Medical Referral HAS THE ANSWERS!

Transcription

1 Medical Referral HAS THE ANSWERS!

2 MEDICAL REFERRAL ABROAD A medical referral is when your GP determines that you have a medical condition that needs to be evaluated and possibly treated by a specialist. If the specialist required to treat the illness or medical condition is not available in the Dutch side healthcare system, then a referral to that specialist is called a medical referral abroad. Conditions: There are many reasons an individual can be referred for treatment abroad by their doctor however for SZV to consider a medical referral abroad these main conditions should be met. Namely: - The doctor referring the individual must be an SZV associate (medewerkende) - The individual must be under treatment of the doctor referring the individual (treating physician) - The individual being referred must be insured by SZV - All possible treatment options for the condition or illness that is available on St. Maarten must be done and proven ineffective in resolving or improving the medical condition or illness - The necessary specialist or medical treatment must not be available in St. Maarten Process: The Medical Referral Abroad process consists of the following steps: - The treating doctor sends in a request for a medical referral abroad for an SZV Insured by sending in a medical report. - The SZV medical advisor evaluates the request and based on the information sent in determines if it meets all the conditions for a medical referral abroad. - If the request is approved, the SZV medical referral officer requests an appointment with the specialist abroad. - Once the appointment is received SZV notifies the Insured of the appointment and travel date to the country abroad. 2 - SZV makes the travel arrangements, hotel accommodations and arranges transportation for the Insured referred abroad. - The Insured attends a mandatory Intake Meeting with a SZV Medical Referral Officer 5-7 days prior to the travel date abroad. - The Insured travels abroad and sees the specialist for evaluation and receives the necessary treatment or procedures for their condition or illness. - The Insured returns to St. Maarten. Any necessary continued care indicated by the specialist abroad available in St. Maarten is given if the condition or illness is not resolved. - A medical report from the specialist abroad is given to the GP or local specialist who referred the Insured for medical care abroad. Obligations of the insured: Once the doctor treating the Insured has sent in a referral request, the Insured should: - Make sure he/she has a valid passport. If the passport has expired, the insured should have it renewed as soon as the request is submitted. - Make any necessary preparations to be off island (pay bills, refill medications, arrange for child care) - Secure a companion to travel abroad with the insured in case it is necessary for a companion to travel with the insured. - Check back with the doctor that referred the Insured if it has been more than 2 weeks since the referral request was sent in and SZV has not notified the Insured of an approval or an appointment. - Read the Rights and Duties of the Insured Referred Abroad (RDIRA) policy and the Insured Companion Guidelines Policy (ICGP)

3 Types of requests and Processing: The length of time it takes for a medical referral abroad to take place depends on: - The type of request - The country, hospital and specialist selected for the medical referral abroad - The availability of an appointment There are three types of medical referral abroad requests that a doctor can send in: an emergent, an urgent and a standard/normal request. An emergent request is sent in if the Insured s condition is life-threatening and they need to receive treatment immediately in order to survive. An emergent referral is arranged within 24 hrs by SZV and the Insured is flown out within hours by air ambulance. An emergent request can only be submitted by a treating specialist. An urgent referral is sent in if the Insured needs to receive treatment within 7 days in order to prevent the condition/ illness from becoming life- threatening. An urgent referral is arranged within 3 days by SZV. The insured can expect to travel commercially within 1-7 working days from the time the request is received at SZV. Urgent requests that do not meet the above condition will be processed as a standard/normal referral. A standard referral is sent in if the Insured has a non- emergent, non- urgent medical condition or illness that needs evaluation and treatment. A standard/normal referral is arranged within 10 working days by SZV. The Insured can expect to travel within 2 months of the referral being sent in to SZV. A follow up medical referral abroad request is sent in when the Insured was treated abroad and cannot receive the indicated follow up care in St. Maarten or if the Insured is not improved or is having complications after being treated abroad. A follow up referral is arranged in the time frame indicated in the discharge medical report from the treating specialist abroad. Delays in the time frames listed can occur if: - There is a long waiting list in the selected country or for the selected specialty. Currently there are delays for medical referrals abroad for Urology, Neurology and Neurosurgery in Saint Martin. 3

4 - The Insured s passport is expired and awaiting renewal or the Insured needs a visa to go to the recommended Country of Care and has to go through a visa process. - The contact information provided by the Insured or the doctor referring the Insured is incorrect and SZV is unable to contact the Insured to make the necessary travel arrangements. - The medical report sent in by the doctor referring the Insured is incomplete. - SZV has not received a confirmed appointment date from the designated country, hospital or specialist abroad. Destinations: SZV has worked with a number of hospitals in various countries over the past years of conducting medical referrals abroad. Based on certain conditions like quality of care, cost effectiveness, available services and distance the following countries make up the network of Medical Referrals Abroad (the MRA network): - Curaçao - Aruba-limited - The Dominican Republic - Puerto Rico- limited to diagnostic studies - Colombia (Bogota, Cali) - The Netherlands- limited to long- term care for children and certain long term care not available in other countries in the MRA network. Aruba will no longer be part of the MRA network in the near future due to difficulty with providing services in a timely manner. What is provided by SZV: - Medical cost of treatment abroad - Hotel accommodations (for the Insured and SZV assigned/approved companion only) for the duration of treatment - Transport to and from the airport, to and from the hotel to medical appointments - Daily allowance (to be replaced with a meal card) 4

