Understand funding for hospital admissions (Part 1 of 3)

understand funding for hospital admissions part 1 of 3

Understanding the funding role of medical schemes can be tricky.

The following series of articles will provide valuable insight and understanding into the funding role of Genesis Medical Scheme during in-hospital medical treatment.

Nobody can afford heavy co-payments after being hospitalised.

“After all, I belong to a medical scheme”, you say.  “I should have no co-payment and my medical scheme must pay for everything.”

Does this sound familiar?  ‘Sure it does, but far too often, members sit with huge bills after a hospital event, either because they did not understand their benefits, or because their scheme did not cover all the costs in full.

For ease of reference, this article refers to “you”, meaning you or your dependant (whoever is / was hospitalised).

Does Genesis provide authorisation for treatment?

NO, Genesis does not authorise any treatment or admission to hospital.

Why not?

Genesis may not and does not provide any medical service or treatment to members.  We also do not interfere with any clinical decisions or protocols made by or recommended by your doctor(s).  Our role is solely to provide funding for the treatment and service(s) you receive whilst in hospital, but having said that, there may be certain limits applicable to the funding that the Scheme provides.

The fact that a member is in hospital, does not mean that all expenses, tests, treatment and medication received will be covered in full.  It is for this reason that Genesis does not provide an authorisation number, as we do not authorise any treatment.  To put it differently, HOW a member is treated, is entirely up to the expertise and judgement of the member’s doctors / specialists, but whether we will fund such treatment or service(s), depends on the benefits and limits as set out in the Scheme Rules.

So whilst the Scheme does not provide an authorisation number per se, we will issue members with a reference number for qualifying in-hospital treatment.  This reference number is however not a guarantee of payment by Genesis.  It simply means that at that time you are a member in good standing and Genesis will cover the cost of an admission in line with the benefits and limits in the Scheme Rules applicable to your chosen benefit option.

Important facts to take note of before going to hospital

  • Genesis will only fund a morning admission where the theatre is scheduled before 2 PM. If your procedure is scheduled for theatre after 2 PM, then we will only fund an admission after 12 PM on the same day.
  • Afternoon (“PM”) discharges from hospital must be clinically indicated for it to be funded by Genesis, in other words, the Scheme may request additional clinical information if your discharge could have taken place before 12 PM.
  • All consultations, procedures and / or special investigations done on the day prior to your procedure (or the morning, when your procedure is scheduled for the afternoon) and for which a hospital facility is not necessary, will be for your own account, unless it can be shown that there were particularly extenuating circumstances, in which case we will use our discretion.
  • Should there be a change to your procedure or treatment for which a reference number was provided, you have to inform Genesis beforehand. Failure to do so may cause all claims related to an admission to be rejected.

Hospital accounts are separate and independent of provider accounts

Hospital costs (e.g. ward fees, meals, theatre cost, consumables such as drips, needles, bandages and the like, nursing care, medicines, etc.) will be reimbursed at our Medical Aid Rate (Scale of Benefits).  These costs are usually reimbursed in full by the Scheme.

It is important to remember that except for public hospitals, doctors are not employed by private hospitals.  This means that during a typical hospital admission involving surgery, separate claims will be submitted by the hospital, the treating surgeon, any assistant surgeon, the anesthetist, the radiographer, the pathologist, the pharmacist, possibly physiotherapists etc.  Each healthcare service provider that treats you in hospital is an independent profit centre, running their own business for profit.  So, whilst you think of your admission to hospital as a single event, in the back end, the administration side of things, a very different picture is in play.  Each individual account or claim has to be audited for correctness and appropriateness in terms of the benefits to which you are entitled in terms of the Rules.

Remember too, that you are responsible for the correctness of the account.  Genesis is not present with you in theatre and so the scheme has no way of verifying the correctness of the treatment administered to you.

Continue reading this topic in Parts 2 & 3 of our series on “Understand funding for hospital admissions”.

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