360º Care Initiative

Fedhealth members will need a referral from their GP for a specialist consultation

360º CARE INITIATIVE

At Fedhealth, we take pride in not only being a Real Medical Aid, but also in making smart moves that benefit our members and the Scheme in the long run.

To this end, we’ve implemented a < strong >360° Care approach, which we introduced our members to in their renewal letter in October last year. The aim of this is to enable their General Practitioner (GP) to directly coordinate their care, so that all their healthcare needs are met responsibly, smoothly and efficiently – saving them time and money.

Specialist referrals

As part of this new initiative, Fedhealth has implemented < strong >Coordination of Specialist Care on all Fedhealth options. This means that if our members have any health concerns, they will first need to consult their GP who will assess their healthcare needs, and, if necessary, refer them to the appropriate specialist for their condition. In so doing, < strong >their GP will now have a complete picture of their health history enabling him or her to provide them with the most suitable ongoing care for their needs.

What if a member has already made an appointment with a specialist?

In this case, they are not expected to see their GP before their consultation with the specialist. They must please contact the Fedhealth Customer Contact Centre to notify us of this consultation and a reference number will be issued. They must please include this reference number on their specialist claim when submitting it to the Scheme for payment. In future, members must please consult with their GP first at all times, and if he or she feels that it’s necessary for them to see a specialist for their condition, they will then refer them.

What if a member has a long-term relationship with a specialist?

A GP referral will be valid for a six month period. This means that if they do have a long-term relationship with a specialist, they will be required to visit their GP every 6 months to get a new referral. This way, their GP is aware of the condition that their specialist is treating them for.

What if a member is pregnant?

Consultations for pregnancy with gynaecologists are currently excluded from this process and therefore no referral is required.

Why is the Scheme implementing specialist referral?

The key benefits of specialist referral, for members and the Scheme are:

  • It will improve quality of care by enabling access to the appropriate specialist care
  • It will enable the Scheme to introduce electronic health records which will allow the healthcare providers treating our members to access and exchange their medical information easily
  • It will prevent unsafe combinations of treatments, including medicines
  • It will also prevent unnecessary duplication of costly clinical tests and treatments – which contribute to rising health care costs and increases in members’ contributions.

How will the referral process work?

If the member’s GP decides to refer them to a specialist, the GP will contact the Scheme to obtain a referral for the specialist type (e.g. orthopaedic surgeon), not the name or practice number of the specialist. This means that the member can visit another specialist of the same type should the first specialist be fully booked.

The members’ specialist claims will be assessed against the information collected as part of the referral process:

  • The referring GP on the specialist claim is the same as the GP who created the referral;
  • The member and beneficiary on the claim is the same as for whom the referral was created. The date of birth will be used to ensure correct identification of the beneficiary;
  • The specialist claim is of the type for which the referral was created;
  • The treatment date on the claim falls between the “From” and “To” date of the specialist referral. The referral is normally valid for 6 months.

Please note:

  • Female patients, for conditions other than pregnancy, can have one Gynaecology visit per annum without a referral number;
  • Children below the age of two (2) can visit a Paediatrician without a referral number;
  • Oncology, ophthalmology, pathology and radiology (general and specialised) are excluded from this process.

We’re committed to optimising the health of our members and we are confident that our Coordination of Specialist Care initiative will not only provide them with them with responsible, smooth and efficient healthcare, but also the future sustainability of the Scheme.

Which specialists do our members need a referral for?

Cardiologist

Dermatologist

Gastroenterologist

Gynaecologist

Neurologist

Neurosurgeon

Orthopaedic surgeon

Otorhinolaryngologist (ENT)

Paediatric cardiologist

Paediatricians

Physician

Plastic and reconstructive surgeon

Psychiatrist

Pulmonologist

Rheumatologist

Surgeon

Urologist