Insurance carriers and third party administrators (TPAs) sometimes develop guidelines that document their understanding of a medical condition and their process of administering claims and payment for treatment and services for or related to that condition.
Different administrators refer to these guidelines with different names, names that can reflect subtle differences in the administrator's focus. For example, these guidelines may be called "Medical Policy,""Clinical Guidelines" or "Utilization Management Policies."
What guidelines do
Guidelines are generally intended to:
- Ensure that highly technical or expensive treatments are used only in those cases where they are specifically medically indicated in order to maximize the success (and therefore the cost effectiveness) of treatment; and
- To minimize medical errors by helping to ensure that particular treatments are well-matched to a person's clinical needs (e.g., that the individual has been appropriately assessed for treatment; and
- To demonstrate consistent approach to specific areas of medical concern, including the administration of claims (e.g., prior authorization of services) and subsequent claims payments either to providers or to the insured individual; and
- In the case of managed care plans (e.g., Health Maintenance Organizations or HMOs), they may also be used to guide treatment by the participating network of care providers.
Guidelines typically cannot override the exclusions or other specific language in a given insurance plan; however, in the absence of exclusions in a given plan, guidelines are usually assumed to guide insurance coverage decisions/determinations.
Does every condition or treatment have a guideline?
Guidelines are most often developed for conditions for which there are choices between treatment options of varying costs and effectiveness, or for treatments for which adhering to a particular protocol has been shown to be particularly effective. Guidelines usually outline internal procedures and provide detailed references to medical journal articles validating the specifics of treatment modalities that have been most successful or, conversely, which have been less so.
Most such guidelines are reviewed on an annual or biennial basis, to ensure that they reflect the most recent medical practices and standards of care. Nonetheless, many guidelines specific to transition-related treatment do not reflect current medical practice as indicated by the World Professional Association for Transgender Health's Standards of Care.
What about guidelines for treatment of transsexualism?
Many carriers have guidelines specific to the treatment process for sex reassignment, but may be titled variously (e.g., "Medical Treatment of Gender Identity Disorder", "Sex Reassignment Surgery", "Gender Reassignment Surgery"). However, significant gaps exist between these policies and the most widely recognized protocols for treatment of transsexual individuals: the Standard of Care issued by the World Professional Association for Transgender Health (WPATH SOC).
As a result, to ensure that their transgender employees' and employee dependents' healthcare needs are covered, employers may need to specify coverage that is consistent with current medical practice.
How can I find guidelines?
Guidelines are sometimes available on an administrator's public website; however, many administrators' guidelines are not available outside the insurance company, making it more difficult for employers and employees alike to assess how coverage under a particular plan will be handled for a given condition. This is true for many conditions, not just those related to transition care.