5 Companion: If indicated SZV will approve for one companion to assist the Insured abroad. A companion is approved if among others: - The Insured is incapacitated physically or mentally - The Insured will undergo a surgery or procedure that will prevent them from being able to take care of themselves (perform ADLs - activities of daily living) The companion is expected to assist the Insured with bathing, dressing, eating if necessary and will have to accompany the Insured on a full time basis in the hospital if the Insured is hospitalized. If the insured does not have a companion to travel with them SZV can provide a sitter or nurse assistant in the country of treatment. However, family members or friends living in the country of treatment who assist the Insured are not eligible for companion benefits as they are not displaced from their living environment. The selected companion should be available to stay with the Insured for at least 3 weeks to 1 month. The companion if employed should take vacation days because volunteering to be a companion does not entitle the companion to sick-leave or loss of wages. If the Insured chooses to bring a companion that is not assigned or approved by SZV then the Insured and his/ her companion are responsible for paying hotel costs, transportation charges and meals for the non-assigned, non-approved companion. Intake meeting: During an Intake Meeting SZV s Medical Referral Officer provides the Insured with all necessary information regarding the Medical Referral Abroad. At the meeting the Insured is given the ticket/itinerary, the hotel and contact information of the transportation service. The appointment date/time and the specialist information is also provided. The Medical referral officer will review the policies of the medical referral process and provide further insight into what the Insured can expect during their time spent abroad. The Medical Referral Officer will also review all medical documentation that the Insured should take with them to the specialist abroad. The intake meeting is mandatory to ensure that the Insured has all the necessary documentation and information for the proper resolution of the medical referral abroad. If the Insured does not attend this meeting he/she cannot travel abroad. 5

6 Frequently asked questions: Can a Medical Referral Abroad request be rejected? Yes, the SZV Medical Advisors will not approve a medical referral abroad for a certain reasons. The main reasons are: - If the doctor requesting a medical referral abroad does not provide a complete medical report with all the information stipulated by SZV. If information is missing, SZV will notify the doctor and he/she will have 10 working days to send in the necessary information. If the information is not received within the specified time the medical referral abroad request will be rejected. - The requested treatment or specialist is available on St. Maarten - The requested treatment is not covered in the Insured s SZV insurance package - The individual is not SZV insured. What does the Insured do if their medical request abroad is rejected? SZV will notify the Insured by phone if the medical referral abroad request is not approved. A letter confirming the rejection is sent to the doctor requesting the referral within 7 working days. The insured should visit the doctor that referred him/her to discuss other treatment options and to receive a copy of the rejection letter. Therefore SZV will not send the Insured to Aruba. Also, the doctor referring the Insured may suggest treatment in the Dominican Republic, however SZV knows that all the treatment the Insured needs is not available in the Dominican Republic or that there is a long waiting time for that specialty in the Dominican Republic so SZV will designate Colombia as the country to be treated in. Because of these and other issues SZV has the final word on the designated country where treatment will be done. What happens if the specialist abroad recommends the Insured follows up? Depending on the follow up treatment recommended by the specialist the insured can receive follow up care on St. Maarten. If the care is not available on the Island the Insured should be re-evaluated by the doctor who referred him/her abroad in the first place. The doctor will request a follow-up medical referral abroad and send in a new medical report on the Insured s current condition. Can the Insured or the referring doctor choose where the insured would like to be treated? No, SZV has established selection guidelines for the designated country abroad in which the Insured is referred to abroad. At times the doctor referring the Insured may suggest a designated country however this is merely a suggestion. SZV decides in which country the Insured will be treated based on their knowledge of the quality of care, available services and promptness of care. For example, the doctor referring you may suggest you go to Aruba for Orthopedic treatment of your hip. However, SZV knows that although there is Orthopedic care in Aruba, the orthopedist does not provide hip treatment. 6

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8 Disclaimer: The information contained in these documents is for general information purposes only and has been prepared with the utmost care to ensure a high level of accuracy and completeness. As we continuously improve our services, the information and/ or services of SZV presented in these documents may differ over time and SZV cannot be held liable for the information presented and possible changes. Harbour View Building, Sparrow Road 4, Philipsburg, St. Maarten SZV Social & Health Insurances Call us: +1(721) us: info@szv.sx