Very Disappointed in the New Prime 3 Network Rules

From 2021, Medihelp Prime 3 Network Option has changed their rules. From January, you have to get a referral for a Specialist via a Network GP. My son has needed to go to an ENT this year. I went to a non-network GP around 2 weeks ago. She monitored my son for 2 weeks and on Friday, 5th Feb, she made the call that he needed to go to the ENT. I fortunately anticipated this and made an appointment at a Network GP on Friday morning and she assisted me with the referral and number.

On 8th February, I had an appointment with the Network ENT. He agreed that he needed to get grommets. The ENT only operates at Pinehaven, Robinson and Krugersdorp. When I phoned for authorisation, the lady told me that because it is a day procedure, I should now go to the Day Clinic because from 2021, if you have a day procedure, it must be done at the Day Clinic, otherwise I would be paying 35% of the hospital bill (which by my call to Pinehaven is going to be around R4000).

I have been with Medihelp for 2 years now and it has been a very good experience up to this point. But it seems to me that Medihelp has not educated their Network Providers on the new procedures for 2021 relating to the Network Rules and particularly relating to operating in Day Clinics vs Hospital.

My other issue that all Network ENTs closest to me (a whole 3 specialists), are in Krugersdorp / Mayfair which would mean that they would probably operate at the same hospitals and there are no Day Clinics close to the Specialists.

I find that this whole process is messed up! They are expecting you to following the network way but clearly they haven't thought this through properly.

At the end of the day, I now having to go to my previous ENT as he operates at one of the Day Clinics but even with this, I am going to be landing up paying a copayment as he is a non-network specialist.