Why medical aids ask pre-authorisation for certain procedures

Discovery wanted pre-authorization for our new born to go into NICU... was a complete nightmare at the time. They eventually apologized, but the way they handled the situation was horrific.
 
Johand said:
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.
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This. I agree with what you've said. The cost of medical procedures and equipment isn't regulated in this country, as far as I can tell. There's no governing body that says this insulin shot can cost no more than R100, or this mask is worth R2.50 for example. As for as I can tell, companies and hospitals just label what they THINK they should cost and then charge it to the medical aids. Kind of how the great nation of the United States of America does it.
 
xrapidx said:
Discovery wanted pre-authorization for our new born to go into NICU... was a complete nightmare at the time. They eventually apologized, but the way they handled the situation was horrific.
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I understand.

Inaccuracies and mistakes on their part become your own problem to resolve when you stressed in a waiting room with nothing more than mobile phone screen phone to work on.
 
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, and what is listed, the Medical Aid part or medical aid administration and life insurance and short term insurance and investment/retirement products and bank or whatever-else-they-do part?

Discovery Medical Aid is non profit.
 
xrapidx said:
Discovery wanted pre-authorization for our new born to go into NICU... was a complete nightmare at the time. They eventually apologized, but the way they handled the situation was horrific.
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Better a bit of trouble up front than getting a bill a month later for R100k.
 
Well for those that want to do some reading:

1) The Competition Commission has done a great job in unpacking what is going on in our health care industry https://www.compcom.co.za/wp-conten...ommendations-report-Health-Market-Inquiry.pdf

2) You can review the financial statements of the non-profit part of a medical scheme. It is normally published on their website. E.g. for Discovery you can read it at https://www.discovery.co.za/assets/discoverycoza/corporate/investor-relations/2021/dhms-ir-2020.pdf (the audited financial reports for 2021 does not seem done yet - this is previous year). An indication of where your premium goes: 1650363333487.png

3) Fun fact - members elect the trustees of a medica schemes (most people ignore it). The trustees can decide to switch administrator. So it is technically possible (although highly unlikely) that the Discovery Medical Scheme can decide to drop Discovery (the for profit company) as administrator :)
 
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mypetcow said:
Yes Discovery makes money and they must increase shareholder value. Easy as that.
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They have no obligation to increase shareholder "value". They certainly have no obligation to drive up the share price.

YoungSandwich said:
This. I agree with what you've said. The cost of medical procedures and equipment isn't regulated in this country, as far as I can tell. There's no governing body that says this insulin shot can cost no more than R100, or this mask is worth R2.50 for example. As for as I can tell, companies and hospitals just label what they THINK they should cost and then charge it to the medical aids.
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It used to be regulated. One of the few things the previous government did right.

Hospitals and doctors will charge whatever they can get away with. The medical schemes also don't care whether you try to minimise costs, so just use the maximum benefit.
 
noxibox said:
They have no obligation to increase shareholder "value". They certainly have no obligation to drive up the share price.
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Medical Schemes are "owned" by their members with Trustees appointed by them. The company's make money by doing the administration and the Trustees jobs are to make sure the admin fee is reasonable. You can nominate and elect Trustees as a member.

noxibox said:
It used to be regulated. One of the few things the previous government did right.

Hospitals and doctors will charge whatever they can get away with. The medical schemes also don't care whether you try to minimise costs, so just use the maximum benefit.
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Almost. Read the competition commission report I posted above.

Medical schemes do try to minimize cost because it filters directly to premiums and they need as many members as possible -e.g. Low premiums.

My biggest gripe is actually that employers often decide on the scheme and you have to comply. I happened to be on a very good closed medical scheme due to my employer but I would appreciate the choice. Although thinking about it most sheeple would just go to Discovery for "gym" and not because it is the best medical aid. Legislation really need to outlaw coupling administrator add-ons like Vitality to medical schemes.
 
xrapidx said:
Discovery wanted pre-authorization for our new born to go into NICU... was a complete nightmare at the time. They eventually apologized, but the way they handled the situation was horrific.
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That's bizarre.
Admission into an ICU facility is usually, if not always, as a result of a life threatening condition.

