It does not mean, as the name implies, that the surgery is optional but rather that it doesn’t need to be performed immediately. It can be scheduled at the patient’s and surgeon’s convenience.
Dr Morgan Mkhatshwa, head of operations at Bonitas Medical Fund, says there are pre-hospitalisation requirements for those going in for elective surgeries. Here’s a quick checklist:
Medical schemes negotiate preferential rates with Designated Service Provides (DSPs) who have partnered with them to ensure that members get the best quality services, at the most cost-effective rate so that benefits are optimised. If you use a network hospital, doctor or pharmacy you will not be charged more than the agreed rate. This will help you avoid co-payments and make your medical aid last longer. So, to reduce co-payments and even avoid them altogether, find a healthcare professional on your schemes network.
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.
A quote is not the same as a pre-authorisation. 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. Asking for a quote prior to being admitted to hospital means you will know what your medical aid will pay and what payment you might be responsible for. It gives you an opportunity to negotiate and eliminates any additional ‘surprise’ co-payments required after the procedure.
Medical practitioners, hospitals and pharmacies often charge more than medical aid scheme rates, which could be between 100% and 300% of the medical aid tariffs. A co-payment refers to the outstanding portion of the account, for which the member is responsible. This co-payment varies from one medical scheme to another and is sometimes not required if members use DSPs or network hospitals.
Consult with your surgeon to see if your surgery can be done in a day hospital. Globally, day surgery hospitals have changed the experience of patients by offering an alternative to acute/conventional hospital surgery. The advantages include: No overnight stay, ideal for children so they don’t have the trauma of overnight stays; there is a lower risk of infection because patients go home on the same day and there is a decreased waiting list.
Your medical aid will stipulate the number of days you need to stay in hospital and check whether you will need a step-down facility when you are discharged. There are several facilities where patients can be cared for and start rehabilitation in conjunction with other medical professionals, for example physiotherapists.
Find out if you are eligible for home-based care after your procedure. Many patients prefer to be discharged from hospital as soon as possible and receive Hospital-Level Care at home. This means good, clinical quality care which translates into a great patient experience and is also more affordable
With Hospital-Level Care at Home, nurses, other health providers and caregivers are an essential element of the care continuum and play a critical role in recovery.
Gap Cover is an additional insurance cover that complements medical schemes. It helps to pay the difference in cost between the amount the specialist or hospital charges and the amount paid by a hospital or medical plan. You will be required to pay any shortfalls (co-payments), after which you may claim from your Gap Cover. Keep all documentation related to the surgery and hospitalisation to submit to the Gap Cover provider.
For emergency admissions, a Rapid Antigen Test is performed at the hospital, but for elective surgery you are required to have a PCR test a maximum of 72 hours before admission. If your test is positive, you will have to delay your surgery by at least 10 days and then re-test.
Pre-admission can be done a few days before you are scheduled for surgery and makes the admission process less stressful on the day. Pre-admission involves answering a series of questions and tests to eliminate the possibility of allergic reactions, drug interactions or physical complications before, during and after the surgical process. For administrative purposes the following items are required upon admission:
Dr Mkhatshwa says: ‘In addition to these, remember to take any chronic medication you are on to the hospital and make sure the doctor/anaesthetists are aware of what you are taking. By following this checklist and making sure the surgeon and hospital have all the necessary information, you will eliminate unnecessary stress ahead of your procedure and prevent unpleasant surprises when you are supposed to be recovering.’
