BONITAS DECLINING URGENT MANAGEMENT FOR PMB DISEASE

Letter sent to Council For Medical Schemes: My name is J and I am a medical doctor and a member of Bonitas medical aid for most of my life. I am sending this email as a last resort after having spent the entire day trying to get pre-authorisation from Bonitas for a newly diagnosed PMB condition for URGENT initiation of medical management.

On the 30 November 2017 I was admitted to hospital with an acute inability to speak, chew and swallow properly which was worsened by usage of the muscles. I was seen by neurologist Dr ZS who clinically and based on the history was almost certain I had Myasthaenia Gravis. I had numerous blood tests including an acetylcholine receptor antibody test. The next day I had a CT Chest, Brain and nerve conduction studies and repetitive nerve conduction tests. Dr ZS then started me on Mestinon 60mg tds and monitored for 24 hours, because I was responding he said I could go home while we waited for the acetylcholine receptor antibody test results (which can take up to a week to get). These test results were required to have some evidence of confirming the diagnosis and would be required by medical aids for approval of the urgent treatment he felt I required (Intravenous Immunoglobulin: Polygam). We received the acetylcholine receptor antibody test results today which were >8 (raised and indicative of Myasthenia Gravis. See report) and Dr ZS wanted to admit me ASAP for the Intravenous Immunoglobulin. Dr ZS immediately did a motivation letter requesting the urgent need for Polygam (Intravenous Immunoglobulin) and also attached the acetylcholine receptor results to this (see 1. Dr Khan). This was emailed to Bonitas twice for pre-authorisation. I called an hour later to enquire if Bonitas had processed this, and it took 3 calls to 3 different people and I was still not given an answer. Bonitas said they were having technical problems and had absolutely no measures in place to help their members who required urgent assistance. Eventually after many calls and being highly frustrated I contacted an agent on the Bonitas app. I had explained that this was NOT a pre-authorisation for chronic medication, but that on Bonitas’ Brochure (page 53, see excerpt attached 3.) it clearly states that Immunoglobulins (oral and parenteral) are exclusions unless pre-authorised. On the CMS Brochure regarding Myasthenia Gravis (see attached 4.) and the PMB list of all conditions (see excerpt 6.) It states “Initial diagnosis; initiation of medical management; therapy for acute complications and exacerbations”. Intravenous Immunoglobulin (Polygam) falls under the initial management as per the CMS brochure. I was thereafter told by the Bonitas agent that the authorisation department told her I needed to submit a script to the CHRONIC department for the Polygam. I explained to numerous agents that this was NOT a chronic medication requiring authorisation, but an urgent in patient medication that required pre-authorisation as per Bonitas Brochure. I was then told that I still needed to send it to Chronic department to process and then only could it be pre-authorised. I told them that going this route I was certain that it would be declined because it was not one of the diseases on CDL but was one of the 271 PMB’s. Myasthenia Gravis is not one of the conditions covered on the standard option, but as per the CMS 271 PMBs I was still entitled to: “Initial diagnosis; initiation of medical management; therapy for acute complications and exacerbations”. Dr ZS then did the script, and after I been given the wrong email address twice, I finally got the correct email from yet another agent and the script was emailed twice to ********** I called again and was told yet again that Bonitas did not receive anything. Their email system was not working properly and yet again this became my problem. I was now told that the urgent request submitted by a neurologist for my in patient management, would take the Chronic Department 5 working days to process. I was in contact with them from 11am and it was now 4pm and I was told that they now had not received the motivation letter or script. After another hour of calls I got through to someone who managed to find the email I sent because I forwarded it other Bonitas email accounts hoping it would go through. She said she loaded the information and that I should call back tomorrow to follow up. Ten minutes after this I received an email from Bonitas Chronic Medicine Department stating: Authorisation for payment of the condition Myasthenia Gravis-has been Declined. This condition is not covered under your chronic medicine benefit (see no.7 and no.5). This was EXACTLY what I said would happen to every agent who said I should submit a script to the Chronic Department. I am very well aware that I would not be able to receive chronic medication for Myasthenia Gravis on Bonitas Standard. The Polygam is NOT being prescribed as chronic medication but as urgent INITIAL management of a PMB condition. Aside from the extreme stress of having to deal with a life changing diagnosis I have now been unduly stressed because of the incompetence of Bonitas. Should this not be sorted out as a matter of urgency I will be taking legal action against Bonitas. I have approached CMS in the hopes that you could intervene and get this medical scheme to cover me for this treatment and not violate my rights.

Here are some of the many reference numbers I was given: BON ********** 3 051217QHZM31 051217QJ093Y BON ********** 371