“If you believe popular medical TV dramas such as Grey’s Anatomy and Private Practice, patients are rolled into theatre for ground-breaking or experimental surgeries every day, and a plethora of expensive diagnostic tests are ordered at the drop of a hat,” Jeremy Yatt, the principal officer of Fedhealth, says. “In reality, it doesn’t work like that. If schemes operated like that, we would have to close our doors in a matter of months, because we wouldn’t be able to fund claims of that nature for long.”
To contain the costs of providing you with benefits, schemes may engage with healthcare providers – usually through their representative organisations – and decide on the most cost-effective, best-practice treatment or procedure for a particular condition. These decisions are referred to as managed-care protocols. If your doctor recommends a treatment that differs from the scheme’s protocols, your claim may be denied or paid only in part.
“We don’t want to prescribe to healthcare providers how they should treat their patients, and we will pay for claims that fall within the accepted treatment protocol. But we cannot fund every experimental treatment that does not meet very specific criteria. This is to protect our pool of members as a whole,” Yatt says.
“We will, however, always consider outlying cases and do the best we can to assist all our members with the best possible care.”
Schemes have a range of programmes that set out the most cost-effective ways to manage diseases such as HIV/Aids, diabetes, high blood pressure, asthma, heart disease, hypertension and even cancer. If you have one of these conditions, your scheme may require you to register with a disease-management programme. If you do not, your claims will be rejected.
These programmes may stipulate the number of consultations and diagnostic tests you need and have a list, or formulary, of the cost-effective medicines that can be used to treat your condition. Typically, the formulary will include cheaper generic medicines and will exclude newer, more expensive ones that have yet to be proved cost-effective for treating a particular condition.
Managed-care protocols are usually developed by a managed-care entity, which may be separate from or housed within the administrator of a medical scheme and must be accredited by the Council for Medical Schemes (CMS).
Medical schemes’ managed-care protocols are usually based on what is accepted as best practice by the association or society that represents the relevant medical discipline, and your doctor should be aware of that best practice, schemes say.
However, there are often disagreements between the doctors who treat you and the doctors who sit on the teams that are appointed to manage a scheme’s costs, and this can expose you to gaps in your medical cover. You should therefore ask your doctor if the treatment that he or she has recommended is in line with best practice, and if it is not, what the doctor’s experience of a typical medical scheme’s cover for the treatment has been.
One of the best ways to determine whether or not you will have cover for the treatment is to obtain a “quote letter” from your doctor that outlines the treatment or procedure using the relevant ICD-10 codes. You should then ask your scheme to check whether it covers all the services listed.
Telephoning your medical scheme for pre-authorisation for an in-hospital procedure or chronic medication will also help you to establish what your benefits are and whether or not the scheme is likely to cover the procedure or medication.
You can also ask for a written copy of the managed-care protocol, but it is likely to have been written by doctors for doctors, so you may need some help interpreting what it means.
Before you start a course of medication, find out whether or not your scheme has a formulary. If your doctor prescribes a medicine that is not on the formulary, check with him or her whether you can use one that is.
If your doctor has sound medical reasons for prescribing a medicine that is not on the formulary, or if you have already tried the formulary medicine and it has not worked, your doctor should provide a motivation to the scheme for alternative treatment. The scheme will be obliged to consider this or tell you what alternative it will cover.
If the scheme’s clinical experts and your doctor cannot agree on a treatment that the scheme will cover, the regulations under the Medical Schemes Act say there must be a way for you to appeal against a decision made by a managed-care entity.
Unless your scheme provides you with a complaint process to follow, take your complaint to the office of the principal officer of the scheme. If you do not resolve your complaint there, you can take the matter to the CMS.
If you do not agree with the council’s ruling, you can appeal to its Appeal Committee and from there to the Appeal Board – an independent board of legal experts appointed by the Minister of Health.