(by Khalil Lindsay, EBS Account Coordinator at Risk Management Services Ltd)
Common questions our Employee Benefit client’s have asked are “Why haven’t I received payment, my doctor indicated the diagnosis on the claim form, abdominal pain.” Or “What do you mean by services ‘rendered are not related to the diagnosis?’”
The answers that are given are “Sir/Madam abdominal pain is not a diagnosis but a symptom. Your Attending Physician has to indicate the cause or diagnosis for the abdominal pains on the claim form. Only then, the claim can be reconsidered for payment.” Or “For the areas highlighted the Attending Physician must indicate or clarify the specific diagnosis or exact reasons for the medical services or prescription drugs for the claim to be reprocessed?”
Within recent times we have noticed some inconsistencies on claims submitted relating to the two subject areas. In some instances the symptom rather than the diagnosis is stated while in other instances the relevant diagnoses for medical services rendered is not indicated. Both result in claims being returned to the insured for clarification.
In light of this the Employee Benefit Unit would like to highlight below the differences between a symptom and diagnosis and also ensure all relevant medical services rendered are accompanied by the respective diagnosis.
SYMPTOM VS DIAGNOSIS
Please be reminded that in order to facilitate payment of your medical claims, your Attending Physician (AP) must accurately complete the section designated for your doctor’s diagnosis on the claim form of the Attending Physician Statement (APS).
The doctor’s diagnosis should be his or her final determination or opinion of the nature and cause of the patient’s discomfort or abnormality. This discomfort or departure from the body’s normal function is called a “symptom”. Typically, a patient experiencing a symptom or symptoms will consult their Attending Physician to determine the exact nature of these symptoms. The Physician will in turn obtain or review the patient’s medical history to formulate a likely diagnosis or series of diagnoses. The Attending Physician may also request further testing to confirm the exact nature of the patient’s symptom(s), thereby forming a diagnosis.
DIAGNOSIS IN RELATION TO MEDICAL SERVICES RENDERED
Similarly for every medical service performed or drugs prescribed, the Attending Physician must indicate all diagnoses’ that pertain to the same on the Attending Physician Statement. These could be for the different prescription drugs, or diagnostic services for which the insured was referred by the AP. In addition the Doctor’s Visit should indicate more than one diagnosis if this is the case. This would ensure that maximum payment would be made by Provider according the Insured Schedule of Benefits.