Do normally medical insurance request for your medical records post op ?

[swweet]

I am covered under my employer's medical insurance. I am about to get a treatment for my health issue.

My health condition is between 'the conditions they cover ' and 'the condition they dont'. Its a grey area, it can be argued as one or the other. They have approved my treatment.

Just wondering what kind of documents normally insurance obtain post op from the hospital and the GP ?
I am unable to afford many thousands of pounds if they change their stand later.

I would have thought that if they have approved it in writing, unless you have lied about the condition in some way they can’t just change their mind.

The only documentation the insurer will received post treatment is the invoice from the hospital and one from the consultant. Both will give a clinical code for the diagnosis and for the treatment given along with the costs of care & treatment. They will receive no communication from your GP at all. And if they do want information from your GP, the GP will ask you to pay for a private medical report

As Mad says if they have agreed to cover the cost of treatment prior to treatment commencing they are highly unlikely to go back on this once treatment completed.

Bear in mind however that the approval process will need to happen every time you want to claim so you're only guaranteed payment for this particular treatment at this particular time. So there' an outside chance they could refuse in future.

Agree with @DPotter . If your treatment is preauthorised then they won't rescind that after treatment. No medical records are sent following treatment unless it's ongoing and your insurer asks for further information.

Thanks for the responses :) i was much worried

If you had a procedure done via insurance, did your insurance provider request any letter from the consultant (via you) ?

Used to work in PMI - we would only request a report from the consultant to clarify eligibility for the condition to be treated and / or the treatment. It's possible for the condition to be eligible and for the treatment not to be covered. But this would be done upfront - assuming the insurer required pre-authorisation, prior to the treatment commencing which most seem to these days.

We would have requested the report directly from the consultant to speed up the process

@DPotter Thanks :)

I got the procedure code from consultant and shared it with my insurance.
My procedure is pre-authorised by the insurance provider.

Is there any chance that they reject the claim later after the procedure ? I dont mind if they reject it before the operation.

Do the insurance obtain any notes/letter from the consultant post-op ?

Though my procedure is approved, I am worried if I need to go ahead with the procedure.

Once an insurer has agreed to pay, they've agreed to pay. Do you have written confirmation, eg an email with a pre-auth number. Because if you do, there's nothing to worry about, they are contractually obliged to pay.

The only thing the insurer will see after is the consultant's invoice which will have the diagnostic code plus the treatment code on it. very rarely the consultant may request an extra payment if the treatment was unusually complex. But they will pick this up with the insurer and they may send a written report to back up their request. This is unusual.
The invoice will look something like
----
Invoice no 54321
Mr Bloggs presents his invoice
For treatment carried out for Ms swweet on 28th Nov

                  for condition 12345 
                  procedure AZ345             £1000

                                 <span class="line-through">-</span><span class="line-through">-</span><span class="line-through">-</span><span class="line-through">-</span>----

IME the consultant's private secretaries are usually very helpful and re-assuring about the payment processes between their bosses and insurers. You could make contact with your consultant's private secretary to talk about it. Not his NHS secretary, unless they are the same person.

And just in case you're worried neither the insurer, consultant or hospital will share your treatment information with your employer, even if they contribute to the cost of your cover.

You've got the most difficult phase done and dusted as far as getting the insurer to agree to pay. So you can now concentrate on getting better

@DPotter Thank you very much xx

@DPotter got a question please :) In case if the insurer asks for discharge summary,is it from the hospital or from the consultant ?

My hospital discharge summary looks slightly different from my approved procedure code.

not sure why my consultant gave the specific procedure code while there is a more appropriate procedure code for my procedure.

Thanks and Happy holidays 🌲

Discharge summaries are usually from the consultant.

There are many and varied reasons why the consultant has used an alternative code including but not exclusive -

typo
consultant actually performed a different op
code doesn't exist to describe exactly the procedure being done, so consultant has gone for what they think is the nearest
or a combination of all 3.

Clinical coding can be a nightmare ........

@DPotter Thanks very much 🙏

Just wondering if insurance gets the discharge summary from the hospital to verify if they have done the right treatment ? My hospital was telling me mixed answers ( they werent very sure when I asked, just gave some superficial answers ) leaving me confused.

Things may have changed since I moved on from PMI, but back then consultants would submit an invoice with diagnosis, dates of treatment, treatment given and price charged.

There would be no clinical info other than the diagnosis,dates and the clinical code / name of treatment, eg biopsy, hip replacement.

The only time more clinical information would be offered and /or requested would be when the treatment was unusually difficult and / or took longer than usual.In these cases the consultant would be requesting a higher rate of pay for the additional time and effort.

The vast majority of hospitals will have an arrangement with most insurers covering the charges they can make and be reimbursed for. So just like the consultants they will submit an invoice with dates of treatment and treatment given. They hospitals will receive a flat rate to cover the treatment, unless again like the consultant they are charging more because the procedure was outside the norm in some way.

Basically very little clinical information passes between the consultant and insurer and hospital and insurer. At some point an audit is done, but a lot is done on trust - all parties have to work together and trust each other to keep the system going basically.

if your procedure /treatment has been preauthorised all the financial stuff should happen automatically behind the scenes. You may get a statement from your insurer showing you what they have paid but that’s dependent upon the insurer’s policy. You would only be contacted by the hospital or consultant if you had an excess to pay and so had to settle the outstanding amount directly with the hospital / consultant.

are you thinking the hospital and consultant have charged for different procedures ? Rare as hen’s teeth but I’m not saying it’s impossible. If this is what you’re worried about I would contact your insurer, explain the situation and ask them to investigate.

HTH

@DPotter Thanks a ton, that was much helpful ❤

Wishing you a merry christmas :)

You're very welcome and a good one for you too !!