Insurance Based Medicine and the world of the ICD

There is a lot to be said about the ability to seek medical care under the protection and financial aid of a medical insurance policy.  In fact the cost of medicine has soared so high in this country that it is very difficult to get help without such support.  But there is one unfortunate part about it all that may actually be working to undermine the success of the therapy and the overall well-being of the patient.  In short I am talking about the ICD-9 code fee structure which dictates how the doctor is paid and therefore how the patient is treated. 

So what is an ICD-9 code?  In short it is a diagnosis code.  For example I often bill insurance policies for neck pain which has the ICD-9 code 723.1.  They seem to like this one and generally pay readily for this diagnosis.  I find that other codes don’t work as well so I end up limited by what diagnosis codes each insurance policy will pay for.  It puts the practitioner in a bind if the patient comes in with a concern that does not fit nicely into the insurance company’s idea of a covered medical condition.  The patient may be suffering nonetheless.   

Now what we also need to understand is that these codes are really just a numerical description of a set of symptoms and not the cause of the problem.  You may have neck pain, low back pain, migraine headache, lower left quadrant abdominal pain, or anxiety to name a few.  But these are just the end product of something at a more base level that created the problem.  Let me put it this way…  Let’s say a person comes in complaining of migraine headaches.  Acupuncture, chiropractic, massage, prescription medications, etc. may just help the symptom (ie. the pain) but what if that migraine is brought on by an unknown gluten sensitivity reaction?  Or what if it is from a chemical sensitivity with a concurrent autoimmune condition?  Or what if it is hormonal?  What are the ICD-9 codes for looking into this kind of thing?  Is there a code for a practitioner to run a predictive autoimmune antibody test or a gluten sensitivity panel?  Well no. These would be considered medically unnecessary given the lack of association that the mainstream puts on these types of conditions, and by the basic standard of care that we receive in the medical clinics today.   But what if these tests held the answer for this patient?  What if missing this little tidbit of info led the patient to years or even a lifetime of medical treatments to quell the symptoms?  Wouldn’t that end up costing more in the end and never really solve the problem?  Wouldn’t that potentially lead to a continuation of suffering for the patient who pays good money to receive help?  Wouldn’t you think that the patient would expect to have their problem fixed (not just moderated) if there were ways to do so?  Well I certainly do and I personally expect nothing less than good medicine if I am paying for services or suffering a medical concern.  I would hope that you agree.

I bring this up today just to shed a bit more light on our medical experience.  Most all of us are completely unaware of how the system works. All we know if that we either have insurance or we don’t!  And those of us that do are usually pretty discouraged to find that the coverage isn’t as good as the several hundred dollars a month premium should probably be.  The medical experience is one of the only services that we consumers have no knowledge about cost before we buy!  In fact the doctors and nurses don’t even know the price.  There is a billing department for that and they generally don’t work with the public.  It is therefore extremely difficult to know before you buy what you are paying.  Where is the empowerment in that? 

So take this little tidbit and go to your medical provider understanding the situation.  Understand that the service you are receiving may just be dictated by what the insurance company wants to consider “medically necessary.”  Understand that the practitioner may not be able to order the proper testing, or provide the proper service under these circumstances.  Understand that most all of medicine is symptom based relief and very little is being done to address the underlying cause.  Do you really always want to use your insurance for your health care?  Insurance companies dominate the daily business and practice of the medical provider.  And believe me when I tell you that it is usually not in the best interest of the patient.  Keep the insurance for emergencies.  That is what it is there  for. But honor yourself and go to a practitioner who is able to order the tests needed and provide the services required to fix your particular concern.  Anything less is just not good medicine!