Do Medical Aids Cover Scopes and Scans?

March 30, 2018

Scopes and scans can be extremely expensive procedures and it is important for medical aid members to understand any payment limitations.

Scopes and scane include well known diagnostic procedures such as:

  • A CT (computed tomography) scan
  • MRI (magnetic resonance imaging)
  • Colonoscopies and endoscopies

 

Outpatient vs In-Hospital

Scopes and scans are generally considered to be outpatient procedures, which should be paid from day-to-day benefits. Scopes and ScansThis presents problems for members because:

  • These benefits have severe limits and often don’t cover the full cost of the procedure.
  • Patients on hospital plans have to pay from their own pocket, which can be very costly.

 

As a result, many patients try to go to hospital for the procedures. In that way they get cover under their hospital benefits. Doctors often attempt to help patients by admitting them, but medical aids are trying to stamp out that practice. Many medical aids say hospital benefits may not cover outpatient procedures. That is, unless the patient is already in hospital for valid reasons.

Without medical aid assistance, these procedures are unaffordable for most people – an MRI, for example, costs about R6000. As for a procedure for which hospitalisation is not necessary, one of the following will pay for it:

  • day-to-day benefits
  • a savings account if your plan has one
  • the investigation benefit of your plan (which covers all procedures such as scans, scopes and blood tests) if your plan has one

 

Doctors still try to motivate for hospitalisation for their patients, but new restrictions are making this more challenging. Some low-cost hospital plans have even specifically excluded these procedures, making it very difficult for patients to get the diagnosis and treatment they require.

Medical Aid Authorisation for Scopes and Scans

All medical aids now require members to get authorisation prior to undergoing any procedure, including scans and scopes. The medical aid might not agree to cover the cost. The patient can still undergo the procedure but the member will have to pay the doctor or hospital directly for it.

Many medical aid members are uninformed about authorisation processes. That is especially because they are a relatively new practice. Members are responsible for getting the correct authorisation codes, not doctors or hospitals (although they will often assist patients). Without the correct authorisation for a scan or scope, the doctor or hospital can refuse to do the procedure or may require upfront payment or a deposit.

However, in the event of an emergency, authorisation is not required prior to treatment and medical aids may pay for the procedures performed.

 

 

All info was correct at time of publishing