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Understanding Health Insurance in America

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Routine vs Medical [Jun. 10th, 2006|06:44 pm]
Understanding Health Insurance in America


Routine services verses medical services

I'll start out this post by pointing out, right off the bat, that the words "routine" and "medical" do not mean the same thing in the insurance business as they do in regular English.

Why you should care:

Health insurance generally has different coverage for routine care, as opposed to medical care. Whether the routine coverage is "better" or "worse" depends on the policy and, sometimes, your point of view. Sometimes routine care is not covered at all. How will you know? Well, you've read your Plan Document, right? Right??

Routine, in insurance terms, is synonymous with screening or preventative. Routine services are those things that doctors recommend to ordinary people, who are healthy as far as they know, in order to screen them for things that may not be causing symptoms yet.

Medical services are those which are recommended by a doctor in order to diagnose symptoms, or treat or monitor a known medical condition. If it's testing that's being done, it might be called diagnostic testing.

Note that the exact same service can be either routine or medical, depending on why it's being done:

- A routine, annual gynecological exam and Pap smear is recommended for all women, symptoms or no. This is routine.

- If you have an abnormal Pap and have had treatment for it, and your doctor wants you to come back in 6 months for a follow-up Pap, that is medical.

- Checking your blood pressure as part of a regular annual exam is routine.

- Checking your blood pressure when you are on blood pressure medication for hypertension is medical.

- A colonoscopy ordered because you have reached the age of 50 is routine.

- A colonoscopy ordered because your dad was just diagnosed with colon cancer is probably routine but you should check with your insurance carrier or administrator. Different companies see this in different ways.

- A colonoscopy ordered because you are having rectal bleeding is medical.

- A mammogram is recommended for all women annually over the age of 40. This is routine.

- Going back for a second mammogram because your first one was abnormal is medical.

- Genetic testing recommended because your sister has been diagnosed with cystic fibrosis and you want to know if you carry the gene for it is routine.

- Genetic testing recommended because you have symptoms which are defying a sure diagnosis in a more conventional way, and which might be diagnosable by checking your genome is medical.

The rule of thumb is that if you (you personally) have no symptoms and you are not being treated or monitored for a known medical condition then the service you are getting will be routine.

Now, I know that in the normal English language, "routine" is used to mean something you do regularly. However, just because you "regularly" go back to have your cholesterol checked every three months does not mean that your cholesterol checks will fall under your preventative benefit. If you are having your cholesterol checked that often, it's a safe bet that you have high cholesterol and you are being treated for it in some way. That "high cholesterol" diagnosis makes your testing medical in nature.

Also note that "my doctor ordered this" does not make a routine service into a medical service. Generally, I would hope, your doctor orders every test you have done; most people don't walk into an endoscopy center off the street and ask for a colonoscopy, after all, and labs won't do more than look at you funny if you come in without doctor's orders and want your cholesterol checked. The reason why your doctor ordered the test makes it either medical or routine.

You should make sure you know, up front, why your doctor recommends everything. Usually it's pretty obvious, but if it's unclear you should ask ... is this because of my age/gender/ethnic group/social history or because of symptoms? You can be assured that your insurance company will ask, and how your claim is processed will depend on the answer.

You do not get to "pick and choose" which benefit your health care service will fall under. You may prefer to have something covered under one benefit versus another, but you can't select which benefit you'll get. You should know ahead of time what you're getting into, so that you can make informed decisions.

You should also note, when you read your Plan Document what kind of benefit you have for routine services. (You have read it, haven't you? I know I asked this once, but I really have to emphasize that you should.) Some plans have no coverage for routine services at all. It's also common to have a dollar maximum per year, and if you go over that with routine care, the excess won't be covered. Many have no coverage for adult immunizations. It's very important that you check this before you head in for your annual exam. Do not assume that your particular plan will cover anything your doctor recommends. If you do, you are liable to be in for a nasty shock.

A few more examples:

- Immunizations, by definition, are routine in nature. They are preventing you from catching a disease - you don't already have the disease. Although flu shots are definitely recommended for certain groups (such as the elderly), they are not treatment for the flu. They are prevention of the flu.

- Conversely, some premature babies are born with compromised, immature immune systems, and are given immunoglobulin injections to boost their immune response. This is not routine, and not preventative ... although it may seem to be "preventing" communicable disease, it's actually considered to be treatment for the baby's abnormal immune system.

- Similarly, as premature babies get older, they are often given injections of a drug called Synagis during the flu season, which helps to prevent them from catching the flu (which can be quite damaging to a child who was born prematurely). Although this might seem routine, it isn't ... because it's only recommended for children with very specific medical problems, and is again considered to be treatment for an abnormal immune system, and falls under medical. In both of these cases, there is a known medical problem (a compromised immune system) which is being treated.

- Tests which are run because you are pregnant are always considered to be medical (and there is often a special obstetric benefit for these). Why? Because there is a known condition (pregnancy) and these tests are part of the treatment for it.

- Routine services are usually billed using what are called V-codes. The V-codes are ICD-9 (diagnosis) codes which begin with the letter V. Examples are V76.2 (screening for malignant neoplasms of the cervix - which is to say, a routine Pap smear) and V20.2 (routine infant or child health check). However, there are a lot of V-codes which are not routine. Such as V58.1 (encounter for chemotherapy) and V54.0 (aftercare involving removal of fracture plate or other internal fixation device). I don't know of anyone who would consider chemotherapy, or having a screw removed from a bone to be preventative in nature. V-codes are therefore not a very good indicator of whether your service is medical or routine, and you shouldn't let your doctor's office tell you that something will fall under the routine benefit just because they are billing with a V-code.


[User Picture]From: jaymirage
2006-06-12 05:44 am (UTC)
I'm very impressed with your essays, here. I, too, have begun a career in the health insurance arena, and the works you have posted are truly indespensible. Keep it up!
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[User Picture]From: anax
2006-06-12 08:38 pm (UTC)
I try to update about once a week. I'm glad this is helpful!
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[User Picture]From: crabapplemoon
2006-06-16 02:11 pm (UTC)
I hope this will allow me to comment....I've only just joined.
I just wanted to say THANK YOU SO BLEEPING MUCH for creating this comm!!!

I have a lot to learn. O.o

I'm reading thru the Memories section before I ask any questions here.
Thanks again.

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[User Picture]From: anax
2006-06-16 09:18 pm (UTC)
It should allow anyone to post comments, although I've set it so that only I can make full posts.

If you have a specific insurance problem, I can try to help ... although not everything can be fixed, I'll do my best if it's fixable. You can comment anon if you like.
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