{"id":521308,"date":"2021-09-15T08:55:04","date_gmt":"2021-09-15T06:55:04","guid":{"rendered":"https:\/\/businesstech.co.za\/news\/?p=521308"},"modified":"2021-09-15T09:29:03","modified_gmt":"2021-09-15T07:29:03","slug":"hospital-pre-authorisation-vs-quotes-what-you-need-to-know","status":"publish","type":"post","link":"https:\/\/businesstech.co.za\/news\/industry-news\/521308\/hospital-pre-authorisation-vs-quotes-what-you-need-to-know\/","title":{"rendered":"Hospital pre-authorisation vs quotes \u2013 what you need to know"},"content":{"rendered":"<p>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.<\/p>\n<p>However, surgeries are now getting back on track &#8211; even if it\u2019s only a window during which the backlog of elective surgeries can be tackled.<\/p>\n<p>It is the perfect time to talk about the issue of pre-authorisation and quotes and why you should know the difference.<\/p>\n<p>Lee Callakoppen, Principal Officer of Bonitas Medical Aid, says pre-authorisation, ahead of any medical procedure or hospital admission, is always required.<\/p>\n<p>He also stresses the importance of asking for a quote to submit to your medical aid.<\/p>\n<p>This will ensure you know exactly what is covered and whether you should plan for any out-of-pocket expenses.<\/p>\n<p>Does pre-authorisation mean payment, in full, is guaranteed? Not necessarily. Let\u2019s take you through the process and T&amp;Cs.<\/p>\n<ul>\n<li><strong><a href=\"https:\/\/www.bonitas.co.za\/?utm_source=BusinessTech&amp;utm_medium=Article&amp;utm_campaign=September\" target=\"_blank\" rel=\"noopener\">Click here to learn more about Bonitas Medical Aid.<\/a><\/strong><\/li>\n<\/ul>\n<h3 class=\"my-4\">What is pre-authorisation?<\/h3>\n<p>All procedures that take place in a hospital must be pre-authorised.<\/p>\n<p>Essentially, it\u2019s an agreement between the medical aid and the hospital, indicating a willingness to pay for costs associated with the visit.<\/p>\n<p>But even if you do have pre-authorisation your medical aid is not promising to cover 100% of the costs.<\/p>\n<p>All pre-authorisation requests are evaluated against the different schemes\u2019 rules and clinical funding policies however, you remain responsible for any shortfall, including any co-payments.<\/p>\n<p>If you are unsure how to go about the process speak to your broker or your medical aid.<\/p>\n<h3 class=\"my-4\">When do I need to pre-authorise?<\/h3>\n<p>You must apply for a Pre-Authorisation Reference number (PAR) as soon as a visit or admission to a hospital is planned.<\/p>\n<p>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.<\/p>\n<p>You also need pre-authorisation for:<\/p>\n<ul>\n<li>Renal clinic admissions for dialysis<\/li>\n<li>Procedures in doctor\u2019s rooms or day clinics, instead of hospital<\/li>\n<li>Physical rehabilitation care in rehabilitation facilities<\/li>\n<li>Drug and alcohol rehabilitation care in specific facilities<\/li>\n<li>Hospice admissions<\/li>\n<li>Oxygen therapy at home<\/li>\n<li>All specialised radiology<\/li>\n<\/ul>\n<h3 class=\"my-4\">What information is needed?<\/h3>\n<ul>\n<li>Name and surname of the person having the procedure<\/li>\n<li>Membership number and dependent code<\/li>\n<li>The date of admission or procedure<\/li>\n<li>The diagnosis<\/li>\n<li>All proposed surgical procedures, diagnostic procedures or specialised radiology codes available (ICD-10, CPT, NRPL codes)<\/li>\n<li>The name of the facility where the procedure will take place<\/li>\n<li>The names and practice numbers of the healthcare professionals (doctor, surgeon, specialist etc)<\/li>\n<\/ul>\n<p>Once your pre-authorisation has been approved you will receive a confirmation letter.<\/p>\n<p>Read this carefully and check that the information is correct.<\/p>\n<p>If you are any queries speak to your doctor or your medical scheme.<\/p>\n<h3 class=\"my-4\">What about emergency admissions?<\/h3>\n<p>In the event of emergency treatment or admission to hospital, you \u2013 or a family member or the hospital &#8211; must contact your medial aid on the first working day after the incident to obtain authorisation.<\/p>\n<h3 class=\"my-4\">Did you know?<\/h3>\n<p>Your doctor or the facility you are being admitted to, can do the authorisation on your behalf.<\/p>\n<p>Despite this, it remains your responsibility to ensure that the authorisation is completed and correct.<\/p>\n<h3 class=\"my-4\">What happens if you don\u2019t pre-authorise?<\/h3>\n<p>You will either be liable for a co-payment, or your procedure will not be covered.<\/p>\n<h3 class=\"my-4\">Does pre-authorising ensure payment of the procedure?<\/h3>\n<p>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 \u2018rate\u2019 and which they reimburse healthcare providers.<\/p>\n<p>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.<\/p>\n<p>This means you are responsible for any shortfall in the form of a co-payment.<\/p>\n<p>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.<\/p>\n<p>&#8220;We mitigate this as much as possible,&#8221; says Callakoppen, &#8220;by negotiating with hospitals and service providers who are on our network, to place a ceiling on the costs of the procedures.&#8221;<\/p>\n<p>For this reason, it is best to find a healthcare provider on your scheme\u2019s network.<\/p>\n<h3 class=\"my-4\">Quotes vs pre-authorisation for procedures<\/h3>\n<p>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.<\/p>\n<p>&#8220;This gives you an opportunity to negotiate and eliminates any additional \u2018surprise\u2019 payments required after the procedure.&#8221;<\/p>\n<p>&#8220;The most important thing&#8221;, says Callakoppen, &#8220;is to find out, prior to being admitted, what your medical aid will pay and what payment you might be responsible for.&#8221;<\/p>\n<p>&#8220;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.&#8221;<\/p>\n<ul>\n<li><strong><a href=\"https:\/\/www.bonitas.co.za\/?utm_source=BusinessTech&amp;utm_medium=Article&amp;utm_campaign=September\" target=\"_blank\" rel=\"noopener\">Click here to learn more about Bonitas Medical Aid.<\/a><\/strong><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>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.<\/p>\n","protected":false},"author":57,"featured_media":521310,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10459],"tags":[16246],"class_list":["post-521308","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-industry-news","tag-bonitas-medical-aid"],"_links":{"self":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/521308","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/users\/57"}],"replies":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/comments?post=521308"}],"version-history":[{"count":3,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/521308\/revisions"}],"predecessor-version":[{"id":521476,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/521308\/revisions\/521476"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/media\/521310"}],"wp:attachment":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/media?parent=521308"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/categories?post=521308"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/tags?post=521308"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}