Being a member of a medical aid does not entitle you to walk into a hospital and demand hospitalisation unless it is a medical emergency. Hospitalisation is costly and medical aids carefully regulate which patients are to be hospitalised. This largely depends on the request by the attending doctor and medical reasons that make hospitalisation a necessity. Medical aids require members to pre-authorise a hospital visit or procedures that are to be done in hospital. However with emergency medical situations, authorisation is only requested once the patient is admitted to the hospital.
Pre-Authorisation for Hospital Stay
In order for a medical aid to cover the cost of staying in hospital, the doctor’s fees to attend to you while in hospital and other medical costs, the member of a medical must first get a pre-authorisation number. This number means that your medical aid is aware that you will be hospitalised and have approved benefits to cover the relevant hospital expenses.
Hospital authorisation does not occur just by a patient requesting it. The medical aid has to assess the merit of the request in terms of the need for hospitalisation based on the doctor’s findings and diagnosis. This may mean that you will require further evaluation in a hospital setting or surgery. If a medical aid finds that the request is without merit, the scheme can refuse the authorisation. In these instances, unauthorised admission to hospital will not be covered by your medical aid and you will be liable for all costs incurred while in hospital.
Who can obtain hospital pre-authorisation?
Ideally the member of the medical aid should contact the scheme and request pre-authorisation. However, this is not always possible and a family member can do it on the patient’s behalf provided that they have all the necessary information. A doctor’s staff member, the doctor or hospital staff can also request pre-authorisation. Most medical aids have a separate contact number for hospital pre-authorisations which in most instances are manned 24 hours a day. This number is usually printed on the medical aid membership card.
The hospital will require all of the patient’s details, medical aid membership, details of the attending doctor, hospital, reasons for hospitalisation, diagnosis and the tariff codes for the procedures that the doctor intends to undertake in hospital. Once received, this authorisation number needs to be provided to the hospital, doctor and any other health care providers involved in your treatment while in hospital. Failure to utilise this number upon claiming will mean that the hospitals and doctors will not be paid for the services rendered to you while in hospital. You will then be held liable for these medical costs.
Hospital Authorisation Denied
Despite providing all this information, a medical may still deny authorisation. The reason that the authorisation has been denied will be provided by the scheme and where possible, the patient and doctor need to remedy the problem in order for the authorisation to be reconsidered. Sometimes a medical aid may decide that the reasons stated for hospitalisation does not require care within a hospital. At other times a medical aid member may still be within the waiting period before the membership becomes fully active. Medical aids also have a set of approved procedures and if the intended procedure is not within this list, hospitalisation will be denied. Patients can then still be admitted into hospital and undergo treatment but at their own cost.
These days hospital authorisations are denied for various other reasons as medical aids tighten spending by patients. If a medical aid member wants to be hospitalised only to undergo diagnostic investigations that could be done out-of-hospital, then the medical aid may deny authorisation. Many patients in an attempt to save their out-of-hospital benefits or those with cheaper hospitals plans attempt to get admitted and then have the hospital benefit of the medical cover pay for these procedures. Medical aids no longer grant authorisation for these investigations, although it will pay for the investigation should it require hospitalisation.
Some medical aid members are under the false impression that once hospitalised, they can undergo any number of medical procedures that they choose. A hospital pre-authorisation only covers a patient for those procedures that are directly related to the reason for admission. The time span in which a patient is allowed to stay in hospital is also carefully monitored and patients cannot remain in hospital indefinitely without further approval by the medical aid. A hospital authorisation number also does not allow any health care provider to treat you while in hospital unless the attending doctor deems it necessary with regards to your current reason for hospitalisation.