Treatment declined

René Botha underlines the reasons why medical aids may decline treatments and offers other insurance options to help cover this shortfall.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

Following a cancer diagnosis, you often see several specialists within a short amount of time and then get presented with various treatment options. Often, more than one treatment modality will be required for the best chance of treating the disease, either sequentially or sometimes at the same time. 

The treatments offered often include surgery, radiotherapy and systemic therapy (chemotherapy, targeted therapy, or immunotherapy).  

After all these discussions if, for example, systemic therapy or radiotherapy is recommended, the oncologist’s team applies to your medical aid for authorisation while you prepare for the upcoming treatment, but then…the medical aid replies: treatment declined.

Now what? 

May you appeal this decision? Are all cancer treatments covered by medical aid? Unfortunately, the answer is no. 

It’s important for you to understand your specific medical aid cover so that you know what to reasonably expect your medical aid to pay for. Medical aids have different options, the scheme you select as well as the plan option will determine the funds available under the oncology benefit and the terms and conditions that apply. 

Evidence-based guidelines

Once you have been registered for oncology benefits, there are specific evidence-based guidelines that are followed to fund cancer care. 

Most medical aids base their guidelines for funding criteria on the recommendations of professional bodies, such as the South African Oncology Consortium (SAOC) and Independent Clinical Oncology Network (ICON) as well as the Council for Medical Schemes (CMS).

The guidelines for funding criteria assess which treatments are clinically appropriate and then divide treatments into different levels or tiers. The first level, or tier, of treatment is the basic standard of care and is available to all patients. These treatments are usually covered in full and are often also referred to as prescribed minimum benefits (PMBs). 

In terms of the Medical Schemes Act (131 of 1998), PMBs are a set of specified healthcare benefits that medical schemes should cover by law. This cover includes funding for the diagnostic tests like biopsies and imaging studies, treatment, and ongoing care for the listed conditions. 

Not all cancer treatments fall under the PMB classification. Newer drugs, more advanced techniques, and novel treatments may be classified into higher tiers of treatment. While these treatments may be clinically reasonable, they may not be available to all patients. 

These higher tiers of treatment aren’t included under the PMB classification. This means that the medical aid schemes aren’t obligated by law to approve them. Should these treatments be approved, a sublimit may be applied and the treatment may incur a co-payment which you’ll be liable for. Depending on the terms and conditions of the scheme and the plan, some of these treatments may even be listed as exclusions. To manage costs, certain medical aid plans only approve PMB level treatments. 

Make use of designated service providers

Certain schemes have appointed designated service providers (DSPs) who have contracted to specific rates. These schemes encourage their members to make use of these service providers to lower the costs of treatment. 

According to the CMS, funders are legally not permitted to decline treatment at a non-DSP provider. However, the funder may apply a co-payment to the treatment. This would usually be covered in the terms and conditions that you have signed with your medical aid. You should discuss costs with your oncologist before starting treatment to plan ahead.

Reasons for denied treatment

Once a treatment plan is submitted, the first step in the authorisation process is to evaluate if the treatment is clinically appropriate. The next step is to apply the scheme rules regarding the funding criteria. 

When you receive a message that authorisation for a specific treatment has been declined, the first step is to determine the reason for decline. A treatment plan that doesn’t match the guidelines may be referred to a medical advisor or external review committee to assess if the treatment is clinically appropriate. These committees include oncologists who assess whether the treatment is appropriate and then advise the scheme on this matter. 

Should this review find the treatment to be clinically inappropriate, they may recommend that it be declined. Furthermore, this review may find the treatment to be clinically appropriate, but it may not match the funding criteria and then treatment may still be declined by the scheme itself.

Should the treatment plan be submitted with insufficient clinical details, the case manager may not be able to assess whether the treatment is clinically appropriate or not. In this case, providing the necessary information may be sufficient to support approval of the treatment.

Another reason for declined treatment is that it doesn’t meet the funding criteria. This means that the selected plan option doesn’t provide cover for this level of treatment. Even if the treatment is clinically appropriate, the treatment may still be declined if it falls into a higher tier. In these cases, an appeal may be made to fund the treatment despite these rules. However, this appeal may not be successful. 

In certain cases, higher tier treatment may be approved, but with the condition that only a percentage of the treatment will be funded. The co-payments may be up to 50% of the cost and may add up to large amounts, so it’s important to enquire about costs before treatment starts.  

Additional insurance options

Gap cover

Gap cover is an additional insurance that may be purchased in addition to medical aid. The purpose of this insurance is to provide additional financial cover for medical expenses that aren’t fully covered by your medical aid. 

It’s important to be aware that having gap cover doesn’t mean that all out-of-pocket expenses will automatically be covered. You need to ensure that you understand your gap cover policy well to know what costs are reasonable for the insurer to cover. 

Many gap cover policies allocate a certain amount to oncology costs and may assist to cover some of the additional expenses from co-payments. 

Dread disease cover

Dread disease cover is another additional insurance option. It covers pays out in the event of a dread disease diagnosis, such as cancer.

Different percentages of the insured amount may be paid out depending on the staging of the cancer and the effect on your physical abilities. This insurance is useful in many ways. If you’re unable to work for some or all of the duration of your cancer treatment, this pay-out may assist to cover this loss of income. It may also be used to assist in paying for treatment that isn’t covered by your medical aid. 

When purchasing dread disease cover, read your policy documentation carefully so that you know what you can expect when you claim.

The love-hate of grudge purchases

Medical aid and insurance decisions are often made when you’re well. They are the in case grudge purchase that you don’t really want to pay for when you don’t need it. Policy documents may be vague and may not always list exclusions. The finer details of the oncology benefits can’t always be documented in full as guidelines change as new evidence becomes available. 

Oncology treatments may be very costly and may quickly deplete the allocated benefits available. Understanding which treatments should still be covered in full under these circumstances may make a big financial difference. 

Having open discussions with the oncologist regarding treatment plans and expected costs may help you prepare for any associated costs that may not be covered. It may also help to know about any unexpected co-payments to see if any of the amounts should be reprocessed under PMB cover. Also, be sure to check your claim statements regularly to ensure that claims have been paid under the correct benefit.