Clarification of Benefits , Allow Cost Comparisions and Speed Claims Payments

Health insurance coverage should be defined by specific ICD-9 codes with associated numbers of CPT-4 (service) codes allowed for each diagnosis.  This structure would permit : benefit and cost comparisions between insurers, allow patients to understand which health problems are covered, and the number of units of service related to that diagnosis are allowed per unit of time. (spell of illness, month or year).

Many Health insurance contracts, written in vague language  decades ago, permit insurers  to interpret coverage or deny beneifts at will.  One insurer can have thousands of iterations of one contract.  This causes confusion in the market place, makes them difficult to compare,  provides opportunities to misfile / mispay claims, and creates concerns for patients left wondering what is or isn't covered.

          For years, the health industry and government has used ICD-9 codes to define specific diagnoses and health related conditions.  The American Medical Association developed the CPT-4 system to specifically define medical services.  Both systems are currently used by health providers to file claims. 

          There two systems could be combined to clearly define which medical conditions are or are not to be covered under a specific healthcare contract.  The CPT-4 system could be used to associate the number of units of  specific services to be allowed per diagnosis with an added provision to define a time period in which the services could  / should be provided, i.e, "spell of illness," or unit of time, one year or one visit. 

          I would suggest some large national health related organization bring together appropriate groups of medical specialists to help establish the number of units of CPT-4 codes that should be associated with a given diagnosis code.  Insurers would have the responsibility to establish what service would or would not be covered based upon a purchaser's request or financial goals.

          This system has the potential for tracking utilization and could form the basis for a quality review system. It would allow the "payer" to evaluate the need for or the elimination of selected services (codes), negotiate fee schedules and establish incentive programs based on proper and effective utilization of services.

           This proposal could be started now and used as a spring board for future national insurance programs.

         

This author consults with leading institutions through GLG