14 May 2020
People covered by medical schemes no longer have to pay for negative Covid-19 tests done in the private sector, as long as they are referred by a doctor or nurse.
A Covid-19 test administered by Pathcare, Dischem, Lancet Laboratories, or Ampath costs about R850 and it takes two to three days to get a result. A test through the state-owned National Health Laboratory Service is free to the patient, but the backlog for results is about a week.
On 15 April, the Council for Medical Schemes ordered that Covid-19 testing should be seen as a Prescribed Minimum Benefit (PMB), which would mean it would be covered by medical schemes. But the definition was ambiguously worded:
“All cases of Covid-19 are regarded as Prescribed Minimum Benefits (PMB) condition, and should be funded in full in line with the current National Institute for Communicable Diseases (NICD) guidelines as published. In line with clinical protocols and benefit guidelines, this should cover:
Medical schemes interpreted this to mean that coverage applied only to confirmed cases. As a result, all medical schemes decided that positive Covid-19 tests would be paid for by the scheme but negative tests would be paid for from a member’s day-to-day account, or, if that account was exhausted, out of the member’s pocket.
But on 8 May, following an amendment to the regulations under the Medical Schemes Act, the Council published an update to the PMB definitions. Now, if the patient has been screened by a health care worker, and is referred for testing by that healthcare worker, the test will “be funded from the risk benefit irrespective of the … result”.
However, medical scheme members are not yet out of the woods. Some patients coming to hospital for elective surgery, who have been told to get a Covid-19 test before admission, will have to pay for their own testing. Medical schemes will not pay for these tests if the patient has not been screened and referred by a health care worker, and patients at some hospitals are expected to pay for the tests themselves.
On 7 May, Netcare CEO Dr Richard Friedman issued a communique to staff in which he said patients must pay for their own tests before admission for surgery.
“The spread of Covid-19 in our facilities by asymptomatic staff and patients remains the most significant risk we face and the most difficult to mitigate. To this end we are insisting that all patients are tested for Covid-19 prior to admission… The cost of the Covid-19 test is the responsibility of the patient or visitor.”
“Patients attending oncology outpatient treatment (chemotherapy or radiation) at a Netcare hospital or treatment at a dialysis unit will be required to provide proof or their Covid-19 status on a weekly basis with effect from 15 May.”
If a patient is tested and found positive, said Friedman, the patient “will be required to self-isolate until such a time that a negative test result is obtained, provided that the delay does not negatively impact the clinical outcome. If admission is absolutely required, the patient will be admitted into the red zone at the appropriate level of care.”
The South African Renal Society (SARS) warned that many dialysis patients would not be able to afford the test. “Dialysis patients are a vulnerable group consisting mainly of unemployed dependents and low-income earners. The majority will not be able to afford weekly Covid-19 PCR tests,” said the Society in a letter to Netcare on 8 May. “Moreover, it is practically impossible … for them to obtain weekly tests since the laboratories are requesting upfront payment or pre-authorisation … Preventing patients from accessing dialysis treatment based on their inability to afford testing would be discriminatory and unjustifiable on medical and ethical grounds. Nephrologists have expressed universal condemnation of this approach. In comparison, other dialysis providers have not introduced such restrictions.”
Momentum medical scheme executive Damian McHugh said that Momentum disagreed with Netcare’s decision to place the costs of mandatory testing onto the patient, saying that Momentum felt that Netcare ought to shoulder at least some of that cost burden. McHugh said that schemes and hospitals should distinguish between people who go for testing voluntarily without a basis for believing that they have Covid-19, and those who are compelled to undergo testing.
Other medical schemes said the question was still being discussed. Lee Callakoppen, Principal Officer of Bonitas, told GroundUp that negotiations with the hospital groups were continuing. Dr Ryan Noach, CEO of Discovery Health, said: “We are currently in active discussions with the hospitals and healthcare professionals, as well as appropriate specialist advisors, to determine appropriate pre-admission policies.”
Fedhealth said the scheme would not pay for negative tests unless “clinical reasoning” deems it appropriate that patients are tested, in which case the tests would be “funded according to scheme rules and benefit structures.”
In the case of dialysis or oncology, Fedhealth would pay. “Where a patient is diagnosed with a confirmed PMB oncology diagnosis, and they require testing as part of treatment progression … these will be covered. This is because the patient has been confirmed to actually have the diagnosis.”
Dr Charl van Loggerenberg, GM of Emergency Medicine at Life Healthcare, said all patients would be screened before entering the hospital. “ In the majority of cases, the admitting doctor will request patients to be tested for Covid-19 prior to their admission – even if they are not displaying any symptoms.” Patients at mental health, rehabilitation, oncology, or dialysis facilities would now require testing. “Testing will be funded where indicated by the patient’s medical scheme according to scheme rules,” he said.
Dr Stefan Smuts, Chief Clinical Officer of Mediclinic Southern Africa, said all patients coming in for elective procedures had to show a negative Covid-19 test. Emergency admissions would be tested on arrival, while for repeat patients, such as those in need of dialysis, “baseline testing will be performed with daily symptom checks and routine screening prior to a patient re-entering the facility.”
GroundUp asked Netcare for further comment but after two days had not had a reply. This article will be updated when comment is received.