Last week, I posted on social media my frustrations with the policies of national insurer Philhealth, and it quickly went viral. The trigger was that the billing section personnel of a hospital in which I work told me that I could not place a diagnosis of community-acquired pneumonia, moderate risk (CAP, MR) on a patient since the chest X-ray was not read as pneumonia by the radiologist, despite having a compatible clinical picture. I think this is not only a bad precedent but also results in real harm to the patient and to the practice of medicine in general.

My patient (details changed to protect his/her identity) was admitted from my clinic due to fever and a productive (producing phlegm) cough for the last several days. I listened to her lungs with my stethoscope, and I could hear crackles on one side of the chest. Crackles usually signify fluid in the lungs, most likely due to pneumonia, given her medical history. I prescribed oral antibiotics with instructions to get herself admitted if she felt worse. The next day, she came into the hospital for admission, and I started intravenous antibiotics. Her complete blood count (CBC) showed an elevated white blood cell (WBC) count. An elevated WBC count on the CBC is consistent with a bacterial infection. Her chest X-ray was abnormal, but it was not read as pneumonia. She had other comorbid medical conditions, and so I had to call in some doctors to help. Thankfully, she improved quickly and was ready to be discharged after a few days. I filled out the paperwork for the final diagnosis and put in CAP, MR. CAP can be low risk, moderate risk, or high risk. Since the patient was sick enough to need hospital admission but did not require intensive care unit admission, moderate risk was the most appropriate diagnosis.

During the process of sending her home, the hospital billing office called me to request that I change the CAP, MR diagnosis. I asked why, and they said it was because Philhealth might deny the coverage since the chest X-ray did not show pneumonia based on their past experience. While this might sound like a reasonable request from a layman's perspective, let me assure you that it is problematic for many reasons.

First, pneumonia, like many other diseases in medicine, is a clinical diagnosis. A clinical diagnosis means that it is the doctor who decides what the patient has based on a holistic assessment of the patient’s signs, symptoms, and laboratory findings. Deciding whether a patient has or does not have pneumonia based on an X-ray, despite having all the other elements present, is not good medicine. There are many reasons why someone with pneumonia might not have infiltrates (the usual finding in pneumonia) on an X-ray. These reasons include being dehydrated (which the patient was), radiologic lag (a known phenomenon where it takes a while for X-ray findings to catch up with the clinical picture), and improper technique (which can occur for many technical reasons). The known sensitivity of an X-ray to detect pneumonia can range from 30 to 80 percent, meaning that it can miss the diagnosis 20 to 70 percent of the time. Therefore, basing a diagnosis on a single diagnostic test like an X-ray is not recommended, especially when the clinical picture suggests the presence of the disease.

Second, downcoding the patient from CAP-MR to a less serious diagnosis, like acute bronchitis, which can have a normal X-ray, can result in a reduction in benefits available to the patient. An acute bronchitis case rate will cover only one-third of what a CAP-MR case rate will cover, resulting in a heavier financial burden for the patient, especially if they are accessing private care. This can also lead to incongruence of what is written in the final diagnosis versus the treatment that the patient received, and can result in misunderstanding and legal liabilities for the doctor and the hospital.

Third, not allowing the use of the final clinical diagnosis in the Philhealth record has public health implications. This can distort the true prevalence of a disease in our country and can lead to fewer resources being committed to mitigating the problem. For instance, pneumonia remains one of the highest reimbursed diagnoses, and so it informs the healthcare community and the government that we need to do more to prevent it through vaccinations, and to train more physicians and medical staff to adequately care for all these patients.

Apparently, my post resonated with a lot of doctors, who promptly related their own difficulties and frustrations with these policies and gave numerous detailed examples of denied claims and benefits. To its credit, Philhealth immediately contacted me (on a holiday) and explained that it was absolutely fine to use the clinical diagnosis as the basis for the diagnosis on the Philhealth form. They explained that the chest X-ray was still a required element, but it did not have to be read as pneumonia as long as the clinical picture was compatible. This had been addressed previously following numerous complaints from the hospitals and professional medical societies.

Unfortunately, our hospital billing personnel were still operating under the impression that these claims could be denied as they had been in the past. Philhealth NCR called our hospital billing department directly to clarify the issue, and the patient was able to leave the hospital with full benefits applied. Philhealth NCR also promised to remind hospitals that their billing personnel need to be updated on the latest policies so as not to disenfranchise our patients. Given my previous experiences with claims denial (I still have additional horror stories for another day), I can’t really blame the hospital personnel who may even end up being liable for the difference, as per some hospitals’ policies. Hopefully, this experience has called attention to the problem, and the policies and procedures will improve.

Having done my specialty and subspecialty training in the US, I have had my share of insurance claims denials. I have spent hours arguing with claims personnel with no formal medical training on why I need approval for a specific drug or diagnostic, which is truly an unproductive and frustrating situation. This takes away from doctors’ time with patients and contributes to physician burnout. As we transition to universal healthcare in our country and Philhealth plays a bigger role as a national insurer, I sincerely hope that we do not repeat the mistakes of many countries where doctors need to justify their medical decisions to non-MDs to get proper care for their patients. The quick action I got from Philhealth is encouraging, along with their assurance that they are listening to the medical societies. If they take good care of doctors, we will be able to take better care of you.