It’s scary to be denied health insurance or a job due to a health condition. It gets even worse when our medical records contain diagnoses and treatments for conditions we do not have or never have had. It might lead to a full-fledged denial of insurance or job. Other doctors may even end up misdiagnosing us or prescribing incorrect treatment based on the off beam information in our charts.
How can this happen, you ask?
This usually takes place due to doctors constantly having to authenticate their practices to the dictates of insurance companies. Insurance companies recompense for diagnostic testing and treatments for an ailment or condition, or even a symptom, but they do not rule out a disease or condition.
If one experiences persistent tingling in the hands, feet, lips and ears, few months down the line, one decides it needs to be checked. The primary physician may detect nothing wrong on examining. He may then refer you to a neurologist and may have you get a CT scan done. He may add tingling as the diagnosis, because the symptoms are all he has to go on.
Later, even the neurologist may detect nothing on the CT scan or on examining you but will want you to return for an EMG. He might also send you for an MRI to rule out multiple sclerosis. He may add a diagnosis of MS on the referral and the bill for the office visit, expecting your (very good) health insurance plan to cover tests for a diagnosis of MS.
The MRI might show a possible tightening around a nerve, but this wouldn’t necessarily cover the tingling on only one side of your body. Since you tingle on both sides, ‘pinched nerve’ isn’t really the correct diagnosis for you. But they’ve ruled out MS.
When you return back to the neurologist, expecting the EMG, he tells you that you must have carpal tunnel disease, because you spend your days working at a computer. That’s exactly what he must be looking for, so that’s what he finds. He completely ignores the tingling in your feet, earlobes and lips. And thus, carpal tunnel disease is added to the list of diagnoses on your medical record.
Your health insurance company now assumes that you have MS, a pinched nerve and carpal tunnel disease. That’s because it’s in their records of the claims filed for your medical bills. You will have none of these. You may have a mild tingling.
The incorrect diagnoses gets compounded, because the office clerk sees MS and carpal tunnel from the prior visits and puts that on all subsequent referrals and bills. It came from the doctor, so the question arises that why should it be questioned.
It would be very easy if we needed to apply for a private, individual health insurance plan.
Knowing the neurologist had tunnel vision about carpal tunnel disease, you may move on to another neurologist, who may confirms there’s no evidence of carpal tunnel or MS. At this point, he may detect some mild loss of temperature sensation, but has difficulties coming up with a firm diagnosis and so uses ends us using ‘peripheral neuropathy’ as his diagnosis. All ‘peripheral neuropathy’ basically means is that there’s something odd going on with your sense of touch. It’s a catch-all term that your symptoms fit into. It’s not as good as a diagnosis of a disease, because it suggests no treatment plan or prognosis. Insurance companies might cover testing for it. However, it may turn out better than a lot of incorrect diagnoses on your medical record, because you can be least assured that it is accurate.
It would make perfect sense for the insurance companies to just accept ‘rule out’ diagnosis codes and to pay for charges incurred for them. Because, the whole point of diagnostic testing is to find out what the problem is, and that very often involves ruling out certain possibilities. Another solution for doctors is labs, etc. to just use the diagnosis codes for the symptoms the patient is reporting. In this case, ‘tingling’ could be second-handed as the primary physician wrote. Or the physician could pick a generalized descriptive diagnosis like ‘peripheral neuropathy’ as the second neurologist did.
Unfortunately, patients cannot count on medical providers to do this. One has to have a look at what’s on the bills and in the records. Most of us wouldn’t know what the diagnosis codes meant.
Technology helps, because both procedure (CPT4) and diagnosis (ICD9) code translators are now on the Internet. With EHRs (electronic health records, the patient’s medical records) are becoming more available. This will enable us to see all the details right in our records. If we come across an incorrect diagnosis, we could then insist that we want it corrected.
We need to be meticulous about this if we don’t want incorrect medical information to take over and give us results in denial of coverage or in causing our physicians to miss a diagnosis or give the wrong treatment.