Life threatening conditions do not require authorisation prior to admission.
Nor is a patient limited to the partner DSP's of the medical scheme in the event of a life threatening condition.

I sincerely hope disco offered an appropriate apology and explanation
 
mypetcow said:
Do you mean under Zuma? Did Ramaphosa undo it?
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Mbeki
2004

Price of medicine is still controlled.
Products may be sold up to a maximum price per product.

Dispensing outlets may charge less than the maximum price.
A dispensing fee may be added to the cost of medicine purchased
 
Ppl. Medical care is expensive.
Monthly contributions to a medical scheme are expensive.

Medical schemes will try strong-arm you into their way of doing things, which sometimes skirts the bounds & parameters of the law.
Understand your rights.

First and foremost, all medical schemes are obliged to be registered with the Council of Medical Schemes, and abide by their regulations.

As to your rights, see here:

Prescribed Minimum Benefits | Council for Medical Schemes

Prescribed Minimum Benefits (PMBs) are defined benefits to ensure that all medical scheme members have access to minimum health services.
www.medicalschemes.co.za www.medicalschemes.co.za

And here:

Frequently Asked Questions | Council for Medical Schemes

Is there anything you would like to know? Find answers to some of the most frequently asked questions regarding medical schemes.
www.medicalschemes.co.za www.medicalschemes.co.za

Oddly, the council has teeth, sharp teeth - and act very quickly in investigating a complaint.
In critical instances, like @xrapidx experienced where life or death can hang in the balance, they often act immediately when complaint is lodged, contact the chairman or directors of the scheme, and lay down the law, resolve the matter within the day - often within hours.

In the case of an emergency admission, admission and treatment trump authorisations.
The attending physician will diagnose and embark on a course of treatment to stabilise the patient.
In the background, a hospital case manager will contact the scheme giving diagnostic pairs / icd-10 codes.
The scheme will usually / automatically give a 48hr authorisation for the purpose of further diagnostic examination . Diagnostic examination could be radiology, pathology or even exploratory surgery.

If the patient landed up at a non DSP hospital, the patient can only be transferred to a DSP facility when stable.
A physician will not sign discharge papers for transfer if the patient is not stable.

Some medical schemes have state hospitals as a DSP.
A patient may only be transferred if a receiving doctor is available & a bed is immediately available.
This is where the DSP rule for state hospitals falls apart. There is seldom a receiving doctor available and the probability of an immediately available bed is near zero. The patient has to be kept at the private facility.
For those with parents who are pensioners (who often have state hospitals as the DSP), please understand this.
For those who live in the sticks, if a DSP hospital is not within the radius of 50km or 60km (I can't remember the exact distance off-hand) from home - you can go to any closer hospital of your choice.

Majority of emergency admissions will fall within PMB conditions - the scheme has to pay.

Know your rights and enforce them.
 
Grant said:
That's bizarre.
Admission into an ICU facility is usually, if not always, as a result of a life threatening condition.

Life threatening conditions do not require authorisation prior to admission.
Nor is a patient limited to the partner DSP's of the medical scheme in the event of a life threatening condition.

I sincerely hope disco offered an appropriate apology and explanation
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Fortunately the hospital was great in my case - they just went ahead with everything and told me to try sort it out with the medical aid, so there was no delay from their side.

Discovery on the other hand were useless, I got various excuses (including that the new born didn't have an ID number and couldn't be registered on my plan - duh!) I eventually asked them to stop calling while we were dealing with a new-born in NICU - something they also couldn't respect and phoned relentlessly.

