Educational psychologists are awaiting an answer to why some SA medical aid schemes have withdrawn coverage.

Dr Martin Strous, chair of the Educational Psychology Association of South Africa (EPASSA), the largest in South Africa, is quoted in a News24 report as saying 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.

The report says the problem arose after the Health Professions Council of South Africa (HPCSA) 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.

According to the report, three educational psychologists (EPs) have discussed how the unexpected change has affected their day-to-day dealings with patients and in their practices.

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 persecution. “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 1 June.” 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.”

The report quotes Gerhardt Goosen, a 64-year-old EP with 36 years’ experience in Port Elizabeth, as saying 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. He also said he received no notification of the change, neither as a practitioner nor as a GEMS client himself.

The report says a third EP in Gauteng, who is also the chair 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 said in the report. Strous added that some medical aid schemes have chosen not to follow the pattern. Discovery Health, for instance, still covers the profession.

The report said communications executive for GEMS Liziwe Nkonyana responded to 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.”

According to the report, the HPCSA said 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 said. “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.”

According to the report, Sekhonyana said the HPCSA’s primary mandate was to protect the public and ensure that psychologists are properly trained in their professional category.

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