If it falls under their coverage as items covered yes I do when they say we cover such and such service it should be their responsibility to do so. Not many persons can afford two insurance companies and they dearly love to play the good old the other company is responsible game and place doctor and patient in the middle.
All they need to know is a very basic numerical diagnostic code. They do not need to be making medical decessions on your behalf or rather theirs. The answer is simple. A basic binding agreement of services covered and services not. Insurance companies do not belong in any doctors exam room. The HMO Industry is book cookings just waiting to be discovered. There is no concievable way they can cover their so called plans simply by the way they are set up.
BTW my former employer was my health insurance source. We were self insured. My employer didn't have to know my diagnoses or prognoses all they saw was a simple services code and re-embursed me those expenses with zero hassles along with my medications again all that was required was a print out of prescription drugs total cost to me with just a print out from my drug store. Again they didn't have to know each and every medication I took just my cost.
This was a nursing home BTW that did this. The Administrator and Board of Directors were tired of Insurance Companies ripping them and us off and their never ending demands and denials of services. It can be made simple but the insurance industry by it's very nature and with help from lawmakers is allowed to continue abuses not afforded other businesses or industries.
Those simple service codes are standard throughout the industry. You dont think anyone with half a brain wouldnt be able to determine what the likely diagnosis was by the tests that were done. You get a VDRL and they will know VD. You get a code for seeing a psychiatrist, they will know you are not there to clean your teeth.
All they need to know is a very basic numerical diagnostic code.
Those codes that you speak of as if they are the be all and end all are, in actuality, nothing more than a very general idea of where to account for the payouts of the insurance company. They are anything but definitive. You think that the insurance does not need to know the diagnosis to pay prescriptions, just try to file a prescription that does not match any known diagnosis. It will be denied.
You tell me that the insurance company has to pay according to the contract, but then you also tell me that they do not need to be able to verify that what they pay is in accordance with the contract. That makes no sense. Do you pay bills because they are sent to you? or if they do not make sense do you start asking questions and refuse to pay until you have answers?
Now, back to the coding. When I first worked in insurance in the early 80s I got an unusual claim. It was from a surgeon, there was not prior history (some think that does not matter), there was no diagnosis, there was a code for surgery. The bill was $1000. My guidelines said that the prevailing charge for that kind of surgery in my area would allow me to pay $25. Was this mis-coded? No. Was this fraud? NO. I requested more information, that lead to my requesting more information. After receiving this information I realized that the code that was given was for a large laceration, but not so large as to be defined as "other". While the laceration was not huge, it was deep. It was also a laceration to the skull. It seems that this insured was heading to college on his motorcycle and was not wearing a helmet. He was in an accident and cut his skull very deep. The coding was not designed to tell how deep a laceration was, and certainly did not account for a skull injury. After the details came in there was certainly justification to pay for the surgery. Also after I paid the surgery and anesthesia bills and a couple others that had come in the meantime, another bill came in. Because of the work I did to get details early on the person who got the surgery bill didn't do much other than blink when she got a hospital bill for $200,000. She ask the supervisor, then paid the bill. Information is needed, especially in a complicated field such as medicine, and having the information may seem a pain and time consuming, but it can also make a difference.