Why medical aids ask pre-authorisation for certain procedures

Hanno Labuschagne

Hanno Labuschagne

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Why medical aids ask pre-authorisation for certain procedures

Medical aids in South Africa require pre-authorisation for non-emergency hospital procedures to help keep costs down, the Council for Medical Schemes and Medihelp have told MyBroadband.

It also gives medical schemes a chance to warn members if their plan doesn’t cover a procedure.

“Pre-authorisation is a critical component of managed care health services and is permissible in Regulation 15 of the Medical Schemes Act,” a spokesperson for the council said.
 
r00igev@@r said:
My mom had per-authorisation and the leechers still rejected the claim afterwards.
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I get one free doctor visit every year. My only time making use of medical aid was a doctors appointment and got a flu injection. Medical aid declined it xD
 
Because medical aid != national health insurance

It’s just like car or household insurance therefore your service provider has terms and conditions. If you don’t abide by them then tough luck (even if you paid your premiums).
 
Pre-authorisation is because like any risk-based insurance, they need to be very clear on what they're spending their profit on, and whether or not they could save a penny if your procedure falls within one of the 99999 exclusion clauses.

I'm not saying its a bad thing, because they do often pay hundreds and hundreds of thousands out for hospital admissions. But ultimately the house has to make more than it spends...
 
neoprema said:
Pre-authorisation is because like any risk-based insurance, they need to be very clear on what they're spending their profit on, and whether or not they could save a penny if your procedure falls within one of the 99999 exclusion clauses.

I'm not saying its a bad thing, because they do often pay hundreds and hundreds of thousands out for hospital admissions. But ultimately the house has to make more than it spends...
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Well, no. Medical aid schemes are not for profit.
 
mypetcow said:
Because medical aid != national health insurance

It’s just like car or household insurance therefore your service provider has terms and conditions. If you don’t abide by them then tough luck (even if you paid your premiums).
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Rubbish. Its typically administrative bubbling on the service providers part.
 
mypetcow said:
Discovery may want to disagree with you on that one...
www.discovery.co.za

Investor Relations

www.discovery.co.za www.discovery.co.za
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Its law.

You didn't link to anything specific. Medical aids make money of admin fees not of the Medical aid fund that they administer. It's a technically and why Medical aids are generally shít and expensive.
 
Nothing gets my piss boiling like medical aids. Currently with Discovery and although I'm happy so far, costs are just through the roof. Something R2800 a month or something for just me on Coastal Saver, and I had to make a dentist visit a few months back. Haven't used it before or since for anything, and still had to pay like R200 after the visit. It was a routine crown. I was thinking to myself, I've been with them 6 months - haven't used them yet - 6*2800 = R16 800 and I must still pay in a R200???
 
rietrot said:
Its law.

You didn't link to anything specific. Medical aids make money of admin fees not of the Medical aid fund that they administer. It's a technically and why Medical aids are generally shít and expensive.
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Discovery is a for-profit stock market listed company. Last time I checked not many non-profits were listed on the stock exchange. Yes Discovery makes money and they must increase shareholder value. Easy as that. Technicality here and there they may be "non-profit" on the fund but they make up on it on everything else. Who do you think funded their head office in Sandton?
 
mypetcow said:
Discovery is a for-profit stock market listed company. Last time I checked not many non-profits were listed on the stock exchange. Yes Discovery makes money and they must increase shareholder value. Easy as that. Technicality here and there they may be "non-profit" on the fund but they make up on it on everything else. Who do you think funded their head office in Sandton?
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Yes, buddy. Learn to read then try again.
 
If it makes anyone feel better these medical aid companies took massive hits because of covid :-P
 
YoungSandwich said:
Nothing gets my piss boiling like medical aids. Currently with Discovery and although I'm happy so far, costs are just through the roof. Something R2800 a month or something for just me on Coastal Saver, and I had to make a dentist visit a few months back. Haven't used it before or since for anything, and still had to pay like R200 after the visit. It was a routine crown. I was thinking to myself, I've been with them 6 months - haven't used them yet - 6*2800 = R16 800 and I must still pay in a R200???
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R16800 feels like wasted money until you actually land in the hospital. I also thought my money was wasted because I never got sick, until I landed in ICU after which CT scans needed to happen, and an emergency operation needed to happen. R150k later, and I am happy that I stuck to my medical aid, which covered everything.
 
Must say, it is a lot of admin, but honestly the doctors fill in most of the stuff. Had an operation last year costs came to nearly 250k, I had to pay in exactly R17 of that....so all in all, worth it
 
Medical schemes are not for profit. Medical scheme administration and extras like Vitality is for profit. You can get the full Financials for any medical scheme - they publish it (separate from the administrator).

The cost of medical schemes is not because the administrators are squeezing the members - it is because medical inflation is insanely high. Don't blame the medical scheme, blame the medical industry that is actually charging more and more.

I am sometimes shocked about how little people know about the scheme and plan they have signed up for and what risks it might cover.

Personally I am with a scheme with no day-to-day benefits but when the paw-paw hits the fan they have excellent cover (especially oncology). Of course all medical schemes must pay for prescribed minimum benefits and that covers my chronic as well.

Point is medical cover is insanely expensive - even in countries with NHI the tax for it is high.
 
mypetcow said:
Because medical aid != national health insurance

It’s just like car or household insurance therefore your service provider has terms and conditions. If you don’t abide by them then tough luck (even if you paid your premiums).
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Medical Aid = Sucking the members dry
National Health Insurance = Sucking the tax payers dry while the ANC cadres are looting all the money. Then no money left for ANY medical procedure and then more debt to keep the freeloaders happy
 
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