Discovery actually paid back over R11,000 due to their mistakes in processing the claims related to the above childbirth over a year and a half later. No matter what I tried, I couldn't get them to put in writing what the refund was for - they kept phoning and saying they'll send it - but never did. (I spent over 40min on the phone with the one "manager" who said they had a call recording with me on the above - which I denied happening - eventually she said there was a system problem loading the call and she'd call me back - never did)

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RE: your other comment regarding regarding the medical schemes board - I tried them once in 2016 and also found them to be all but useless. I logged a complaint where Discovery Health refused to settle a claim properly (on more than one occasion) - because they "had an agreement" with the doctor to charge a certain rate, where the doctor was charging more.

Discovery refused to budge, the doctor said she had no agreement with Discovery, and Discovery would provide no proof of the agreement - I went through the complaint process and eventually logged a complaint with the medical schemes board.

The person assigned had no interest, ignored multiple emails, and didn't address the complaint properly, they waited until after the maximum period (120 days) to respond, only to agree with Discovery that Discovery didn't have to pay as they had an agreement with the doctor - even though the doctor refuted this and Discovery provided no proof to their claim.



--- out of interest, I could be wrong - but isn't the medical schemes board also run by the very medical schemes they oversee?

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While I've always had a medical aid with MSA - after my second poor experience similiar to the above just under a year ago - I've now downgraded to a hospital plan. Less dealing with the incompetence that surround these companies.

I just this week received a revised claims statement from my previous healthcare provider who seem to have reprocessed their/my claims and owe me a little bit of money - I left them in 2013.

This entire industry stinks.
 
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xrapidx said:
Fortunately the hospital was great in my case - they just went ahead with everything and told me to try sort it out with the medical aid, so there was no delay from their side.

Discovery on the other hand were useless, I got various excuses (including that the new born didn't have an ID number and couldn't be registered on my plan - duh!) I eventually asked them to stop calling while we were dealing with a new-born in NICU - something they also couldn't respect and phoned relentlessly.

Discovery actually paid back over R11,000 due to their mistakes in processing the claims related to the above childbirth over a year and a half later. No matter what I tried, I couldn't get them to put in writing what the refund was for - they kept phoning and saying they'll send it - but never did. (I spent over 40min on the phone with the one "manager" who said they had a call recording with me on the above - which I denied happening - eventually she said there was a system problem loading the call and she'd call me back - never did)

--------------

RE: your other comment regarding regarding the medical schemes board - I tried them once in 2016 and also found them to be all but useless. I logged a complaint where Discovery Health refused to settle a claim properly (on more than one occasion) - because they "had an agreement" with the doctor to charge a certain rate, where the doctor was charging more.

Discovery refused to budge, the doctor said she had no agreement with Discovery, and Discovery would provide no proof of the agreement - I went through the complaint process and eventually logged a complaint with the medical schemes board.

The person assigned had no interest, ignored multiple emails, and didn't address the complaint properly, they waited until after the maximum period (120 days) to respond, only to agree with Discovery that Discovery didn't have to pay as they had an agreement with the doctor - even though the doctor refuted this and Discovery provided no proof to their claim.



--- out of interest, I could be wrong - but isn't the medical schemes board also run by the very medical schemes they oversee?

--------------

While I've always had a medical aid with MSA - after my second poor experience similiar to the above just under a year ago - I've now downgraded to a hospital plan. Less dealing with the incompetence that surround these companies.

I just this week received a revised claims statement from my previous healthcare provider who seem to have reprocessed their/my claims and owe me a little bit of money - I left them in 2013.

This entire industry stinks.
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Hideous experience all round.
I'm surprised at your bad experience with the Council. I've helped a couple of ppl and had 2 matters myself - they came shining thru. I guess perhaps luck of the draw as to who handles your complaint. There is good and rubbish in every industry.

The council board has a variety of members appointed by minister of health. They are drawn from private sector - doctors, attorneys, advocates etc, to handle a wide range of issues.

The private healthcare sector needs some serious legislative overhaul, from private hospital groups through to medical schemes.
There was a conference a little while back held at the Steve Biko Bioethics Centre at Wits.
Hopefully some good comes out of it.
 
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