Image
Icon

Directory

IconAccounting & Tax
IconAccreditation Bodies
IconActuaries
IconAssociations and Institutes
IconAuditors
IconBBBEE Consulting and Verification Agencies
IconBusiness Process Management
IconBusiness Process Outsourcing
IconCompany Secretarial Services
IconCompare Medical Scheme Benefits
IconCompliance
IconConsumer Protection
IconCorporate Governance
IconCredit Bureaus
IconDebit Order Collection Facilities
IconEducation and Training
IconEmergency Medical Rescue
IconExpatriate Cover
IconFAIS
IconHealthcare Consultants
IconHuman Resources
IconInformation Technology and Software Partners
IconLegal
IconManaged Healthcare Service Providers
IconMedical Aid Administrators
IconMedical Aid Schemes
IconMedical Schemes Trustees Liability Insurance
IconMedical Service Providers
IconOmbud
IconPolicy Administration
IconPublications
IconRegulatory Authorities
IconSurveys & Research
IconTraining Courses & Workshops
IconWellness Programs
Image
  Subscribe To »

The importance of referral letters when operating in a co-ordinated care environment

Published

2017

Fri

21

Apr

By Cape Medical Plan

Co-ordinated care is not a new concept to the healthcare and medical scheme world, but it is one that hasn’t been utilised in South Africa for a long time. Co-ordinated care involves putting all healthcare providers on the same page when it comes to treating the patient, which will ultimately result in us providing better care, at a better price, with better results.

Instrumental to co-ordinated care is using your GP or family physician as the first port of call. Many difficult illnesses – some Prescribed Minimum Benefit (PMB) conditions for example – can be handled at a GP level and don’t require you to see a specialist or pay specialist rates.

Recommending you see a GP first is not a way of ensuring the GP is making all the money – it is in fact helping a scheme, and by extension you the member, to save money because specialist rates can be very costly, are unregulated and therefore often inflated when the doctor knows they are dealing with a PMB condition.

If your GP or family physician believes they have exhausted all conservative and reasonable treatment, the next step should be for them to send you to a specialist. You might then be required to provide your scheme with a clinically appropriate medical report/referral letter from your referring GP or family physician before seeing the specialist should you need any form of hospitalisation or procedure.

This report or referral should include information such as why you need to see a specialist, what conservative treatment has been followed, a description of your recent medical history and any supporting information.

Examples of acceptable referral letters would be ones that contain information along the following lines:

“…patient with severe osteoarthritis of both hips. They take daily painkillers and still walk with pain. Please assess him for further treatment. His x-rays are included”

“…this 60 year old patient is due for a follow-up colonoscopy following a previous history of colonic polyps.”

One-liners often received, which are unacceptable would be:

“Bad vision. For further handling.”

“Please consult for possible surgery – has a hernia.”

When s scheme doesn’t receive proper referral letters, it has to then request further information from your doctor in order to ensure that the scheme is making the best possible funding decision on behalf of the member and the scheme. This obviously takes time – and can be frustrating for both the member and the scheme.

This protocol may seem tedious and time consuming to some, but co-ordinated care is a strategy that when implemented correctly is there to benefit you. It’s a safeguard against possibly undergoing a treatment or procedure you might in different circumstances not necessarily need, and incurring extra costs to the -scheme or yourself.

 
Source: Cape Medical Plan
 
« Back to previous page Print this page » |
 

Breaking News »

Debarment and Treating Customers Fairly

The necessity for a process to ensure that those who fall foul of the fit and proper requirements are not allowed to practice was never in question. Unfortunately, the application and execution of the debarment ...
Read More »

  

New findings contradict NHI White Paper

Recent research conducted by Econex, a leading firm in competition economics, paints a different picture to that portrayed in the NHI White Paper on healthcare in South Africa. In a research note published this ...
Read More »

  

Why I love FAIS

By Tamara Jacobsen: Director- Applied Learning Academy The provisions of the Financial Advisory and Intermediary Services Act, 2002 (FAIS) have been in place for more than a decade now. Financial advisors, ...
Read More »

  

The reality of medical aid late-joiner penalties

The law clearly states that late-joiners to medical schemes may be penalised, depending on proof of previous South African medical aid membership. Anyone who is 35 years or older will be eligible to pay a late-joiner ...
Read More »

 

More News »

Image

Investment »

Image

Life »

Image

Retirement »

Image

Short-term »

Advertise Here
Image
Image
Image
Image
Advertise Here

From The Glossary »

Icon

Quintile:

A value that divides a sample of data into five groups containing (as far as possible) equal numbers of observations.
More Definitions »

 
 
By using this website you agree to the Terms of Use.
Copyright © Stoker Risk & ICT (Pty) Ltd 2004 - 2017.
All Rights Reserved.
Icon

Advertise

  Icon

eZine

  Icon

Contact IG

Icon

Media Pack

  Icon

RSS Feeds