AIA-min

AIA 照美國標準處理索償申請有乜問題?

AIA 最近為咗控制醫療保險索償成本,向醫生發出一封信,如果照腸鏡果啲,如果證明唔到係醫療上必需(medically necessary),就只會用日間醫療中心嘅水平喺俾番索償,唔會當入院咁俾賠償。醫學會蔡堅班友之後就發爛渣,又話決定medically necessary嘅權力喺醫生手中,唔喺保險公司手上,物物乜乜。

我諗蔡堅,肯定當咗啲香港人,好多未喺外國睇過醫生,其實 AIA 嘅做法,係連美國政府自己都咁做。

AIA 旨在防止保費上漲

喺美國,買過政府Medicare嘅人,都會知乜叫medically necessary,呢個定義唔係無標準,呢個定義係有美國政府嘅標準,根據美國政府定義,

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

來源:https://www.medicare.gov/glossary/m.html

成個定義有兩個重要元素:需要(needed),同埋合符醫療容忍標準(accepted standards), 簡單嚟講,果啲optional嘅嘢,已經唔叫medically necessary,例如大部分情況,入私家房都唔會叫medically necessary。

就算喺美國,照腸鏡呢啲嘢,計費用係當assignment,乜叫assignment,

An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

assignment嘅費用,係要醫生同醫療保險供應商,即係政府同意,同埋張單可以扣幾多錢,係政府話事,唔係你班醫生大帝話事。

當然,友邦封信係簡單咗啲,喺美國,Medicare啲費用點計,係有個database,講明果啲service,喺medicare嘅角度,係咪一定要留院,而medicare網頁都有以下警告字眼

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

醫生或醫療服務供應商,見你係保險客,美國都recommend services more than medicare covers,更何況香港?依家周一嶽嘅做法,只不過想揸正嚟做,特別依家香港唔似美國,有政府醫療保險嘅classification去跟。但如果照美國政府嘅玩法,明明可以日間醫療中心搞掂嘅事,要送入私家醫院,除咗要賺多啲,搞到保費上升,我睇唔到其他理由。

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