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Doctors have always tried to help patients with their medical costs particularly when it came to inadequate cover in the form of lower plan medical aids. One such instance is when it came to expensive diagnostic procedures like a CT scan (computed tomography), MRI (magnetic resonance imaging) and endoscopic procedures such as upper GI (gastrointestinal) endoscopy, colonoscopy and sigmoidoscopy. Normally these outpatient procedures may be paid for from the day-to-day benefit but patients on hospital plans may instead have had to fork out cash. These procedures are expensive and costs several thousands rands.

In order to overcome this hurdle, many patients opted to be admitted to a hospital for further investigation where the in-hospital benefits could pay for these procedures. However, medical schemes have now started clamping down on this practice. A procedure that can be conducted on an outpatient basis and does not require hospitalisation may not be paid for from the hospital benefit. The situation may be different if the patient had to be hospitalised for valid medical reasons but not if the sole purpose of hospitalisation is to cover the cost of these procedures.

Costs of Scans and Scopes

An MRI can cost as much as R6,000. An upper GI endoscopy will set you back between R3,000 to R7,500 depending on your various factors. These procedures are not affordable for most people without the assistance of medical aid. However, it is an outpatient procedure meaning that it does not require a hospital stay. Therefore it is paid for from the day-to-day benefit of your medical aid. If your plan has a savings account then it will be paid from this portion. On a medical aid with allocated limits for different disciplines, a scan or scope will be paid for from the investigation benefit which also includes other procedures like blood tests.

Many plans still allow patients to be hospitalised and then have the procedure conducted if a doctor motivates for it. However, the medical aid industry is under increasing strain to cut costs and have had to implement tougher restrictions. Some of the lower plans now will not allow for these procedures to be paid from the hospital plan. Even if you have day-to-day benefits and the costs of the procedures cannot be fully met by these benefits, your scheme will not pay the remainder from your hospital cover. You will have to make up for the shortfall in cash.

Authorisation for Scans and Scopes

Before being admitted into a hospital or undergoing any procedure, you will need authorisation from your medical aid. It is not different for scans and scopes. If your medical aid will not cover the cost of these procedures in hospital then they will refuse to issue an authorisation number. This does not mean that you cannot have the procedure. It simply means that the medical aid will not pay for it so you will have to pay cash to the doctor, hospital and for the use of any medical equipment. For long term medical aid members, the entire authorisation process can be quite frustrating as it is a fairly new procedure.

Most medical aid members are still uninformed when it comes to authorisation procedures and get caught off guard at a time when they need immediate care. Remember that your doctor and the hospital are not responsible for getting authorisation numbers – you are as the patient and medical aid member. Without authorisation for scans and scopes or any other procedure for that matter, your doctor and the hospital can refuse to do the procedure unless you can pay upfront or at the very least put down a cash deposit. However, in the event of a medical emergency, most of these authorisation procedures fall away and your medical aid may pay for the procedure.