Who is responsible for obtaining authorisation?

A question that arises from time to time, is “Who is responsible for obtaining authorisation for my treatment?” Many doctors’ practises provide this service on behalf of their patients. However, the HPCSA is very clear on its stance regarding this:

“2.5.2 Pre-authorisation is the patient’s responsibility

The majority of medical schemes require their members to obtain authorisation before receiving services from healthcare practitioners registered under the Health Professions Act.

While acting in the best interest of their patients, some practitioners offer to assist them with obtaining authorisation from their medical schemes for services to be rendered. Unfortunately, this has left members of

medical schemes with the impression that it is the healthcare practitioner’s responsibility to obtain permission from their medical schemes.

The HPCSA has received numerous complaints against practitioners emanating from this misconception and as a result, some patients have experienced financial losses.

Patients who are members of the medical schemes are advised as follows:

Healthcare practitioners have no relationship with the patient’s medical scheme except that which is provided for in managed healthcare arrangements;

 The responsibility for obtaining authorisation for treatment or services to be rendered lies with the member of the medical scheme after receiving prescribed information from the patient’s treating practitioner;

Patients are also reminded that it is their responsibility to ensure that the authorisation obtained from their medical scheme covers the scope of their treatment and services to be rendered;

Patients should communicate with the practitioner concerned, especially when there are any limitations to the authorisation given.”

In emergency situations, the admitting facility ie hospital often performs this service.

However, it should be noted that if the authorisation is declined, the member remains liable for payment.

It is therefore this practice’s stance that members obtain pre-authorisation for all procedures themselves. Where necessary, the practice will assist with eg letters of motivation. This is to protect the interests of both the member, as well as the doctor.