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Current State of Affairs: Medical Aid Schemes and Psychology Professionals
The Psychology Scope of Practice (click to view) has been the subject of much debate and contention amongst psychology professionals. Recently certain medical aid schemes have used the SoP document and implemented payment restrictions for specific categories of psychology professionals and the types of clients they see. Most certainly there is a pressing need to resolve this issue for private practitioners whose livelihoods are directly affected, but there is a greater concern here in that access to mental healthcare services is now under significant risk.
Here you will find updated information on the situation as well as news and media reports relating to the issue.
Letters from Medical Aid Schemes that are at the root of the concerns
Timeline Responding to Medical Aid Issues
24 June 2016 - Rejection of claims by medical schemes
18 May 2016 - HPCSA & RELPAG MEETING
17 Feb 2016 - Update on Medical Aid Correspondence - Mailer
Dear PsySSA Member
Last year also concluded with PsySSA reporting on activities undertaken with Discovery, Polmed and Profmed. This has continued in 2016 with the following having been achieved:
The representatives on the Professional Board for Psychology at the HPCSA have agreed to a meeting with PsySSA. PsySSA is currently awaiting a date and time for the meeting. Once this is confirmed, PsySSA will approach all PsySSA divisions who have voiced an interest in meeting with the Board to request one representative to attend the meeting
PsySSA met with Discovery late last year and have another meeting scheduled for the first week of March. The December meeting was productive with Discovery being willing to listen and work towards resolutions with regards to its communication on in-hospital claims for clinical psychologists.
Polmed has advised that as per their legal advisers they cannot meet with PsySSA. PsySSA is in the process of drafting a second letter to Polmed in response to this pointing out why their decision disadvantages their members. PsySSA will communicate with other organisations who have objected strongly to Polmed’s communication to become co-signatories on the letter.
PsySSA is still waiting for a response from Profmed but the PsySSA office has been following up on this weekly since December.
PsySSA is engaging GEMS regarding Registered Counsellors being paid from a block benefit for Allied Health Professionals.
PsySSA conducted a survey late last year with members to determine whether there were patterns of claims being rejected by other medical aids. 125 members responded. Other than Discovery, Polmed and CAMMAF, there were no other consistent responses. There were other findings in the survey re: billing, coding and claims as well as the amount of cover in medical aids for mental health in relation to other cover. A summary of the survey was emailed to all members earlier this week.
We wish to assure members that PsySSA is committed to engaging and negotiating with health care funders to resolve this matter. As indicated in the previous communiqué, PsySSA will update divisions regularly on developments in this regard and will call on Divisional Executive members to assist in responding to the medical aids.
Prof Anthony Pillay
17 Feb 2016 - PsySSA Survey and Results re Medical Aids
PsySSA Medical Aid Survey
Last December the Psychological Society of South Africa (PsySSA) conducted a survey amongst members to determine if any were experiencing difficulties with medical aid claims. A total of 125 members responded to the survey. Most respondents were from Gauteng (50%) followed by the Western Cape (17.7%) and KZN (14.5%). The majority of the respondents were registered as Educational Psychologists (42.4%) followed by Clinical Psychologists (30.4%) and Counselling Psychologists (21.6%). Respondents ranged in experience from one to 30+ years in practice.
A number of medical aids were listed as not paying certain claims, but Polmed (25.6%) was reported by the majority of the respondents as not paying Educational and Counselling Psychologists in certain instances. Discovery and CAMAF (14.2%) were the other two medical aids reported as being problematic with settling claims.
An examination of qualitative responses revealed that with Polmed it was clearly a case of the communication from October 2015 being actioned. In October 2015, Polmed issued a communication to Educational and Counselling psychologists indicating that they would no longer be reimbursed by the medical aid.
Some of the qualitative responses were linked to Discovery’s communication re: in-hospital treatment by psychologists. The CAMAF-related responses to the survey were unclear and PsySSA is attempting to follow up on why claims are being rejected by CAMAF. All other medical aids were reported by between one and 10 respondents (less than 8% of the sample) with very little consistency across the various schemes.
Three issues were clearly evident from the responses:
- Psychologists experience difficulty in using the codes required by medical aid billing systems. This is linked to issues on the side of medical aids (eg. codes that were previously paid for one client are not being paid for another from the same medical aid) but also to the individual psychologist who was not familiar enough with codes and billing and made mistakes in billing resulting in rejection of claims.
- The code system for psychological consultations is very limiting and might need to be re-visited.
- Medical aids provide very little annual cover for psychological consultations in comparison to other medical cover.
