Discovery Health Medical Aidauthorization - new membership

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Never EVER rely on Discovery to help you preserve your dying dad's health.

Discovery has a very valid process in place where, if you claim for a procedure that requires authorization in the first 12 months of your policy, they put your claim through their "Standards" committee. The committee checks for pre-existing conditions. The idea is to help prevent the abuse of medical aids by individuals who sign up just to take advantage of the medical aid.

** Wednesday, 1 Feb:
My dad is rushed to the ER at Life Carstenhof Clinic with trouble breathing. After 4 hours of care, we leave the ER with a referral to an ENT and a prescription for some medication.

** Friday, 3 Feb:
We see the ENT. Long story short, I'm not happy with the level of care and diagnosis so I go for a second opinion to an ENT in Netcare Rosebank Clinic. He expresses concern that there is stridor and my dad has very obvious trouble breathing. He notes my dad's careful demeanour to not overdo himself and cause any further complications with his breathing.

He examines my dad, very thoroughly, and expresses concern that he may have 4 malignant growths in various parts of his larynx. He clinically diagnoses C32.9 and requests authorization from Discovery to hospitalize my dad on the basis that he needs assistance and monitoring with his breathing and he needs to get scans and a Fine Needle Aspiration done ASAP!

At this point Discovery starts the process of authorization (around 2pm Friday afternoon). The consultant he speaks to lets him know that, because he's indicates it's an emergency (due to my dad's diminished ability to breathe), we will have our auth within 8 hours.

Dr Eisenberg receives the PMA form (an investigatory form sent to confirm some details about whether or not my dad has been treated for this before - indicating a pre-existing condition). He pushes out his patient appointments because he places serious gravity on my dad's ability to continue without breathing assistance.

Upon asking "Okay, so I have a patient who needs to be admitted asap" the consultant advises they can provide a temporary 24 hours which is usually provided to give their Standards Committee time to conclude their investigation and provide complete authorization... Except that the Standards Committee is not available to complete any investigation outside of business hours - even for a life threatening emergency. "But, Sir, I promise, we'll give you the answer within the 8 working hours as promised".

When I enquire "Okay, so after 24 hours when the cancer hasn't magically disappeared and cleared his airway, what do we do then - it'll be Saturday evening at that point". The honest to God response is "I can't answer that, Sir". Fffffffffuuuuuu

So, we'll take what we can get at this point. We admit my dad and he starts a round of antibiotics, adrenalin nebulizers, saline nebulizers, blood thinning apparatus (because cancer patients have a very high chance of lethal blood clotting) and half hourly observations.

Anyway, after the 24 hours, the doctor really wants to keep him but the medical aid simply won't grant authorization. So, he prescribes me some meds and I go on my way. I've never had such a nerve wracking weekend in my life. I checked up on my dad's breathing at least 50 times until Monday morning.

** Monday, 6 Feb:
Monday comes along and I start my nagging (because obviously, Discvovery isn't proactively showing any interest in keeping me up to date). Eventually a woman named Jillian calls me to confirm details (which confuses me because they sound like preliminary questions that should have been asked on Friday). But, we answer the questions and she lets me know she will be calling Dr Eisenberg and asking him for the endoscopy report - again, confusing. They knew there was an endoscopy done on Friday. I wonder why they didn't ask for it then and speed up the process. But such is life.

I find out later that she did get in touch with him and he reiterated EXACTLY what he told the consultant on Friday - the scope report is generally done in theatre. Since there is no authorization, there is no scope report. So, he reiterates that his clinical diagnosis is a C32.9 - laryngeal cancer.

He is then called about 40 minutes later and quizzed by, presumably, a member of the Standards Committee. One of the questions that bothered me was "But surely this couldn't have presented so quickly. Surely, you must think that this existed a while back". I've not got a problem with the investigation as a principle but you've asked the Dr for the PMA form and you're now second guessing it. He's already dedicated about 5 hours of his time completing Discovery related admin in lieu of this process and we're taking more of his time. But, Dr Eisenberg is a consummate professional - he undergoes the interrogation with a smile on his face.

