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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
 
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