Emergency / crisis support: /emergency
If you have received large post-procedure bills, had a claim declined, or are facing ongoing medication costs your scheme won't fund — this guide covers the specific steps to take now.
In A Cardiac Emergency Right Now
If you are in hospital following a heart attack or emergency PCI:
- Your PMB rights apply. Emergency cardiac care cannot be refused regardless of your scheme status, your savings balance, or any administrative issue.
- Ask the hospital's billing office to confirm pre-authorisation numbers for both the hospital stay and the cardiologist's procedure.
- If pre-authorisation was not obtained (common in emergencies), request retrospective authorisation immediately. Most schemes allow this for emergency admissions.
- Request a dedicated case manager from your scheme's hospitalisation line.
- Do not discharge before you are clinically ready due to financial concerns — speak to the hospital social worker if the billing situation is creating pressure.
Common Post-PCI / CABG Financial Crises
1. Large cardiologist or surgeon shortfall account Your scheme paid its tariff; the cardiologist billed at 300%+; you owe the difference.
2. CDL medications not being covered Your statins, beta-blockers, or ACE inhibitors are being charged to your MSA instead of the CDL benefit.
3. DAPT medication declined Ticagrelor or clopidogrel has been refused post-PCI.
4. Gap OPL exhausted after complex CABG All specialist shortfall protection has been used; remaining specialist accounts are fully out-of-pocket.
5. CDL registration never completed Medications have been funded from savings for months; retroactive registration and reimbursement is needed.
If Your CDL Medications Are Being Charged to Your MSA
CDL-registered CAD medications must be funded from your CDL benefit — not from your medical savings account. If this is not happening:
Write to your scheme's chronic benefits department: state your CDL registration details (or register now if you haven't), list the medications being charged incorrectly, and request reprocessing to the CDL benefit.
If CDL registration has not yet been completed, register immediately. Some schemes allow retrospective CDL reprocessing for 3–6 months of prior claims. Ask your scheme explicitly what their backdating policy is.
If Your Post-Procedure Specialist Bill Is Large
After PCI or CABG, cardiologist and surgeon accounts above medical aid tariff are a near-universal experience in SA private practice.
Step 1: Request itemised accounts from each specialist (cardiologist, cardiothoracic surgeon if CABG, anaesthesiologist, perfusionist).
Step 2: Confirm what your scheme paid for each specialist on the remittance advice. Identify the shortfall per specialist.
Step 3: Check whether your total shortfall is within your gap cover OPL (~R220,000/year). If so, submit these to your gap cover provider.
Step 4: If the gap OPL has been exhausted, contact each practice manager directly. Payment arrangements on outstanding balances are routinely available — specialist billing offices typically prefer a payment plan over a protracted collection process.
Step 5: If any account line item appears incorrect (e.g., a procedure you did not consent to, a duplicate charge), dispute it in writing before paying.
If DAPT Medication Is Declined
Post-PCI antiplatelet therapy is medically essential — stopping it prematurely risks stent thrombosis. If your scheme declines clopidogrel or ticagrelor:
- Clopidogrel is on most CDL formularies. If declined, request reprocessing with CDL ICD-10 code.
- Ticagrelor: ask your cardiologist to submit an urgent clinical motivation if ticagrelor is the preferred agent. Escalate to CMS if the scheme declines an urgent cardiac PMB medication.
Do not stop antiplatelet therapy while awaiting a scheme decision. If cost is the barrier, ask your cardiologist about generics or alternative agents in the interim.
CDL Registration Backdating: Don't Leave Money Behind
If your CAD diagnosis has been established for months but CDL registration was never completed, you may be entitled to claim back the medications charged to your MSA during that period. Most schemes allow CDL reprocessing for 3–6 months of prior claims once registration is confirmed.
To pursue this: register now, then write to the chronic benefits department requesting retroactive reprocessing from the date of diagnosis. Include your cardiologist's confirming letter and the ICD-10 code (I25.x). The scheme processes these claims against the CDL benefit and can credit the incorrectly charged amounts back to your MSA.
This is a common administrative gap — particularly for patients who are newly enrolled on a scheme and did not know to register their CDL conditions separately.
Outstanding Bills: Triage Table
| Situation | Priority | Action |
|---|---|---|
| CDL meds charged to MSA | High | Reclassification letter to chronic benefits + reprocessing |
| DAPT medication declined | Urgent | Clinical motivation + CDL appeal + do not stop medication |
| Post-PCI specialist shortfall within OPL | Medium | Submit to gap cover provider |
| Post-CABG shortfall exceeding OPL | Medium | Payment plans with each specialist practice |
| Emergency PCI without pre-auth | Medium | Retrospective authorisation with clinical documentation |
| Cardiac rehab not covered | Low | Physiotherapy benefit alternative; appeal with cardiac rehab motivation |
Escalation Contacts
Council for Medical Schemes (CMS): 0861 123 267 | www.medicalschemes.org.za Heart and Stroke Foundation SA: 021 422 1586 AURA Emergency: /emergency
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This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).