4 Things HMO Insurance Won’t Say

It feels weird making a new blog post after almost three months of not writing one. Sorry, but my mind sometimes short circuits and does not come up with any useful information. As you know, this is not my job and I just do this during my free time.  But I still hope you can get something from this little blog of mine. So before you yawn and hit the delete button, those of you with HMO insurance might want to know some things these HMOs won’t tell you.

  I recently had a patient who came in with her family. They reminded me of Goldilocks and the Three Bears where one was too large, one was too small, and one was just right. The Goldilocks look-alike was the mother.  The father and kids all look like bears.  (I pity the kids. Hehe. JokeJ). Anyway, the mother needed an operation for a torn knee ligament. She told me they got a Health Maintenance Organization (HMO) insurance and this will take care of her operation. At first, she was smiling and ready to schedule the surgery.  But when she realized that there were things that she didn’t expect from the HMO insurance, her face suddenly changed like that of a child whose lollipop was taken by another person.

    From experience, here are some things your HMO won’t tell you when you avail of the HMO insurance, so take note and be prepared to ask so you won’t feel disappointed.

          1.      They will not tell you that your medical insurance is not always enough for your surgery.

HMOs usually have a maximum benefit limit (MBL) for each disease and if you have used any of these benefits before, such as consultations or lab exams, there will be deductions from your total benefit. Also, implants are usually not covered. So if you need surgery for a fractured hip and you were advised by your orthopedic doctor that you need implants to fix or replace them, chances are, you need to churn out money for the implants. In some cases, these implants are not cheap at all.

This particular patient of mine even had a heated argument with the insurance agent because she felt that the amount being deducted from her salary was big enough to cover her surgery.

                                 

       2.       They will not tell you that your preferred doctor and hospital are not always accredited with your HMO insurance.

 There are even instances that your favorite doctor may be accredited in his or her clinic, but not accredited in the hospital.  So be sure to inquire about this. 

          3.       They will not tell you that they will pay your doctor with a discounted or “negotiated” rate after 3 months, 6 months, 1 year, or worse, never at all. Then, they will make all sort of excuses such as documents not signed, lost documents, etc, despite having a contract with us, doctors, stating that they will pay within 30 days.  The problem with us, doctors, is that we are generally poor negotiators since most of us are not businessmen, and we end up providing quality health services without being paid or paid on time, while making you, the patient, believe otherwise. 

For most patients, this does not really concern you, as long as you get the appropriate treatment.  That’s all right. But I just want to inform you why some doctors do not accept or ask you the option of paying more than what the insurance company is willing to pay us, before we agree to operate on you.  “Tinitipid nila kami, sobra.”

          4.       They will not tell you that you need to have Philhealth coverage, or else, you will need to pay the amount what Philhealth normally pays for.  From what I know, Philhealth pays 20-30% of the total hospital costs.

For employed individuals, this is usually not a problem since Philhealth contributions are mandatory by law when you’re employed, this being automatically deducted from your salary. You just need to bring the proof of contributions prior to surgery, either from Philhealth office or from your HR department. So make sure you or your employer is up-to-date with your Philhealth contribution, and that you have clearly stated in your Philhealth Membership form, who your dependents are.  For self-employed individuals, you have to make sure you pay the Philhealth contributions yourself, or ask someone to do it for you if you don’t have the time. The last time I checked, you should have contributed at least 6 months prior to your scheduled surgery to avail of Philhealth benefits.

When I was just starting my private practice a few years ago, my daughter was confined in the hospital. I thought I can use my Philhealth. But it turned out I had missed contributions the past months before her confinement because I was abroad undergoing fellowship training.  So too bad I wasn’t able to get my Philhealth benefits then. 

It is also good to ask your surgeon if the medical facility where you will have your surgery is Philhealth-accredited.  With the popularity of outpatient or ambulatory surgery centers, like those in the malls, some may or are not yet Philhealth-accredited.  In such cases, you will not be able to avail of your Philhealth benefits.

It is imperative that you read and understand your medical coverage and benefits, and have the surgery or procedure approved first by your HMO, especially for elective or non-emergency cases, before you decide to get admitted and go under the knife. You may end up paying more than what you expected and feel unprepared financially just like what happened to my patient.