The Salty Side of ICD-10’s

Note: Given the current political climate, allow me to state off the top this is not a political post, so please do not respond as if it were. The challenges discussed below exist regardless of political affiliation, healthcare plan and coverage, or policies of the current or previous administrations.

If the world were a perfect place, our insurance plans would always cover everything, the TSA folks would have the word kindness written into their job descriptions, and Doritos would be considered a health food.  I would love to say that there’s possibility for one of these three, but I can’t, unless you can convince someone at the FDA those green specs on Cool Ranch Doritos really are tiny vegetables.

Good luck with that. Keep me posted.

Some time back in late 2015, the folks who sit atop the highest tower in the land of majestic insurance suites moved from their beloved ICD-9 code definitions on up to ICD-10. The move was, for all intents and purposes, a functional step in the ever increasing land of confusion known as insurance coverage.  Actually, it’s the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Heath Organization (WHO) – kudos to our friends at Wikipedia.  The revision was, their latest attempt to better define the multiple diagnoses now prevalent around the world. At last count, there were 68,000 of those definitions.  Depending on where you sit in the current healthcare paradigm, this might be good news, and it might not. A doctor who removes warts from your big toe, for instance, may be happy as a clam since he or she now has multiple codes to choose from. (Note: I just used removes warts and happy as a clam in the same sentence – you’re welcome) For the providers, who at times are referred to as “fringe” or “experimental”, which by the way is my personal favorite, ICD-10 has become just another hurdle in our daily routine. There are a few loopholes to be found, but generally speaking, life gets challenging in a hurry.  Patients hope their respective plans cover our services at 100%, we have the privilege of telling them “no such luck”, and sadly, the only winner left standing is the third-party with their ever burgeoning bank accounts. It’s akin to playing a real life game of Jenga, trying to figure out which blocks of treatment can be had before the entire the coverage tower falls, and there’s no clear path to victory.

jenga

It always bothers me just a little too much when we allow insurance carriers to dictate treatment.  When you stop and think about it, a company responsible for collecting and redistributing financial assets is making decisions about our respective medical futures, albeit by way of an indirect path. Essentially, they give you a choice: pay for it yourself or don’t receive treatment. Should we come across a treatment like Vision Therapy for instance, which may be somewhat, partially, or not at all covered, the choice becomes challenging. On the one hand, there’s a credible doctor’s office reporting findings and recommending treatment which may, in fact, be helpful; and on the the other hand, there’s a third-party coverage team saying “nah, not worth it”.  This all came to light recently, as it seems to do a few times per year, when I was speaking to the mom of one of my patients.  Her son has an alternating esotropia (inward eye-turn) and has been receiving treatment in our office for the last several months, and making some nice gains.  Sometime last December, her insurance carrier notified her of an “adjustment to her coverage after careful review”, effectively eliminating Vision Therapy and Occupational Therapy from their plan.

I could, at this juncture, go on a rant about how I feel about insurance companies, perhaps by even making a crack about legalized extortion, but I’ll leave you to your own perceptions.  The bigger point to be had here though is the damage this inherently creates in the relationships we have with our patients, and I’m not just thinking Vision Therapy either. Several colleagues in the OT, PT, and SLP arena with whom I’ve had this conversation, express similar frustrations. While I’m sure patients try to keep it separate, I would venture a guess there’s some out there who “despise an office” simply because of the challenges incurred while deciphering their insurance plan, and not all because of the quality of care. My only hope is that someday, somehow, patients understand their insurance company exists to make money and to stuff their own coffers. Sadly, that process does not always include 100% coverage.

As a solution for the aforementioned mom whose insurance carrier “changed their minds on coverage”, our approach was pretty simple.  We communicated simply that while the relationship between our office and the insurance company is a necessary evil of our business, it in no way surpasses the importance of our relationship with our patients.

Her son needs our help. We’re going to make it work.

Want to read more? Please join my Vision Therapy: Insight Out book project by clicking here!

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Posted on January 22, 2017, in From My Perspective.... Bookmark the permalink. Leave a comment.

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