Drug & Alcohol Rehab

Don’t take a one-liner from call centre staff as gospel. Start with your scheme rules, not marketing. Ask for (1) your plan’s benefits booklet and exclusions, (2) whether the facility you’re considering is an in‑network provider, and (3) who your case manager is. Then get a clinical referral from a GP or psychiatrist that includes an ICD code (substance use disorders are usually coded in F10–F19), a clear clinical diagnosis, and a motivation for inpatient care (detox risk, safety concerns, failed outpatient attempts, psychiatric comorbidity). Many schemes will require pre‑authorisation and a written treatment plan before they commit funds. If your scheme mentions Prescribed Minimum Benefits (PMBs) in relation to mental health, ask the case manager how they interpret PMBs for addiction — some admissions qualify, some don’t. Do this before moving a patient into a private bed in Johannesburg; once you’ve paid privately it’s much harder to get reimbursed.

Schemes want clinical risk and measurable need, not good intentions. Provide a psychiatrist or emergency physician assessment documenting withdrawal risk (seizures, delirium tremens, severe intoxication), comorbid psychiatric diagnoses, urine toxicology results, history of prior treatments and outcomes, and a structured severity assessment (use whatever standard the provider uses — ASAM leveling, an addiction severity score, or a psychiatric acuity note). Include a clear treatment plan with expected length, daily components (medical, psychotherapy, group, family work), medication needs, and discharge/aftercare arrangements. Make the motivation specific: “Patient X has had two recent ED admissions for alcohol withdrawal with seizure risk, has not engaged in outpatient CBT or pharmacotherapy over 12 months, and requires medical monitoring and 24/7 nursing for safe stabilization.” The more objective data you supply, the fewer arbitrary denials you’ll get.

This happens often. Schemes will approve acute, medically necessary detox but balk at longer psychosocial rehabilitation. Options: ask for a written clinical rationale for the partial approval and immediately lodge an internal appeal with your treating psychiatrist’s extended motivation; push for a PMB review if there’s a linked psychiatric emergency. If the scheme stands firm, negotiate payment options with the facility (shorter inpatient with intensive outpatient follow‑up, phased admissions, or a staged programme combining a private hospital detox and a lower‑cost residential centre in Joburg). Look into gap insurance, short‑term loans, or family contributions while you pursue an appeal. If you believe the refusal breaches scheme rules, lodge a complaint with the Council for Medical Schemes — but use that as parallel pressure, not your only tactic. Clinically, don’t discharge someone who is unsafe solely for financial reasons; escalate immediately to the facility social worker and the treating psychiatrist to document risk and seek urgent reconsideration.

Integrated care is the standard and schemes expect it where indicated. If there’s a comorbid mood, anxiety, or psychotic disorder, the treating psychiatrist must be part of the inpatient plan and supply a concurrent diagnosis and medication strategy. For opioid dependence, ask the scheme about funding for opioid substitution therapy (methadone/buprenorphine) — access varies, and you must have a psychiatrist or addiction specialist prescribe and justify it. Expect schemes to scrutinise psychotropic prescriptions for appropriateness and continuity; abrupt medication stops are red flags. Insist on a documented handover: who will continue psychiatric meds after discharge, what prescriptions are authorised, and what outpatient appointments are booked. This reduces readmission risk and makes the authorisation process smoother because it reads as coordinated clinical care, not fragmentary interventions.

Medical schemes can apply waiting periods or upward adjustments for late joiners, but they don’t automatically share clinical details with your employer — schemes and providers are bound by POPIA and confidentiality standards. However, if your employer provides the medical aid, HR may see limited claims summaries if you’ve signed consent forms; avoid blanket consent and be precise about what you authorise. A treatment episode declared before joining a new scheme can be treated as a pre‑existing condition under certain rules — get written confirmation from the scheme. If you’re worried about premium hikes or exclusion decisions, request a written explanation for any adverse action and use the scheme’s appeal process; if unresolved, escalate to the Council for Medical Schemes. For families: insist on signed medical consent before staff discuss a patient’s care with relatives—clinicians can involve family with consent and must balance confidentiality against immediate safety concerns under South African mental health legislation.