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Question
Posted by: Linette | 2011/10/24

Medical Aid does not want to pay

How much do you know about PMB conditions? Discovery refuses to pay for my Psychiatrist and Psychologist from my hospital benefit even though I was admitted to hospital. Apparently its the plan option I''m on. According to the council for Medical Scemes they must pay for Bipolar from the hospital benefit. This has been going on the the past 2 months now. I''m stuck with 3 weeks worth of bills that came from my out of hospital mental health benefit that was already exhausted. Everyone, please beware of the way Discovery pays claims for psychiatry. I would love to know your opinion. I''m going to take them to the Council for Medical Schemes. Just concerned my Dr used the incorrect codes and his receptionist is not very helpful. Have to wait to seem him in 2 weeks time.

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Our expert says:
Expert ImageCyberShrink

I find it impossible to keep up with changes in practices of the different medical aids, but maybe other readers are familiar with PMB. Generally, Bipolar Disorder i considered a Chronic Condition and should receive the appropriate benefits for that ( actually, so should major Depression, but they don't want to admit that ). If there is an acute problem, the doctor should agree to look into this without making you wait 2 weeks to see him about it - and his receptionist is required to be helpful. She must at least be able to tell you whether he submitted the codes for Bipolar Disorder or something else, and she should brief him on the problem, as he could possibly make representations to Discovery to sort this out

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Our users say:
Posted by: Candy | 2011/10/25

When I was admitted for PND all the accounts from my psychiatrist were paid in full by Discovery. I have no savings account with them only hospital plan (coastal core). I did notice that the specialists charge crazy prices for a few minutes! I assume they do that because they think the medical aid will pay. My experience with Discovery was great - all specialists were paid whilst I was admitted.

Reply to Candy
Posted by: Linette | 2011/10/25

Well what the Council for Medical Schemes told me is that they may not pay a PMB from your day to day benefits if you are hospitalised. And I saw the account today, I was admitted for Bipolar Affective Disorder, Mixed Episode. So it is a PMB. I was admitted in 2007 and all my claims came out of my hospital benefit, so I don''t know what nonsense this is and why they discriminate against psychiatric conditions. Because I had a DVT last year and everything was paid from the hospital benefit. I think they are merely discriminating and they are doing so with next years benefits where I have to share my Psycologists benefits with other allied health professionals. At least, and correct me if I''m wrong - the Dr is paid in full from you saving account. I have an ATB. I''m on the executive plan, the top plan and I have to deal with this. I feel it is unacceptable. At least I know the correct code was used in hospital. It is just to find out if the correct code was used by the Dr. They say they give you 21 days, but then you can''t see your Dr. And I''m upset because my Dr was off for the weekend and a locum walzed in the room telling me what a wonderful day it was and if I had any problems and I got charged for Saturday and Sunday, full rate. My Dr does not charge more than 100% of the Discovery Health rate. His consultations are below R500. So, he''s not expensive. But really, to charge me for the locum that saw me for 2 miinutes. That''s ourageious. I also know Discovery quite well, but they never told me about the payment of in hospital claims from your out of hospital mental health benefit and I was too depressed and out of iit to ask about it in detail. Imagine, on day 3 I saw the claims coming through as not paid and I phoned them and they told me an lovely story about the incorrect place of treatment beiong used. If I was notified about that on day 3 I would have discharged myself.

Reply to Linette
Posted by: Liza | 2011/10/24

What plan are you on?

Discovery have the policy that even though you can be admitted to hospital, the psychiatrist and psychologist accounts are still paid out from you savings account and above threshold benefit(depending on your plan - some don''t have an above threshold benefit).

What you have to understand with Discovery, is that they only pay out of the PMB benefit if you''ve got prior approval for those bills. My psychiatrist always sends a motivation form at the beginning of the year to Discovery to pay for a certain amount of visits each year. These bills then get paid out of the Prescribed Minimum benefit and NOT the regular mental health benefit. This means that even when my medical aid is exhausted, my bills are still paid. And if I''ve used all the visits, the doctor can always send in another motivation for more visits. Without that motivation, the visits are paid from regular benefits. You can lay a complaint with the Council for medical schemes, but it won''t help unless a motivation was sent in for the consultations and approved.

It also depends on the psychiatrist. Some of them charge more than medical aid rates. I know that the Classic plans pay up to 200% of the medical aid rates, but that the Essential plans only pay 100% of medical aid rates.

If you''ve got anymore questions - feel free to ask. I''ve been on Discovery for years and know their benefits inside out.

Hope this helps
Liza

Reply to Liza
Posted by: cybershrink | 2011/10/24

I find it impossible to keep up with changes in practices of the different medical aids, but maybe other readers are familiar with PMB. Generally, Bipolar Disorder i considered a Chronic Condition and should receive the appropriate benefits for that ( actually, so should major Depression, but they don't want to admit that ). If there is an acute problem, the doctor should agree to look into this without making you wait 2 weeks to see him about it - and his receptionist is required to be helpful. She must at least be able to tell you whether he submitted the codes for Bipolar Disorder or something else, and she should brief him on the problem, as he could possibly make representations to Discovery to sort this out

Reply to cybershrink

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