How to avoid health-care headaches when you need a procedure outside N.S.

This is part of a series from CBC's Information Morning where Halifax health-care consultant Mary Jane Hampton discusses her "health hacks" — ways to make your experience with the health-care system better.

Travelling outside Nova Scotia for medical care is a reality for some, but health-care consultant Mary Jane Hampton says a doctor's blessing isn't enough to save patients from a hefty bill. 

In last week's health hack, Hampton offered tips for people who find themselves away from home when illness or injury strike. But she says unexpected headaches can arise even when a procedure is planned.

Hampton pointed to a recent case in New Brunswick where a patient was told she couldn't get life-saving cancer surgery in that province or Nova Scotia. Marilyn Steele's doctor instead wrote a letter of support to New Brunswick Medicare for her to travel to Florida.

But when she returned, she learned her claim had been denied. The family appealed that decision and it was eventually reversed.

"Make sure that you have everything in writing before you step foot outside the province or you potentially expose yourself to tens or hundreds of thousands of dollars in cost." Hampton told CBC's Information Morning.

How to get coverage

Anything that's "medically necessary" is covered under the Canada Health Act, but nobody really knows what that means, said Hampton.

"For more than a decade actually there have been suggestions that maybe it would be a good idea to come up with some Canadian definition of what is medically necessary," she said.

Typically, a procedure is covered outside Nova Scotia if a patient proves these three criteria:

1. That all reasonable effort has been made to provide the service in Nova Scotia.
2. That it would have been an insured service had it been available in Nova Scotia.
3. It needs to be provided in an accredited medical facility, not a private clinic.

If MSI covers the trip, Hampton said patients receive $1,000 toward a return flight, plus a daily allowance. 

What isn't covered

But an important thing to remember, said Hampton, is that having to wait for a procedure doesn't necessarily mean you can go elsewhere for it. 

Quebec is also the only province that doesn't participate in the reciprocal billing agreement, so if you are referred to a specialist in Quebec you must pay upfront and be reimbursed later. 

If your request is denied, there's an appeals process. 

"My advice to people is if that occurs, you probably should appeal because obviously your specialist in Nova Scotia feels that it's an appropriate treatment for you to get," said Hampton.

"Sometimes it's a matter of needing to find just a bit more evidence to support your case."

Still, just because someone else may have gotten a procedure covered, it doesn't mean you will, she said. 

"Each request is considered on its own merit. So it's not that a precedent is set and then the door is open for everyone who follows. You need to make that case each time."

READ MORE FROM OUR HEALTH HACKS SERIES