Why medical aids in South Africa ask for pre-authorisation
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.
“Pre-authorisation prepares the scheme for the planned event or procedure and ensures that it complies with the necessary protocols where these are in place.”
This could also help the medical aid negotiate favourable rates and ensure cost-effectiveness, which, in turn, helps keep monthly premiums down.
Medihelp said that pre-authorisation is the safeguard through which members’ benefits are optimised.
It also creates an opportunity for Medihelp, as custodian of all member contributions, to act as a member advocate.
“Pre-authorisation is the gateway to accessing benefits,” Medihelp stated.
It explained that pre-authorisation is often the trigger that alerts the scheme to a member’s clinical situation.
“Such as members facing severe acute illness or even the fact that a chronic condition is not fully controlled,” said Medihelp.
“Pre-authorisation activates the next step in guardianship, namely case management that allows for hands-on care coordination and, where necessary, also discharge planning.”
The council said pre-authorisation also serves several purposes with elective procedures such as refractive eye surgery, including LASIK, PRK, LASEK, SMILE, RLE, and phakic IOL.
“Before the procedure can be authorised, physicians adhere to the relevant clinical practise guidelines and standard treatment guidelines relating to refractive surgery,” the Council for Medical Schemes spokesperson said.
“In terms of financial risk management for both the scheme and the member, members are advised to use the scheme’s preferred providers,” the council said.
“Preferred providers will charge a negotiated scheme rate, ensuring that members are protected from excessive co-payment levied by non-DSP.”
What happens if you forgot
Although failing to apply for pre-authorisation will likely get your claim rejected, some schemes will allow you to appeal for late authorisation. However, this usually involves paying a penalty.
“Scheme rules provide members with a late authorisation, subject to a penalty generally stated in the scheme rules,” said the council.
“In case of a medical emergency, the scheme rules allow a period of 24–48 hours to obtain authorisation with no penalty imposed.”
It also explained that medical schemes are required by law to reject claims where members failed to get pre-authorisation initially.
“Where the rules of the medical schemes require a pre-authorisation, and this is not done, then such a claim must be rejected,” it stated.
“[This is] because the rules of the medical scheme are binding on the medical scheme in terms of section 23 of the Medical Schemes Act.”
Medihelp said it automatically rejects claims where members failed to get pre-authorisation to prevent erroneous claims payments and because many different scenarios could be at play.
“If pre-authorisation was inadvertently omitted, Medihelp can reconsider benefits for the admission after the fact, albeit with the application of a late authorisation penalty,” the medical scheme said.
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