The great South African medical bill shock

Ethical billing, regulatory failure, and the erosion of trust in private healthcare

- SANJITH HANNUMAN

A CRISIS of trust and affordability is unfolding in South Africa's private healthcare system. Patients, already strained by high medical aid contributions, face a second, devastating financial blow: out-of-pocket payments for services billed at 200%, 300%, or even 500% above medical aid scheme rates.

This practice, known as “balance billing’, has evolved from an occasional nuisance to a systemic feature. It forces a painful question: Has the profession's healing ethos been supplanted by unchecked profit pursuit, and where are the guardians of patient protection?

The abstraction of percentages becomes a human catastrophe in real stories. In 2022, a Gauteng man faced an R85 000 shortfall after emergency spinal surgery, with his specialist having charged 480% of the medical aid rate - a life-altering debt for a lifesaving procedure. In 2023, a patient reported to Daily Maverick a radiologist charging 350% for an MRI, leading to an unexpected R4 200 bill.

These are not anomalies but symptoms of a calculated business model. Where is the openhearted, patient-centred, loving approach that defines true care? It is being suffocated by a ledger of excess. This practice persists because South African law lacks a regulated fee structure for healthcare providers. Since the National Health Reference Price List (NHRPL) was declared invalid in 2010, providers may charge what they deem appropriate, constrained only by the vague requirement to offer “fair value” — a subjective standard with no enforcement mechanism.

The statutory regulator, the Council for Medical Schemes (CMS), has acknowledged that co-payments are a key driver of complaints and member financial risk. However, the Medical Schemes Act only mandates full coverage for Prescribed Minimum Benefits (PMBs), creating a significant loophole. It does not prevent providers from charging exorbitant multiples for nonPMBs or demanding top-ups for PMBs —a gap exploited without consequence.