General

When Diagnosis is not Covered

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23 Sep 2016 - General
 

Healthcare insurance protect their business by putting a limit on the services that they provide for their clients. In most insurances that I've encountered, common conditions that are not covered are traumatic injuries, patients who are under the influence of prohibited drugs or alcohol, psychiatric conditions, congenital diseases and sometimes even pregnancy. In my experience as a resident, I frequently encounter patients who present with headache and after an extensive work up, it turns out they have an aneurysm. Unfortunately, an aneurysm is classified under congenital diseases (in HMO diagnostic standards). After this, the HMO liaison officer usually inform the patient that his hospitalization will not be covered. Sometimes patients would go to the extent of requesting physicians to give a different diagnosis so that they will be medically covered.

What is your experience on this? Have you encountered physicians who agree to putting a different diagnosis so that their patients will be medically covered?

Well yes this is a true scenario in each hospital most especially in private sectors. Most of us nowadays tend to invest more on health insurances which is a good idea. Well most of the cases that are not handled with insurances are already mentioned by Marinelle Castro. I known somebody used to work in a call center wherein he was hospitalized duet o drug intoxication. He has SVT's and has been arrested due to over dosage of illegal drugs. Sadly, the insurance of the call center did not cov...
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Jennifer Winter Yes, the government insurance is really far behind. I think the cost of NSD under government insurance is 1000 pesos. Surgical procedures are way behind the standard prices as well. That is why people still shell out a lot of money when they are hospitalized. Marinelle Castro It would be impossible to tell which pa...
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I actually feel sad for many HMO holders (and even dentists). I don't know how it is for medical but in dental, the standard coverage is just cleaning, simple extractions and temporary fillings. So imagine when patients come to us, expecting they could get unlimited fillings and I tell them, "But temporary fillings are only for "temporary" use, meaning if we're observing tooth reaction and we're not done with the case". Some dentists will bur out teeth and cover a...
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Marinelle Castro oh I know of private insurances as well who even come in to question the treatment, diagnosis etc to find ways not to cover the patient. Definitely insurances with international coverage would be better especially if you travel but that of course would be more expensive. There are many private insurances that really cover patients well. I know of patients who were admitted to the ICU and ended up...
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Jennifer Winter Yup that's true. Sometimes its an overall cap for a limited period of time (usually one year). But it really depends on the insurance type of the patient because I've seen one insurance without limits! The worst healthcare insurances are those given to regular employees. I won't name the worst medical insurance that I have encountered but there are those who will really look for an ex...
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Mark Edmon Tan I agree that's the best thing to do. Sometimes i'm tempted to give them a warning that their illness is not covered but I am hesitant because I might get misinterpreted by the patient. You know how sick people are - sometimes they're overly sensitive and its easy to be misinterpreted when you're talking about money matters. At the other side of the coin, I've also encountered p...
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Yes I have seen the final diagnosis adjusted to some other condition for the patient to be covered by insurance. Though as Mark Edmon Tan said it is a diagnosis not far from what the patient has. I think for AGE you need to place "with moderate dehydration or severe dehydration" for it to be covered by our government insurance. Not sure if that is still the case. We of course cannot completely change th...
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Marinelle Castro I see you are coming from. It is true that schedule gets delayed for public hospitals. There are even some public hospitals that have a priority list wherein you can get bumped off to a later schedule if a priority patient needs surgery. It is sad to hear that even neurological diseases do not get covered by the insurance companies. It is no coincidence that these diseases are the ones that requi...
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Mark Edmon Tan I agree that its a prudent thing to do for the patient - to put a real diagnosis that's covered by the medical insurance. Unfortunately most insurances don't cover neurosurgical diseases. Plus it is pretty obvious that its the primary diagnosis so we really have to put it. I just feel bad because by the time we find out the diagnosis, we have already done substantial work up that's exp...
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Well yes this is a true scenario in each hospital most especially in private sectors. Most of us nowadays tend to invest more on health insurances which is a good idea. Well most of the cases that are not handled with insurances are already mentioned by Marinelle Castro. I known somebody used to work in a call center wherein he was hospitalized duet o drug intoxication. He has SVT's and has been arrested due ...
 (Total 160 words)
We have encountered this once in our hospital. A private patient was admitted due to pain secondary to flare of osteoarthritis. He had other co-morbidities as well (hypertension and diabetes). When he was about to be discharged, all of us were surprised to find out that osteoarthritis was not covered by insurance. This is the most common type of arthritis and it is not covered by insurance companies. We were really disappointed with this development and it was very unfair to the patient who had ...
 (Total 139 words)