PsySSA is using the survey results to engage further with medical aids. PsySSA met with Discovery in December 2015 and will again meet with them in March 2016. Meetings with the other schemes are being arranged and members will be updated. Both the rejection of claims as well as the inconsistencies in interpreting codes will be addressed in these meetings. The annual cover provided for psychological care as well as the claims for assessment and therapy will also be discussed.
PsySSA is also engaging with the Professional Board for Psychology at the HPCSA on the issue of medical aids.
PsySSA is currently searching for a competitive package for PsySSA members that will provide an efficient and effective electronic practice management solution.
The Practice Management workshop at the PsySSA Congress will focus on discussing issues of billing, claiming and codes to assist psychologists in making sense of the systems currently being used.
PsySSA would like to take this opportunity to thank members who have provided feedback on the survey.
08 Dec 2015 - HPCSA letter - Medical Aid Payments
04 Dec 2015 - Counselling Profmed letter
03 Dec 2015 - PsySSA invites participation in survey
It has been brought to PsySSA’s attention that certain medical aids were introducing rules that undermined the role and capacity of psychologists. Discovery Health recently indicated that their scheme would not pay out to clinical psychologists who treat patients in-hospital unless the patient had been referred by a psychiatrist. More recently Polmed and Profmed indicated that they would not be covering claims for services rendered by educational and industrial psychologists. The Polmed and Profmed arguments for this decision were based on an outdated version of the Scope of Practice. PsySSA regards these actions by the medical aids as uninformed and undermining of the profession. In this regard PsySSA has written to all three medical aids (insert links to letters). Polmed and Discovery have responded to PsySSA and meetings to discuss have been arranged. PsySSA members will be informed of the outcomes of these discussions.
PsySSA has been notified by some members that claims at other medical aids were also not being processed. However other than the three medical aids mentioned herein, PsySSA has not seen any official communication from other medical aids with regards to psychologists and claims. In order to get a better sense of the current landscape of private practice and medical aid claims, PsySSA also recently sent out a link to a short survey requesting information on any difficulties experienced with medical aid claims in the PAST 6 MONTHS. If you have not responded yet, please click here to complete the survey.
18 Nov 2015 - Medical Aid letter - Polmed
18 Nov 2015 - Medical Aid letter - Profmed
Why is the decision taken by medical aid schemes to refuse payment of certain category of psychology professionals a significant problem?
Recently the NATIONAL MENTAL HEALTH POLICY FRAMEWORK AND STRATEGIC PLAN 2013-2020 was published. The need for mental healthcare is clearly identified in this national framework. It therefore comes as a surprise that medical aid schemes are attempting to further limit access to mental healthcare services through their interpretation of the Scope of Practice.
For context please consider the summation below (NATIONAL MENTAL HEALTH POLICY FRAMEWORK AND STRATEGIC PLAN 2013-2020, p. 11):
“Neuropsychiatric disorders are ranked 3rd in their contribution to the overall burden of disease in South Africa, after HIV and AIDS and other infectious diseases. The first nationally representative psychiatric epidemiological study, the South African Stress and Health (SASH) survey found that 16.5% of adults have experienced a mood, anxiety or substance use disorder) in the previous 12 months”
Psychologists have been identified as a part of the solution in providing access to care, treatment, and intervention to those in need of mental healthcare.
When comparing the Private vs Public Sector provision of mental healthcare services the disparity is clear. Government is attempting to increase access to mental healthcare by creating employment opportunities for all categories and levels of psychology service providers. Yet the Private sector is doing the exact opposite.
Let’s look at the numbers. If one now considers the general population stats mentioned below and then apply the reasoning that 17% (rounded up) of these individuals have experienced a mood, anxiety or substance use disorder the need for psychology service providers is clear (as per the summation above). Unfortunately, it already seems as if there are not enough service providers to meet the mental healthcare needs of South Africans so the decision by certain medical aid schemes to further deny access to registered psychology professional is concerning.
PsySSA Congress 2016
Call for Nominations for PsySSA Executive 2017/2018
More About the Congress Theme
Internationally, 2015 has been a year that has interrogated the role of Psychology and Psychology professionals in society. In particular, the involvement of Psychologists’ in human rights abuses provided an opportunity for many to examine Psychology’s responsibility to society. The reactions (or lack thereof) from organisations and individuals also brought the responsiveness of Psychology to the fore. In the South African context, the increase in service delivery protests, anti-corruption marches, high levels of crime, violence and trauma and the perpetuation of gross inequality also demand some responsiveness from Psychology. As a profession that focuses on individual and societal wellbeing, Psychology professionals have a responsibility read more…
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