Do you even know what a PMB is

What a terrible way to start a new year, with a complaint, and it is all your fault Discovery. I’m referring to a claim that was submitted by a hospital emergency department because my partner went into anaphylactic shock from eating something that he is apparently allergic to. Resting assured that the claim would be paid by Discovery, because that is why we have medical aid. For EMERGENCIES. Unfortunately, Discovery’s team of useless Case Managers rejected the claim, because apparently they do not know how to read statements. Upon hearing that the claim was not paid, I contacted the scheme’s call centre to find out why. The first consultant (Mpile) said the claim was not paid, because we did not have Pre-authorization. What a joke!! I’m so terribly sorry that in the midst of rushing to the emergency room because my partner was about to die, I didn’t think of phoning for pre-auth! Regardless of her completely useless and incorrect response (because you DON’T NEED PRE-AUTH FOR EMERGENCIES), I phoned the hospital to check if they perhaps have some sort of protocol in place that I was unaware of. The Hospital then phoned and spoke to Lorna, who advised that the claim was not paid because it was not an emergency. What the hell. If I was a Layman, I would be very confused because now two different consultants have given two very different answers. Luckily I am a Pharmacist, so I knew better. I then phoned again and asked to speak to a Team Leader. I was put through to Shaun Govender. Now with all due respect, Mr Govender is a very poor image to portray as a team leader. I explained the entire situation to him. I also advised him that the claim statement contains not only the correct ICD 10 codes, but also the correct medication for the treatment of anaphylaxis. Mr Govender promptly promised to get back to me, after I told him that if they want a motivation, they can get it themselves. A whole month went by and I heard nothing, so I phoned again. Only to hear that Mr Govender had apparently requested a motivation, but that our doctor was on leave, so I waited. I then phoned again after that, when I knew the doctor was back from leave. Nokubonga then informed me that Mr Govender had CLOSED the query. No feedback given whatsoever. As a team leader he should know of better. Absolutely ridiculous. I Nokubonga to get Mr Govender to phone me. Another month went by and again I phoned. I spoke to a very well trained consultant (Anita). She advised that nothing had been done, and she tried phoning the hospital. She asked me to obtain a motivation from the doctor. Feeling defeated, I agreed. Discovery received a motivation and again rejected it. But on the other hand, why in the hell do I need a motivation??? So, since your clinical team of nurses is so very underqualified for their job, allow me to break down this case for you: ICD 10 Codes: - T78.4 (Primary) – Allergy Unspecified - Y34.98 – Idiosyncracy, Abnormal reaction from food or drug. As you can see, the doctor did not put the ICD 10 code for Anaphylaxis, because it was not full on anaphylaxis. We managed to stop it just in time. So if you want that ICD 10 code, I suppose next time we have to wait until he is almost dead? Would that help? Will that fit into your PMB requirements?? Secondly, the medications used in the ward should tell you what is wrong. But sorry, I forgot nurses apparently don’t need to know what medications are for. So allow me to tell you what they are for. 1. Promethazine HCL Fresenius Amps 25mg - Now according to the SAMF (South African Medicines Formulary 11th Edt), which is the book all pharmacists use when they practice, on page 566, promethazine is used for the following • Acute ANAPYLAXIS – Dose in emergency  25 -50mg SLOW IV Now just look at that. Even the dose for emergency is specified in this book, and how odd that it happens to be what the doctor gave my partner? MUST HAVE BEEN AN EMERGENCY! 2. Macleods Hydrocortisone inj 100mg-5 (2) - SAMF on page 267 indicated Hydrocortisone for: • Serious ANAPHYLAXIS – Dose 100-300mg IV That’s two for two. So unless you people feel that the doctor was just prescribing random drugs and doesn’t know what he’s doing. I’d say your whole argument for not paying is completely invalid. I am horrified and disgusted with your service. The whole point of having medical aid, is for these emergencies. I expect a prompt response from you. I have every single reference number from all of my calls. I know how medical aids work, as I said, I am not a Layman.

Regards