With the continual hike of the petrol price and the rising tide of everything else it affects, our pockets are growing holes at a rapid rate. So naturally when it comes to our Medical aid, all of us would like to think that our monthly premium is all that’s required from us and going forward we’ll be covered for any hospitalization that might come our way. However, like with all insurance companies, there are clauses that go unchecked and important information between the lines that go unmissed.
“Many people get confused and have common misconceptions towards what their plan type and Medical Aid will cover” states Rochez O’ Grady, a Pre-Authorization consultant working at a large Medical Aid company in Cape Town. “It’s not that people are unprepared, there is just so much information and red tape for some procedures that it’s impossible to know it all”.
After speaking to numerous people in the industry to help clear the muddy water, I put together some useful guidelines, essential to not being caught in the headlights of a humongous Medical Aid freighter and hopefully save you some grey hairs.
1) You know what they say about assumptions…
Medical Aids have a lot of red tape, especially when it comes to uncommon treatment. It’s imperative to phone their call center or email them your query as to how your specific plan would cover your procedure. This phone call or email may cost 5 minutes of your time but it could save you thousands of rands. As in the case of Luke Viviers who found out only after he paid his specialist, GP and MRi bills, that his medical aid plan would not cover his treatment. “If I had known my plan didn’t cover joint procedures as common as mine, I would never have chosen it” states an angry Viviers. “If I had phoned in before I went to the GP, I could have saved a lot of money and hassle. Now I not only have an aching shoulder but also a sore back pocket”.
2) Get those digits
A reference number seems pointless on most occasions, much like the 5cents change they give you at the supermarket. However, it is extremely important to remember who gave you the information and details about your treatment. If you start to hear new information that’s not similar to what you’ve heard previously, you can use the reference number to go back on what the previous agent said. “It’s a good idea to keep a note pad with all the information regarding your treatment, especially the names of the consultants you spoke to and the reference numbers they gave you.” states O’ Grady.
3) You can’t run away from rates and taxes
Most Doctors and anesthetists charge above the “medical aid rates”. Meaning you will be liable for anything above what the medical aid pays out. For example, if your plan type pays out at 200 percent of medical aid rates and the doctor is charging 230 percent, you will be liable for the amount above 200 percent. Now this might not seem like much but remember there might be an anesthetist involved and these amounts can be as much as 400 percent in some instances. The medical aid should know if the doctor and the anesthetist are contracted in with your medical aid rates. If not, there is a 99 percent chance you will need to fork out some money to pay the doctors bills. Speak to your doctor about the rates, it’s a service they are offering and they are not unwilling to reduce their rates.
4) Being early is not always a bad thing
Medical aids require you to call in for an authorization number at least 48hours before your in-hospital procedure. Phone in as soon as you find out you’ve been booked for the procedure. The earlier you are, the less stress you need to deal with before your procedure. If the procedure you’re undergoing is one of the unlucky ones to be bound by red tape, it could take up to 10 business days to gain approval. They might even need a letter of motivation from the doctor involved and additional tests to be done to assess whether they will fund the procedure.
5) A little love goes a long way
“A friendly caller goes a long way and it will be rewarded” says O’Grady. A sure way to make the process more frustrating is to be aggressive or rude with the consultant. “Most of the agents you speak to are really kind and helpful people. However the high demand of call volumes everyday – sometimes as many as 100 calls a day – can get taxing” advises O’ Grady. Be straightforward, clear and assertive. Try and make the agent who’s dealing with your query fully responsible with the outcome of your case, this is a lot easier than dealing with 4 or 5 different agents across the country and explaining you’re story countless times.
6) Don’t trust anyone, especially not the hospital
I know this seems contrary to belief but it’s meant on the administration side. Some hospitals will do all the leg work for you (gaining an authorization number, calling the call center, etc.) but on most occasions they won’t inform you if the doctors are fully covered by your insurance provider. There have been cases when the hospital has made critical errors, leaving the patient to pick up the slack or even fit the bill. Matthew Riley received a text message from his medical aid wishing him good luck with his delivery date and motherhood. “I started to think I was going crazy but when I phoned my medical aid they advised me that the hospital called for the patient concerned and the cellphone numbers were incorrect on their system. So I received her message.” If the hospital has phoned the medical aid for you, make sure to double check and make sure everything is covered from the nature of the procedure down to the maternity benefits, if that’s the case.
There are many processes happening behind the scenes at your medical aid branch but if you go into the process prepared, early and with an inquisitive mindset, you won’t be disappointed and possibly prevent you from explaining to your wife or husband why you received a maternity package from your medical aid. Good luck