They way insurance handles things

[DonFL (imported)]

I used to work in a central databasing & processing company. We basically processed "live" prescriptions and doctor billing for pharmacies and doctors. We also got to support them when they had billing issues, mostly incorrect ICD9, CPT, or MTMS codes, or they were trying to bill insurance something funky like baby diapers. Ive seen the system from the inside and how it works.

When your calling member services for your insurance, often you were calling one of the database companies groups setup to handle large insurance companies, not the actual insurance company itself. All the big-boys ran though us, 43 of the state medicaid programs, BSCS, Aetna, hartford, and several others i cant think of.)

ALL the major pharmacy chains ran though us, Wallgren's, CVS, Eckards, Walmart, Albertsons, Winn dixie, Publix, Target, and many others. We had entire support groups just for the individual large accounts. Then of course tens of thousands of small chain and independents were connected to us also.

That company didn't store its processing till recently, now its stored and shared between insurance companies and doctors and pharmacists ive heard from some ex-coworkers. Mass petabyte hard drive arrays now make this possible.

One of the runarounds on the pre-existing/elective rule, is after 12 months of coverage in almost every state, some are as little as 3 months, they still have to cover it if it effects your over-all health. Cosmetic corrections are excluded, such as a botched breast enlargement or testicular implants. In many states, if you receive no medical care for an issue 12-3 months prior to the condition, they also cant exclude it as its not considered an actively treated "pre-existing condition". In Florida is 3 months on the state contract with BCBS, it varies by both state and employer. Even then, 12 months after coverage enrollment, all pre-existing condition limits are "sunsetted" and they must cover them under the HIPAA rule as i understand it.

These are group rules of course, most of us cant obtain insurance through any other method anyways. And if we do manage to do it, they start the "death spiral" technique on the plan your on to get you to drop or drop dead, literally. Basically they raise your plans premiums while offering customers who have no to little claims to a cheaper plan, moving them out of the pool your in, eventually its distilled to the worst of the patients, whom they then raise the premium so high no one can afford it (ive heard over 2000$ a month for a 3 person family). There has been legislation proposed to stop this technique, but since its how the insurance companies make so much $$$, it gets halted with lobbyist dollars.

Dr Kimmel works for cash, your procedure never enters the system, the system will never know it was elective, unless you tell them. Same with every other doctor you pay cash for. For them dont give ID and your SSN, say you dont have it memorized and left it at home, for cash patients they dont need it anyways unless your being prescribed a class 2 drug. ID is just to verify the (i know at least Florida has one, dont know if its national or not) narcotic database (stops doctor shopping) and insurance payment identity verification.

I had a consultancy with Dr Reed a while back (a SRS and orchiedectomy doctor) i paid cash for, his office doesn't even ask for SSN and ID...

If they even ask how they were lost, tell them it was an accident, you now have ICD9 878.2 (Castration, traumatic) or just often the doctor will just report 257.2 (Other testicular hypo-function, Eunuchoidism) on your file for life, there is no investigation as this isn't something the mainstream does. If you do it yourself and go to a hospital, they will hold you on psyc grounds, and the injury is considered related to psychological disorder, which means its covered if you insurance has mental health benefits, and most likely the physical side will be also if you dont because you did it under psychiatric disorder and therefore not responsible for your actions. Some insurance companies will kick and scream, but if you get a letter from a shrink stating so, they have no choice. Before you leave be sure you have one from the exit interview shrink...

Most doctors HATE the insurance system and wont help them at all, all they report is the diagnosis code. If YOU DON'T SAY it was voluntary, then they will not enter it as such. There is NO rule that says you have to say a condition is voluntary or not to your doctor, there is no rule they have to ask.

There is actually no ICD9 Code for voluntary elective castration, the closest would be 050.80 (Elective surgery for purposes other than remedying health states), and its rare a doctor will go though the trouble to look that up, its not something they are going to have in the top of their head. They would have to enter it as a sub code, and most of the insurance filing interfaces on the computers dont have sub-coding capability yet, so they would have to file it paper. Now how likely is that? The program interface has one ICD9 blank per diagnosis & one diagnosis blank per office visit. They have multiple PROCEDURE code blanks, but usually only one diagnosis blank.. there is a reason for this, but if you go have an office visit for multiple problems, only the most major one gets reported.

In fact, while i was contracting for many doctors offices in the last 6 years, i never saw one yet that had multiple diag and ICD9 capability. The communications protocol to transmit the infomation developed 15 or 16 years ago is also simple, designed for over phone lines (now often virtual serial connection over Internet IP VPN connection) it only has the capability for one diag code at a time. An entire overhaul of the system or multiple transmissions would be required, making the insurance companies re-do their back end also. This isn't going to happen quick...

All it is is a number in the system, no one in the insurance company cares and no one even knows what it means unless they look it up. All diseases and injuries are just #s to them, they dont care. They only care WHEN the disease was last TREATED if the policy is less than 12 months old. If its last professional treatment date is beyond your 3/12 or 6/12 or 12/12 rule, then they have to pay it.

Since i didn't get professional medical treatment in the last several years for my condition (or any condition, even so much as a cold i never went to a doctor, and excluding myself which doesnt count since im not licensed), I just "certified" that fact over the phone and that cleared authorization for all ICD9 codes that were not on my ICD9 prior authorization list after having to call and get several bills reprocessed due to lack of treatment beyond the HIPAA sunset rule.

Once an ICD9 is in it, its there forever, now how things are reported is your doctors choice. If your concerned how your doctor is going to report it to the insurance company, if he/she is going to report info that may adversely effect you, i would recommend asking if they would please report it more generally, such as just Eunuchism 257.2, many doctors are sympathetic and will, they dont like the system any more than we do, and they dont get paid any more for a more severe ICD9, just for additional procedures in addition to an office visit...

Ever wonder why many doctors offices suddenly stopped giving antibiotic shots? Its because the insurance companies have mostly stopped paying for it.. just one example of how they have effected routine medicine.

This is just a little window of how the system works guys, i could go on and on, how you handle things is your choice, but you need to be aware of how the system works.

[IbPervert (imported)]

Have you seen Micheal Moore's movie Sicko? and if so what did you think of it

[DonFL (imported)]

not yet, but if its what I think it is, i agree with most of his viewpoints..

[plix (imported)]

Thanks for the info.

I know that my doctor put 257.2 on my lab forms. But I do not know what he put in my records. This office uses the new electronic records, and I don't know exactly how accessible those are to future insurance companies.

[DonFL (imported)]

RE: Electronic record keeping sytems.

this is a condrum. Most places Ive worked at its for records only, not billing. UofM does this also. Most of the billing interfaces are on DOS emulators still.. UofM does this also. lol.. As infomation is so easily transportable, I think privacy issues start to kick in.

The insurance companies need to know your diagnosis, not the fact that someone tortured me 20 years ago and destroyed the remains of my reproductive system. It falls way outside their coverage limit sunset, and is frankly none of their business. Its hard enough talking about it with my doctor, how would i feel if its being shared with a hundred insurance case workers?

I think new privacy legislation on infomation restriction needs to be introduced and passed. These records may contain psychological infomation too, which is not covered under the HIPPA act. The insurance companies currently makes demands for records regularly from all my doctors, and most of them send in one page summery reports. My psyc doctor certanily dose not send them her notes, they are no way any business of my insurance company. The only thing they need to know is im under treatment for severe depression and PTSD.