What to ask your medical scheme before a procedure

A medical procedure will affect not only your health, but also your financial situation. Medical treatment is expensive, which is why belonging to a medical scheme is an important part of your financial planning. Even if you belong to a scheme, there is a distinct possibility that your expenses will not be fully covered.

This article outlines the questions you should ask of your medical scheme before undergoing a procedure, and what you need to consider before admission to hospital.

Tip: A personal loan can help to tide you over in a medical emergency. Find out more here.

What to ask prior to hospital admission

For medical scheme members, all procedures that take place in a hospital must be pre-authorised. This forms an agreement between the medical scheme and the hospital, with the scheme indicating its willingness to pay for costs associated with the visit.

Before your planned procedure, let your medical scheme know the date of the procedure, the doctor and anaesthetist’s name and practice number, the hospital selected, the diagnosis codes (you can find these out from your medical team), and the procedure or treatment codes.

The hospital will obtain pre-authorisation on your behalf if your hospital admission is unplanned, as in the case of an accident, for example. This information helps your medical scheme to confirm how your admission will be covered, including any co-payments or deductibles that may apply, and how these may be avoided.

According to Deon Kotze, head of research and development at Discovery Health, questions you should ask ahead of admission are: 

• What will the admission cost?
• How will the hospital’s bills be covered?
• How will the doctor’s bills be covered?
• How will the anaesthetist’s bills be covered?
• How will the costs of rehabilitation after I leave the hospital be covered?

Find out what your member benefits are, as some medical schemes place a limit on benefits for hospital admissions, which affects what you are able to claim after the procedure.

“If your medical scheme has a network option, you may need to go to a hospital that forms part of this network,” says Kotze. “If you choose a hospital outside the network, it may cost you anything up to 20% more than network options.”

You should ask whether your condition will be covered by your medical scheme, as some are not covered due to waiting periods or exclusions. While many treatments and procedures are covered in full, some may not be covered, due once again to waiting periods and exclusions, along with clinical protocols (the rules medical schemes use to determine if a treatment is appropriate or not), and co-payments or deductibles.

“Most medical schemes have payment arrangements in place with contracted doctors and anaesthetists, and settle their bills directly in full,” explains Kotze. “However, find out if your healthcare professionals charge more than the recommended rates.”

Am I fully covered for my procedure and hospital stay?

It’s important to understand what medical schemes mean when they indicate that hospital stays or procedures are fully covered. This invariably means the costs are fully covered in terms of medical scheme rates.

These rates are determined according to the Department of Health’s Reference Price List (RPL), a set of guidelines detailing the recommended cost for hospital procedures performed by specialists.

“Since the RPL only recommends the charges, doctors and specialists are not bound by the guidelines, and can charge what they like. Sometimes this is five times more than what is indicated in the RPL,” explains Judie Schickerling, director specialising in medical funds at Verimed medical aid brokers.

“If you are not aware of this, you may be held responsible for the lion’s share of the cost, despite being a medical scheme member.”

In South Africa, a total knee replacement may cost up to R250,000. Entry-level hospital plans will most often have a medical scheme rate of around 100% of the guideline price, whereas more comprehensive plans may pay up to 300% – three times the guideline price.

“If your knee replacement procedure costs around 500% of the medical aid rate, but your medical scheme only offers a rate of 300%, you will be held liable for the difference,” explains Schickerling.

You should ask your medical scheme what the co-payments on a procedure are likely to be. These can vary between medical schemes, but it’s wise to know if you’ll be liable for thousands of rands beforehand.

Another question you can ask is whether there is a sublimit on a procedure. This limits the cover available to you for certain procedures.

Finally, it’s well worth considering a gap cover product to buffer the effect of shortfalls. As with any insurance, this would need to be taken out prior to a situation arising, and general- and condition-specific waiting periods will apply.

Tip: Medical debt can cost you a substantial sum of money. If you have a number of loans, it’s worth considering debt consolidation.