Presented by Bonitas Medical Aid

Hospital pre-authorisation vs quotes – what you need to know

Due to the different waves of Covid-19 and the emerging variants, a number of elective surgeries were postponed to help minimise the take up of hospital beds and to avoid unnecessary exposure to the virus.

However, surgeries are now getting back on track – even if it’s only a window during which the backlog of elective surgeries can be tackled.

It is the perfect time to talk about the issue of pre-authorisation and quotes and why you should know the difference.

Lee Callakoppen, Principal Officer of Bonitas Medical Aid, says pre-authorisation, ahead of any medical procedure or hospital admission, is always required.

He also stresses the importance of asking for a quote to submit to your medical aid.

This will ensure you know exactly what is covered and whether you should plan for any out-of-pocket expenses.

Does pre-authorisation mean payment, in full, is guaranteed? Not necessarily. Let’s take you through the process and T&Cs.

What is pre-authorisation?

All procedures that take place in a hospital must be pre-authorised.

Essentially, it’s an agreement between the medical aid and the hospital, indicating a willingness to pay for costs associated with the visit.

But even if you do have pre-authorisation your medical aid is not promising to cover 100% of the costs.

All pre-authorisation requests are evaluated against the different schemes’ rules and clinical funding policies however, you remain responsible for any shortfall, including any co-payments.

If you are unsure how to go about the process speak to your broker or your medical aid.

When do I need to pre-authorise?

You must apply for a Pre-Authorisation Reference number (PAR) as soon as a visit or admission to a hospital is planned.

This applies for a CT scan, MRI scan or radio-isotope study. Do this as early as possible in case you are required to submit additional documentation or a motivation from your healthcare provider.

You also need pre-authorisation for:

  • Renal clinic admissions for dialysis
  • Procedures in doctor’s rooms or day clinics, instead of hospital
  • Physical rehabilitation care in rehabilitation facilities
  • Drug and alcohol rehabilitation care in specific facilities
  • Hospice admissions
  • Oxygen therapy at home
  • All specialised radiology

What information is needed?

  • Name and surname of the person having the procedure
  • Membership number and dependent code
  • The date of admission or procedure
  • The diagnosis
  • All proposed surgical procedures, diagnostic procedures or specialised radiology codes available (ICD-10, CPT, NRPL codes)
  • The name of the facility where the procedure will take place
  • The names and practice numbers of the healthcare professionals (doctor, surgeon, specialist etc)

Once your pre-authorisation has been approved you will receive a confirmation letter.

Read this carefully and check that the information is correct.

If you are any queries speak to your doctor or your medical scheme.

What about emergency admissions?

In the event of emergency treatment or admission to hospital, you – or a family member or the hospital – must contact your medial aid on the first working day after the incident to obtain authorisation.

Did you know?

Your doctor or the facility you are being admitted to, can do the authorisation on your behalf.

Despite this, it remains your responsibility to ensure that the authorisation is completed and correct.

What happens if you don’t pre-authorise?

You will either be liable for a co-payment, or your procedure will not be covered.

Does pre-authorising ensure payment of the procedure?

No, unfortunately not. Most medical aid plans have varying hospital benefits according to the level of cover you have chosen and they also have a ‘rate’ and which they reimburse healthcare providers.

This means that even if the payment is 100% of the rate, this is not necessarily what the healthcare provider will charge, they may charge 200% of your medical aid rate.

This means you are responsible for any shortfall in the form of a co-payment.

Co-payments differ from one medical scheme to another and are often higher than anticipated, mostly due to medical practitioners and hospitals charging higher than the medical aid rate.

“We mitigate this as much as possible,” says Callakoppen, “by negotiating with hospitals and service providers who are on our network, to place a ceiling on the costs of the procedures.”

For this reason, it is best to find a healthcare provider on your scheme’s network.

Quotes vs pre-authorisation for procedures

Callakoppen advises private medical aid members to not only obtain pre-authorisation but to also ask for a detailed quote from the hospital and medical practitioner prior to being admitted to hospital.

“This gives you an opportunity to negotiate and eliminates any additional ‘surprise’ payments required after the procedure.”

“The most important thing”, says Callakoppen, “is to find out, prior to being admitted, what your medical aid will pay and what payment you might be responsible for.”

“The last thing you want to deal with is a surprise large co-payment and the stress related to that when you are recovering from a procedure.”

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Hospital pre-authorisation vs quotes – what you need to know