In our previous article on how to avoid co-payments after a hospital admission, we focused on Designated Service Providers (“DSPs”) and private doctors’ fees.
In this article, we will take a closer look at some other aspects that may influence the reimbursement of your hospital and related claims.
Providers’ fees vs Scheme Tariff – when co-payments may apply
There are no guidelines or law in South Africa that prescribe or regulate what doctors or other healthcare providers may charge.
When private providers (i.e. doctors and specialists) charge more than the Scheme Tariff applicable to your benefit option, their account(s) may not be settled in full. With reference to our previous article, provider fees for claims on the Private Choice option will be reimbursed at 100% of the Scheme Rate. Members’ cover for doctors / specialists on the Private and Private Comprehensive options is at 200% of the Scheme Rate.
Members may be liable for co-payments after a hospital admission (difference in cost) that may arise if their doctor(s) charges more than the Scheme Rate.
Medically appropriate treatment
When healthcare providers perform health services, use advanced technology or use / order certain diagnostic or other tests and procedures which are not deemed medically appropriate in terms of the Scheme Rules, your accounts may not be settled in full. The same principle applies when they perform treatment that is not supported by sound scientific evidence, or that is selected for consideration of comfort or convenience. It may also happen that they perform treatment that is not cost-effective in relation to available alternative treatment.
Where possible, always discuss such charges with your doctor(s) before your admission and / or procedure.
What you need to do if any information changes
Except for emergencies, members need to obtain a hospital admission reference number prior to a hospital admission. A hospital admission reference number is always condition and date specific. Should any of the details change and the Scheme is not informed, the reference number will become withdrawn and void.
If there is any change to the procedure(s) notified to Genesis or any change to the ICD-10 codes provided, and you do not inform the Scheme, all claims related to your admission may be rejected.
Treatment vs funding for hospital admissions
Genesis may not and does not provide medical services to our members. The Scheme does also not interfere with the clinical decisions that are made by your attending doctor(s). Its only role is to provide funding for such services and to ensure that such services / benefits are in accordance with the Scheme Rules.
Scheme Exclusions
Members must always familiarise themselves with the exclusions in the Scheme Rules that may be applicable to an admission.
Furthermore, diagnostic tests and examinations that do not result in the diagnosis or confirmation of an illness or disease that necessitates surgery, may be for your own account.
MRI / CT scans
In order to qualify for in-hospital benefits, all requests for CT / MRI scanning procedures must be directly related to the primary reason for admission to hospital. It must also be accompanied by a full clinical history report and examination findings prior to the procedure.
To demonstrate this with an example, the Scheme will not fund an MRI brain scan (because you suffer from headaches) when you are admitted for a hernia repair, as the headaches are not related to the reason for your hospital admission.
Admission and discharge times
The Scheme funds a morning admission only where the theatre is scheduled before 2pm. If the procedure is scheduled for theatre after 2pm, then only an admission after 12pm on the same day is funded.
Afternoon (PM) discharges from hospital should be clinically indicated for it to be funded.
All relevant consultations, procedures and / or special investigations done on the pre-operative day and for which a hospital facility is not necessary, will, at the Scheme’s discretion, be for your own account. Alternatively it may be reimbursed from your available Self Managed Fund (SMF) benefit.
In conclusion
Although this articles contains some medical scheme funding aspects that may result in co-payments after a hospital admission, the above information is not exhaustive. In order to avoid co-payments after a hospital submission, we respectfully refer our members to the Scheme’s website (www.genesismedical.co.za) where the complete registered Scheme Rules are available under the secure member login portal.
