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First let me say I have not been in the insurance industry for several years, but I do understand the concepts and the whys and wherefores.

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.

I could give you many an HMO horror story. When you have been a care giver for 17 years 10 of that fighting an HMO tooth and nail then we'll discuss it. Right now I'm waiting on yet an appeal of yet another denial of service for a possible life threatening problem my wife has. It's been 90 days. Nobody at Hey Moe central can locate the appeal Imagine That. This appeal was to go before an Admin Judge. Someone who could have set them straight. So we'll wait and use the Emergency Room instead and let what would have been about a $1000- $2000 outpatient procedure turn into a week of IV of anti-biotics in a hospital room costing about $10K. But hey what do I know about it? Fools can't say we didn't try to warn them. Yes we proved medical necessity for the procedure but not to the likings of Dr Ghost Practice at the HMO's medical board. I consider the patients regular doctor and the surgeons letters recommending the procedure sufficent for medical justification. BTW Dr Ghost Practice at the Hey Moe never saw her. Let any other medical doctor try making this type of judgement about surgery without an exam and let's see what happens to their career. HMO's by act of congress are exempt.