Medical aids

My extremely part-time job is to help Chris with some of his admin. He meets up with his book-keeper on a fairly regular basis and always comes back in a pretty foul mood as so much of his hard earned money is just not paid out by the medical aids. Medical aids are making huge profits, our premiums are very high and then they fight tooth and nail and try and find all manner of excuses not to pay the doctors. Thank goodness that a lot of his private work is cosmetic and so one has nothing to do with medical aids.

First let me tell you a little about fairly new legislation that we have in South Africa. In order to try and take some of the burden off the state health system the government introduced something known as PMB conditions or Prescribed Minimum Benefit. These include all manner of conditions – most of the cancers, a lot of trauma stuff, think there are over 200 different conditions/injuries included. The idea is that if someone has medical aid and is then diagnosed with a PMB condition/sustains a PMB injury, even if their medical aid is depleted, the medical aid is legally required to cover the medical costs (even room procedures, out of the “risk” pool if the member’s savings are depleted). As long as the doctor doesn’t charge “unreasonably” high rates, they must also pay the doctor’s full account even if the doctor charges above medical aid rates. So, what does this mean? You can imagine how medical aids try and get themselves out of this one. The idea is that instead of the patients being shipped off to the already over-burdened state system because their medical aid is exhausted, the medical aids must carry the costs of their treatment.

Prescribed Minimum Benefit basically means that whatever treatment that patient would receive at a government hospital, they must receive in private. At the moment I am busy trying to get authorisation for a lady to have breast reconstructive surgery following a mastectomy she had 10 years ago. Breast cancer is a PMB condition and part of one’s breast cancer treatment includes breast reconstruction. This means that the medical aid CANNOT refuse to authorise this procedure no matter what plan the patient is on or how pathetic their medical aid is.

So, Chris wrote a motivation letter and attached photographs of the lady (think I mentioned this before). He then managed to actually get 3 different lab reports confirming her breast cancer diagnosis and still, after I don’t know how many phone calls and emails I still don’t have an authorisation number. The call centre people have been okay – sending emails when they say they’re going to and answering the phone within an acceptable time. The absolute pits is the PA to the medical advisor, who never sent me emails she was supposed to and yesterday tells me that I need to wait for a letter from the medical advisor as she needs to say what procedure must be done!!! So I asked her, “What qualification does the medical advisor have?” “She’s a doctor.” she replies. “Just a GP then?” I say-not that I have anything against GP’s but come on so I then proceeded to say,”Are you trying to tell me that a GP is telling a plastic surgeon what procedure he needs to do.” She got furious with me and told me she didn’t like my tone!!!! I won’t even bore you with all the rest of the crap I was told. Later on, I actually got phoned by the medical advisor who apologised to me and told me that they didn’t tell doctors what to do, just advised according to the patient’s plan or whatever. This is anyway all irrelevant, this is a PMB code which means the medical aid HAS to pay but they are making it so difficult that I think they’re hoping I’ll give up. Not a chance. I got promised they’ll get back to me yesterday, obviously nothing. I phone this morning, get told by the flipping PA, oh hasn’t Bongi phoned me (lovely call centre lady). No, I tell her. Why can’t you just give me the freaking authorisation number I’m thinking. I’ll tell Bongi to call you immediately… 2 hours later I phone Bongi to be told that she hasn’t been told anything and that they’re still dealing with it. Such lies. I then phone the PA back, ready to crap all over her but she’s obviously been warned and tells me that I’ll have the letter and authorisation before 4pm this afternoon. STOP PRESS!!!

You will not believe it, but the authorisation letter has just been faxed through!!!! Well done, me. But the hours I have spent getting this organised is just ridiculous, for something that they have no legal right to refuse. This lovely lady will now finally get her surgery 10 years later and only because no one else (I don’t blame them)was prepared to fight for it.

A word to all South Africans. There are many doctors out there who are not even aware of PMB codes and their implications for the medical aids. Your medical aid will certainly not tell you as it means they have to pay at whatever rate the doctor charges (200% of medical aid rates is regarded as a reasonable rate). The medical aid will try and make you pay the balance as they will just say your doctor is charging above medical aid rates. If your savings are depleted they have to cover all costs from the risk/major medical/whatever even for procedures in the rooms. I can’t list all the PMB codes but there are a lot, so check with your doctor and fight with your medical aid because most doctors won’t do it for you, they’ll just send you the bill.

Oh boy, what a nightmare it is just trying to help people and make an honest living.

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