written quote or estimate?
(This helps you compare charges with your scheme’s cover.)
4. Do I need pre-authorisation and is it confirmed in writing?
(Always double-check approval emails or letters.)
5. Are there any co-payments or deductibles on my plan?
(Quick tip: a co-payment is a fixed amount required by the scheme.
A shortfall is the provider charging more than your cover allows.)
Asking these upfront makes it easier to plan. Or to get extra cover in place if needed.
Also note that GapCover offers a pre-assessment service. Just submit your pre-authorisation document to assessments@gaprisk.co.za and you will be provided with advice on the way forward – eg, whether you have to use a designated service provider, contracted specialists, etc. Peace of mind prior to your procedure.
How GapCover helps with tariff shortfalls (and what it doesn’t do)
GapCover helps bridge the gap between what your medical scheme pays and what your provider charges within the limits of your GapCover plan.
GapCover complements medical aid. It doesn’t replace it.
Here’s how it works:
- Your medical aid pays first, according to your plan’s tariff rules.
- If there’s a shortfall (like in our earlier R5,000 example), GapCover may cover it, depending on your plan’s rules and limits.
- You don’t claim upfront. GapCover works after the medical aid has paid.
But remember GapCover is not a blank cheque. There are:
- Limits
- Waiting periods
- Claim rules
GapCover is designed to work with your medical aid, not take its place.
Not sure what your plan could leave you paying?
A quick GapCover quote can help you understand your options before you need them.
Your next step: get clarity with a quote
You don’t need to guess or hope you’re covered. A quote shows what GapCover could mean for your plan, your providers, and your budget.
- Want clarity on your shortfall risk?
Start with a free quote.
- Need cover that works with your medical aid?
Fill in the form. See what options suit you.