No one calls me for the rest of the day. At 4pm, I call for an update. Apparently, at 15:40, the Standards Committee has now decided to send another PMA form to the casualty doctor that we initially saw on 1 Feb. All they're doing is sending it and they're going to wait and hope they fill it out.

So, obviously, this isn't acceptable to me. Not only will we now miss our 8 hour promise, but we're not putting any urgency on the fact that my dad needs urgent scans and diagnosis and treatment for the cancer that is killing him.

So I call through, and push the issue. It's simply not acceptable and someone needs to start taking ownership of this process and rushing it along. So, long story short, I speak to two people - one of them a supposed clinical manager. She says she'll call Carstenhof and find out the progress of the PMA.

She calls, and they confirm that the person that Discovery sent the email to is on leave and will only be in the next day (Tuesday, 6 February). I'm beyond annoyed and beg for there to be some other way to expedite this. Nope, no alternative but to wait for the person to come back from leave. So, out of interest I enquire "So, this person comes back and the extent of their action is to then send it on to the doctor who treated my dad in casualty. But there is no guarantee he is going to fill it in with any urgency. Let alone when he's going to be available again - he is a casualty doctor after all". The response is simply "we have to wait for the PMA". Me: "Despite the fact that my dad's airway is getting more and more constricted and he is in more and more pain?". Discovery "Yep". Sigh.

** Tuesday, 7 Feb:
I call the hospital myself to basically beg someone to help me and speed this up. I speak to the person to whom these emails are sent. She advises that the doctor isn't in today. Fffffffuuuuuuuu.

I've now basically begged her to please bother the doctor on his day off and relay to him that I'm dealing with a high risk, potentially life and death situation in which every passing hour means an increased risk of an emergency tracheostomy - additional trauma that can be avoided. The most she can do for me is call the doctor and relay the urgency and hopefully the doctor returns the PMA today. But she explicitly tells me that the doctor is under no obligation to send this back within any given time frame.

So I call Discovery and my question is simple: "How long do we wait for this PMA to come back? 1 day? 1 week? 1 month? Until my dad is dead?". I'm not joking, the answer is "We wait for as long as it takes for the doctor to return the PMA.". :-O. #IJustCant

Discovery, you're a disgusting mess when it comes to situations like this.

1. You have made promises that you actively didn't keep. You promised an 8 hour turnaround. A turnaround I mentally and emotionally prepared for. "I can do this for the weekend. I'll just keep checking on my dad. I'll keep making sure he's breathing. I will wait on him hand and foot so he doesn't over exert himself. I can do this". Except Monday came around and you basically slapped me in the face and reminded me to whose mercy I'm at.

2. Your procedure to deal with this is unacceptable. You have no emergency Standards Committee members to deal with these issues where such an emergency is very obvious (and made so by the specialist).

3. Your contingency for the unavailability of the doctor is non-existent. How long do we wait for this doctor? Do we wait until my dad is dead? How exactly do you handle the unavailabililty of this doctor? "Sir, we have to wait for the PMA to be returned". "Okay, can it be returned by another health professional that was there? Maybe the Night Matron or someone else?". "No, it must be completed by the doctor that attended to your dad". Fffffuuuuu

4. Your lack of ownership in this issue is astounding. I've not quite come across such a callous approach to a slowly dying patient with an imminent medical breathing emergency before. Truly, your ability to transcend the general idea of not giving a damn, is truly impressive.

5. You're ignoring the fact that, as we progress without authorization, the chances are increasing that my dad has a lethal blood clot or that he needs an emergency tracheostomy. Apparently, you're perfectly happy running the risk of either of these things happening.

I need to ask: Are you simply waiting for my dad to die so that you needn't cover anything related to his health care? Is it better practice and cheaper to simply ignore his need for urgent treatment? As I said, I completely support the Standards Committee process as a concept. But I cannot support how it's being executed and the way in which I haven't been able to ensure my dad's quality treatment.

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