Children stranded as medical aids refuse funds for educational psychologists

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Cape Town - Educational psychologists across the country are still waiting for an answer to why medical aid schemes have withdrawn funding for people with educational health needs.

Dr Martin Strous, chairperson of the Educational Psychology Association of South Africa (EPASSA), the largest in SA, told News24 that as many as seven public and private medical aid schemes have refused to pay for the services of his profession since earlier this year.

The list includes the Government Employees Medical Scheme (GEMS), which covers all government employees, as well as Polmed, Profmed, KeyHealth, Bonitas, CAMAF and Sanlam Health.

CAMAF and Sanlam Health are refusing to pay for the treatment of depression and work done with adults respectively.

The problem arose after the Health Professions Council of SA reclassified the industry's scope of practice in 2011, differentiating between clinical psychologists, educational psychologists, and counselling etc.

As a result, some medical aid schemes have realised they are no longer legally bound to cover the costs of educational psychologists.

Many patients, especially children, have thus been refused medical aid in the process, and are regularly advised to see clinical psychologists instead, who aren't necessarily specialists in educational health.

Three educational psychologists (EPs) spoke to News24 to discuss how the unexpected change has affected their day-to-day dealings with patients and in their practices.

'I have to turn kids away'

An EP who runs her own practice in Woodstock, Cape Town, specialises in identifying and treating learning difficulties in children, such as dyslexia.

She asked to remain anonymous for fear of prosecution.

"It's been extremely stressful. I've been submitting to GEMS and all the other funds for four years now and have never had a problem," she said.

"Then without any warning, they made the decision to no longer pay from June 1."

She said she made a loss of around R40 000 for work she had already done in May and June.

She chose not to tell the parents that the medical aid would not cover their assessment, and decided to take out a personal loan to cover the short-term loss.

"Parents now contact me almost daily, and the first question I have to ask them is: which medical aid are you on?

"Since this all started I’ve had to turn away 15-20 kids, and those children aren’t getting the help that they need."

'70% of my livelihood is gone'

A 64-year-old EP with 36 years' experience in Port Elizabeth, Gerhardt Goosen, told News24 that he has lost 70% of his livelihood, and fears for the lives of some of his more troubled patients.

"It's drastic. It's destructive and it's not just GEMS, it's also Polmed [police] and many others.

"My practice itself, about 70% of it is gone. I'm seriously thinking of closing it and retiring. I'm 64, so it will be hard to find another job."

He also said he received no notification of the change, neither as a practitioner nor as a GEMS client himself.

The poor 'most affected'

A third EP in Gauteng, who is also the chairperson of the SA School Psychologists Association, said the change has drastically affected NGOs working in the Johannesburg inner city.

"Most of the people who we see are poor, so they come to us. But many of them can't afford to pay cash for our services," he said, preferring not to give his full name.

Martin Strous of EPASSA believes that the issue needs to be challenged at government level, as the status quo is in breach of the Council for Medical Schemes' advice.

"What is needed is for the HPCSA's Professional Board for Psychology, which regulates the profession of psychology, and the Council for Medical Schemes, which regulates medical aids, to act in a way that will stop this injustice," he told News24.

Strous added that some medical aid schemes have chosen not to follow the pattern. Discovery Health, for instance, still covers the profession, he said.

GEMS responds to claims

Communications executive for GEMS Liziwe Nkonyana responded to News24's questions around funding last week.

"After careful investigation we have ascertained that there are a number of unresolved issues regarding the interpretation of guidelines impacting the funding of services rendered by educational psychologists," Nkonyana said via email.

"This however does not mean that these claims are refuted out of hand by GEMS.

"It appears that our managed care and administration partners have for various reasons rejected a number of these claims in recent weeks."

Nkonyana said GEMS has called for additional information and will be re-assessing the rejected claims.

"We are pleased that this matter was brought to our attention so that we could intervene in order to ensure that the situation is fully resolved."

HPCSA 'aware' of challenges

The Health Professions Council of SA (HPCSA) told News24 on Friday that it is was aware of the current challenges, but that the change in scope was motivated by inadequate regulations.

The 2011 change actually expanded the scope for educational psychologists to include learning and development across a lifespan, and not just in contexts of family, school, social or peer groups, Communications manager Priscilla Sekhonyana told News24.

"The board is aware of the challenges experienced with some medical aids due to their refusal to reimburse educational psychologists, and is interacting with the Psychological Society of South Africa to convene a meeting in order to assist in these challenges.

"Further, communications with some of the medical aids was also undertaken to assist in the challenges."

A High Court case between psychology association Relpag, the HPCSA and Minister of Health Aaron Motsoaledi is set down for August in Cape Town.

Read more on:    cape town  |  health

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