Unless it is an emergency situation, you cannot simply walk into a private hospital and request admission even if you are on a medical aid. Many medical aid members are under the misconception that having cover means guaranteed and immediate admission at any private hospital in the country when they want it. The is a specific hospital admission procedure that needs to be followed. But if you are in an emergency situation, the private hospital and medical aid will bypass these procedures to ensure that you get immediate medical care.
Doctors Approves Hospitalisation
First and foremost you cannot be admitted into a private hospital without a doctor approving it. Your doctor will have to state the specific reason why you need to be admitted. This can be done by your general practitioner (GP), medical specialist or doctor in the trauma or outpatient department of the hospital.
But even with your doctor’s approval, there is no guarantee that your medical aid will authorise hospitalisation. This does not mean that you cannot be hospitalised. It simply means that you medical aid may refuse to pay for your treatment in hospital for this specific case, procedure or event.
Remember that your doctor is not obliged to admit you into hospital simply because you request it. Hospitalisation by a doctor is only for legitimate medical reasons. You either need to be assessed and monitored on an in-hospital basis or undergo certain procedures that should be done in a hospital setting.
Private hospital admission should be necessary, not optional. While you as the patient may feel that you need to be hospitalised for whatever reason, without your doctor’s consent it cannot happen.
How to get authorisation?
Affording care in a private hospital is not an option for most people without the assistance of a medical aid. But your medical aid will only authorise hospital admission if they feel it is for a valid reason. This decision lies with your medical aid and not your doctor.
So even if your doctor feels it is necessary and your medical aid does not, they may refuse authorisation. Your doctor will then have to motivate as to why he/she feels it is necessary. Failure to do so means that your hospital stay and in-hospital care will not be covered.
In order to get medical aid authorisation for your hospital stay, you will need to phone through to your scheme and speak to the authorisation department. Doctors and their staff do not apply for authorisation on your behalf unless it is exceptional cases or instances where the doctor will need to explain the necessity of admission to the medical aid. Otherwise the onus is on you as the member to get the authorisation directly from the scheme.
Your doctor will provide you with a referral letter which you need to present to the hospital along with your authorisation number. Only then will you be admitted at a private hospital. While some private hospitals will assist you in getting authorisation, usually you will still need to speak to your scheme, if you are able to do so.
Refused Authorisation Number
Most medical schemes will not cover elective or non-essential medical services. Therefore you may not get medical aid authorisation for hospital admission when it comes to events like cosmetic procedures or fertility treatments. Your only option in these cases is to fund your hospital stay and in-hospital treatment out of your own pocket.
But these days even hospitalisation for investigation or observation may be declined by your medical aid. In the past many patients were admitted to hospital under the pretext of observation, and then underwent expensive diagnostics procedures like a CT scan, MRI, endoscopy, colonoscopy and so on. Medical schemes have there clamped down on this practice.
Even if you are admitted into a hospital and the medical aid authorises the stay, these diagnostic investigations may not be covered unless it is warranted. These days, many schemes will tell members that they have to pay 50% of the cost of having the investigation done. 100% payment by your medical scheme will only occur if abnormalities are detected or the investigation is truly warranted.
Be careful about being admitted into a private hospital if your medical scheme has not authorised it. You may be landed with some big bills that you will have to pay out of your own pocket. Medical gap cover will also not be of any use if your medical aid refuses authorisation. Medical aid gap cover only pays for the difference where your medical scheme falls short. If your medical aid is not going to cover the hospital treatment in the first place, the your gap cover will not pay either.