/ 3 November 2009

Trapped in the call centre from hell

I've never had complications from diabetes, but there's a far more complex condition that's more difficult to manage: a medical aid.

In the 25 years I’ve been a type 1 diabetic I have experienced no complications from the condition. But I have another far more complex condition that’s much more difficult to manage: a medical aid.

Mine is one of those new fangled medical schemes with 147 000 members, a glossy magazine and a call centre.

Every year I visit my specialist for a general check-up and this is normally preceded by a small battery of blood tests, the results of which we discuss at my appointment. Then I set aside a few hours to argue with my medical aid about the claim. This is not a chance claim, it’s a claim I’m entitled to in terms of the prescribed minimum benefits (PMB) of my treatment plan, which they have provided for me.

Every year, obstacles are thrown in my way. The largest and most obvious of these is the call centre, which I’m convinced was established to deal with the problems of having a call centre. The staff, while often polite and understanding, have no power to take any action at all. The first tier, the outer, most numerous small branches if you like, can basically just wave around in your face.

If you’re lucky, your call will be ‘escalated” to the next tier, where the wood is a little thicker and it’s a bit more spacious. Here you will encounter a bit more authority, but no real power. If you can sing your membership number in rhyming couplets here you may descend to a lower fork. All your dials will register a little more of what you’ve experienced above, but there’s still no real ability to actually do anything about your problem.

It’s as if this whole outer configuration is hovering some distance above the real superstructure, and only occasionally and with great insistence on your part will one of the woodier branches make a brief foray into the real thicket. You are completely denied access to any of the lower bifurcations, where the thrust and girth might well make a difference to the shape of the tree and nature of your interaction with it.

It’s here I found myself the other day. I had eventually teased out a real telephone number beginning in an area code from a ‘team leader”. I dialled this number where a bored operator transferred me back to the call centre.

My blood tests are performed by a pathology laboratory that sends the invoice directly to my medical aid. Then, I inevitably get the same invoice telling me it hasn’t been paid. Last year it seems someone’s randomiser had scrambled my ICD 10 codes. Yip, try that out on the call centre. You’ll find that many of the operators don’t know what it stands for.

An international code of diagnosis is the magic number which, in conjunction with your prescribed minimum benefits and treatment plan, allows you to claim for particular items. Somehow I had the codes for rickets or dropsy and therefore wasn’t allowed to claim for item number 4064, an HBA1C. This is the quintessential diabetic’s blood test which I’ve had at least annually for the last 25 years. It serves no function other than to test your highest, lowest and average blood sugar readings over a period of six weeks.

In all the time I have belonged to my medical scheme, I have not made a single claim for anything other than my chronic condition. The pathology lab and the medical aid both declare they were unable to change the ICD10 code and so we went around in circles for a while. It all blew up so ridiculously that the scheme’s CEO eventually contacted me and things got sorted out. Not before the bill was three months overdue though.

This year it seems the randomiser is at work again, but I can’t be sure because the medical aid has still not sent me a statement, although I have received an invoice from the pathology lab telling me that payment is late. At this stage it seems the lab and the medical aid both have different ICD10 codes, neither of them for a type 1 diabetic.

My larger problem at the moment though, is payment of my specialist’s consultation fees. I visit him once a year, although my treatment plan entitles me to five such visits. Now, I am informed, I have to co-pay for the visit because my physician is not a designated provider. He was last year and I was not informed of any change to his status. Email enquiries, which I’m encouraged to make, go unanswered and the call centre has no ability to declare my specialist unfit or otherwise. He is a leader in his field, and a man who inspires great confidence and responsibility in his patients. My blood pressure lowers when I enter his rooms.

Also, I’m told, the scheme won’t be paying for item 4188 — a urine dipstick test — because I am only covered if a pathology lab performs this test. It requires no specialist skills (I used to do it myself at home), its results are instant and I have never had it performed by a pathologist. In fact, every time I visit my specialist I am greeted by the receptionist or a stern sister brandishing a plastic beaker with a rallying cry of “Champagne time!” And it costs R8,99, which the scheme happily paid last year.

So, I sit and wait for my phone bill to see whether two hours on a share call number will offset the savings I make by fighting for the correct implementation of my medical aid plan. Mind you, they’re paying half the costs of that too.