Problems with Medical Aid Funds

Every day I claim many prescriptions from medical aids in Roscher pharmacy, and encountered lots of problems from the customer point of view. It seems that there is many misunderstandings regarding claims from medical aids.

There are hundreds of different Medical aids and every Medical Aid have its own rules and exclusions, it is impossible to know everything about every Medical aid ,but as we are in the electronic age it is really easy to check with Medical aids.

How a pharmacy claims from Medical Aid funds

Roscher pharmacy is connected to the internet.

As Medical Aid prescriptions is captured while the customer waits , the pharmacy computer connects with the medical aids computer, every detail is checked and verified by the Medical Aid .

After verification the Medical Aid give a transaction code witch means the prescription is received , all patient details are checked, and the prescription is priced.

1. Patient details
   • What details do the Medical Aids need?
     1. Surname
     2. First name
     3. Gender
     4. Date of birth
     5. Patient Code
     6. Member number
   • The patient code is very important , without the patient code the medical aid does not accept the claim from the pharmacy.

1. Pharmacy Prices

• Pharmacy prices differs from Pharmacy to Pharmacy WHY?
• The cost prices of all ethical medicine is regulated by the Department of Health(DOH).
• Only once a year are cost prices of ethical medicine adjusted upwards by the manufactures, it seems that this happens in March .
• Every Pharmacist is an individual,
• That is why pharmacies are all different and as each pharmacy is run as a business with different expenses , the mark-up prices of each pharmacy differs.

2. Mark-up prices on ethical medicine

• Every Pharmacy use different mark-up prices on ethical medicine.
• Ethical medicine is medical products that is only available on prescriptions from Medical Doctors.(scheduled products)
• Every pharmacy is allowed to decide on what mark-up to use, but there is guidelines recommended by USAP (united association of pharmacies).
• Roscher pharmacy followed the recommendation of USAP.
• The price structure is cost price + mark-up percentage.

3. Co-payments for Medical Aids

• Why is there co-payments on prescription claimed from Medical Aids?
• Medical aids formula for payment is they adopted the 26%/R26 price structure.

The formula typically works like this :

• Medical aids pay cost prices + 26% up to R100-00
• exp: R10-00 + R2-60 = R12.60
• R50-00 + R13.50 = R63.50
• R100-00+R26-00= R126.00
• then problems R200-00+R26-00= R226.00
• R300-00+ R26-00=R326.00
• R400-00+R26-00=R426.00
• R1000-00+R26-00=R1026.00
• Now medical aids pay R126-00 (R100-00+R26-00) * (1)
• pharmacy charge R100-00 + 36% = R136-00 (2)
• price difference (2) R136-00 - (1) R126-00 = R10.00
• co payment by customer to pharmacy = R10.00 that is the amount not covered by medical aids

4. Type of medicine

Acute medicine:

Q: What is acute medicine?

This is all products use to cure minor ailments, like colds and flu, infections etc only ailments that last a few days and are then cured.

Chronic medicine:

• What is chronic medicine?
• This is products use for major ailments , like Diabetes, High blood pressure, High cholesterol etc This is medicine you have to to take regularly (daily) to have quality of life.

1. How to claim chronic medicine

• To claim your medicine from the CHRONIC OPTION from your medical aid , you have to apply for authorization.
• The way to do this is you must get a prescription from your GP.
• The prescription must be repeatable for 6 months
• The prescription must have the ICD10 Codes (ask your GP) this is a must
• Go to your pharmacy and ask them to fax all the detail to your medical aid, then prepare to wait for at least 7 days