Additional benefit application through Discovery Health
- History of additional benefits
- Establishment of a panel
In 2012 the Discovery Psychology panel was established in response to the profession’s objection to new limits on psychotherapy benefits established by Discovery Health Medical Scheme. Following a lengthy negotiation process between Discovery and key psychology organisations in the country, Discovery agreed to establish a panel of psychologists which would oversee cases which evinced clinical need, and therefore required the awarding of additional psychology benefits. This lead to the creation of the Application for Additional Allied, Therapeutic and Psychology benefits.
These benefits are available to members who are on Classic Priority, Comprehensive and Executive plans.
The 6-member panel is composed of psychologists who were nominated by various psychology bodies and then voted in through a comprehensive election process.
- Panel task
The panel task is to review applications made by members through their practitioners for additional psychotherapy benefits. It is the panel’s task to establish the existence of clinical need – ie: the member shows significant occupational/scholastic and/or social distress or dysfunction and a lowered global assessment of functioning, impacting on their capacity to function.
- Panel composition
The panel is comprised of the following psychologists:
Counselling Psychologists: Adene Davis (SAPC rep); Elaine Bing
Educational Psychologists: Vanessa Gaydon (SPC rep); Martin Strous
Clinical Psychologists: Yvette Esprey (SAPC rep); Basil Pillay
- SAPC representation
The SAPC is represented by 3 psychologists, one of each in the scope of practice category. This is significant representation and has shifted the direction and scope of the panel through ongoing advocacy around psychoanalytic practice.
- The panel and psychoanalytic work
- Protocols
Over the last few years Discovery has sought to establish protocols which would automate the process of benefit allocation based on evidence-based practice for different diagnostic categories. Broad protocols have been established, with psychodynamic/analytic interventions being allowed more sessions that CBT interventions. As such, practitioners are encouraged to identify their paradigm in the application form.
- Panel review discrepancies
As panel members are from different paradigms, there has emerged a pattern of discrepancies within the panel review process, depending on who the reviewer is of a particular case. As a result, Discovery agreed to implement a review process which comes into effect if a member or practitioner is unhappy with the outcome of an initial review. This process is outlined below.
- Benefits available
- PMB vs Additional benefits
Attached to this document is a full list of PMB conditions which are automatically covered by medical schemes as a legal requirement. If a practitioner is making an application for one of these diagnoses, the correct form is a PMB out-of-hospital form.
If the diagnosis is not a PMB condition, the correct form is an Additional Benefits form, NOT an Extender Benefit form. At times call centre operators send the incorrect form; it is the practitioner’s responsibility to ensure they have the correct one.
- Form completion
- ICD-10 codes
By law an ICD-10 code must be given – there are a range of ICD-10 codes which can be used for multiple diagnoses.
- Multi-axial diagnosis – comorbidity
It is important to note that if an application is made without comorbidity, for example if a straight diagnosis of Generalised Anxiety Disorder is made, this application will be granted benefits based on an established protocol and will not be seen by a panelist. Cases are sent for panel review when comorbidity exists.
- Symptom presentation
In order to establish clinical need, practitioners need to communicate current symptom presentation as it impacts on social and/or occupational/scholastic functioning. This helps the reviewer to have a clearer picture of the case and to award benefits accordingly.
- Method of treatment
Practitioners are encouraged to be transparent about their particular paradigm as they should not be discriminated against for working in a psychodynamic/analytic way.
- History of member and treatment
Once again, brevity is encouraged with key aspects of treatment and history being noted in order to give a picture of current need.
- Confidentiality issues
The issue of confidentiality is a difficult and ongoing one, and one to be discussed at length with members. Whilst Discovery have given the assurance that information divulged in the application process will not be used more broadly within Discovery, there can never be a guarantee of absolute confidentiality.
In order to maximize confidentiality, when applications are sent to reviewers details of BOTH the member and the practitioner are concealed. In this way panelists are not able to identify either. Practitoners are encouraged to protect member’s identity as far as is possible.
- Review process
It is vital to note that if a practitioner is unhappy with a review decision, they are able to question it.
In order to do so, the initial application with no addition of new information should be sent again to Discovery, requesting a re-review. What happens then is that Discovery will contact the practitioner and the member asking whether new information is being added to the application. If there is new information, the application will be sent again to the same initial reviewer. However if no new information is added, the application will be sent to a new reviewer.
Members of the SAPC are invited to contact their panel representatives if they have any queries, or if they encounter any difficulties in the process of application.