What is a Hospital Authorisation?
An authorisation is an instruction issued by your health insurance or medical aid scheme that confirms that they will cover your medical expenses at a private hospital.
There are differences between how a health insurer and a medical aid work though.
Medical Aid Authorisation
Hospitals contract with the medical aid schemes to determine the rates and tariffs that will apply when you are admitted for treatment. For this reason, the hospital admission desk needs to know who the medical aid scheme is so that they can contact them directly and negotiate your stay on your behalf.
Health Insurance Guarantee of Payment
With a health insurance it is slightly different. The insurer issues the authorisation in the form of a Guarantee of Payment. This confirms to the hospital how much money is available to you, the member, for the claim.
My Hospital doesn't Recognise Episodic or EssentialMED
They don't need to. Episodic health insurance (which is administered by EssentialMED) isn't contracted to the hospitals like a medical aid. The hospital will receive a Guarantee of Payment which acts as a promise to the hospital that a certain amount of money is available. That promise is backed by the insurer.
With Episodic / EssentialMED, authorisations are handled through Africa Assist. The hospitals will recognise Africa Assist as they handle authorisations for many major medical aids and health insurers alike.
Why is there no Hospital Network?
The hospital is not contracted to the insurance so they don't need to recognise the scheme, they just need to accept that a certain amount of payment is guaranteed.
Because of this, health insurance plans, like Episodic, can work with any private hospital. There is no need for a network.
Medical Aids typically have a network because they need to contract tariffs with the hospitals and these can be different in different parts of the country.
Tips for Successful Hospital Authorisations
- Plan ahead! You need to get your authorisations approved ahead of time, usually 24-48 hours in advance. This will ensure there is enough time to work out all the paperwork.
- Know your benefit limits. The insurer can only guarantee payment for benefits that you are covered for under your policy.
- Check your waiting periods. Make sure that you are out of your waiting periods for hospital benefit that you are claiming under.
What if the Hospital wants to be Paid Upfront?
This is an unusual request but we have seen it in the past where a specific hospital wanted a deposit before treating a member.
In these extreme cases, it has been known that the insurer has made an upfront payment as part of the Guarantee of Payment and settled as part of the claim.
A hospital authorisation simply lets the hospital know how much money is available to the member for the hospital stay. Whether this is issued by a medical aid or a health insurance, the idea is still the same.
The only thing that matters here is that health insurance works differently in that the insurer guarantees an amount of money for payment according to the benefit limits of your policy.
We have heard from prospective clients before that their local hospital has never heard of Episodic. Our answer to them is that the hospital doesn't need to need to recognise our health insurance product as a medical aid scheme because it is not one. They just need to process the authorisation through Africa Assist and accept the Guarantee of Payment that will be issued by the insurer. It is that simple.
Looking for an Affordable Hospital Plan?
Episodic offers a uniquely flexible health insurance plan that includes hospital cover as well as everyday primary care benefits like doctors, dentists and medication.
You get to choose the benefits you need at the level of cover you want and save on your premiums.
Speak to our consultants and get a quote today.