HMOs and Inadequate Maximum Benefit Limit

ROJoson’s Health Tidbits – PBL – TPOR

HEALTH MAINTENANCE ORGANIZATIONS AND INADEQUATE MAXIMUM BENEFIT LIMIT

In my practice, I have encountered surgical patients who are members of the Health Maintenance Organizations such as Medicard, Maxicare, Intellicare, etc. who cannot be entirely covered by their insurances, even after inclusion of PhilHealth benefits.

Aside from their maximum benefit limit not being enough for the planned surgical procedures per se (for example, a maximum benefit limit of P100,000.00 will not be enough to cover for a surgical procedure that will cost more than P100,000.00), the other common reasons are that they have significant diseases that have to be controlled before the operation (and these entail cost) and that their preoperative work-ups including the so-called surgical clearances have used up a greater portion of their maximum benefit limit.

Advices: 

  1. Know your maximum benefit limit per year.
  2. Keep tab of how much you have already used up in your maximum benefit limit and ask the surgeon and the HMO liaison officer whether the amount left will be enough for the planned surgical procedure.  Note: always ask the surgeon how much will the hospital expenses be (not the professional fee as this is fixed by the HMO) as surgical expenses is very much dependent on how the surgeon operates and what surgical instruments and materials he uses.
  3. Unless your plans include the so called HMO-identified “major” hospitals, such as Asian Hospital, Cardinal Santos Medical Center, Makati Medical Center, St. Luke’s Medical Center Quezon City, St. Luke’s Medical Center Taguig and The Medical City, go to other hospitals and diagnostic centers which have lower rates for your preoperative workups.   Even if you are utilizing the “major” hospitals, keep tab of the running balance in your maximum benefit limit.
  4. Aside from the hospital expenses during the operation, ask the surgeon how much will the preoperative work-ups and preparation cost and decide how to manage in consideration of your maximum benefit limit, particularly where to have them done.
  5. For those with potential surgical diseases diagnosed by non-surgeons such as gastroenterologists or endocrinologists, at the outset ask the latter how much will be the estimated cost of the possible surgical procedures and the preoperative work-ups.  This will enable you to manage right away your maximum benefit limit. If the non-surgeons cannot give an estimate, request for a consultation referral to a surgeon for both medical evaluation and estimation of expenses.
  6. Take note that a “surgical clearance” is not a routine thing to be done. “Routine preoperative testing (preoperative screening) of healthy people undergoing elective surgery is not recommended. Instead, a selective strategy is safe and cost-effective as long as a complete history and physical examination are obtained.”(http://emedicine.medscape.com/article/285191-overview#a3http://emedicine.medscape.com/article/285191-overview#a3)

ROJ-TPOR@17apr2

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