Professionals

Pre-authorisation

1. Section 4.17 of the HPCSA policy document on undesirable business practices states: pre-authorisation should be conducted according to scientifically developed protocols and should include peer to peer communication prior to any denial of benefits. An appeals process should be available. Section 3(iii) states the HPCSA does not condone intervention from medical advisors (of schemes) and that they share responsibility if such intervention occurs.



2. A medical advisor would be acting unprofessionally where he/she assesses a motivation for authorisation which is outside their scope of practice, as registered under the Health Professions Act, 1974. (J.Makgolane, Legal Services, HPCSA, 6 November 2008).



3. Personal and professional information of a medical advisor must never be withheld from a doctor acting on behalf of a patient, nor from a patient. (Rule 18, Ethics Rules, G.N.No.R717, 4 August 2006).



4. The CMS (Council for Medical Schemes) requires the following from funders (medical aids) in connection with pre-authorisation and protocols.
   1. Protocols must be transparent and verifiable.
   2. The fund must have in place
      • Ethics committees
      • Review committees
   3. The fund must have written copies of:
      • Clinical intervention policies
      • Protocols (must be evidence based including research, expert opinion and patient preferences).
   4. Date of last review of protocol/policies.
   5. Information on committee members
      • Medical advisors
      • Other members
   
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