口腔颌面部正颌外科医疗保险指南的有效性。
Validity of Medical Insurance Guidelines for Orthognathic Surgery.
机构信息
Resident and Graduate Student, Department of Orthodontics, University of Texas Houston Health Science Center School of Dentistry, Houston, TX.
Chairman, Oral and Maxillofacial Surgery Department, Houston Methodist Hospital, Professor of Oral and Maxillofacial Surgery, Houston Methodist Academic Institute, Houston, TX; and Professor of Clinical Surgery (Oral and Maxillofacial Surgery), Weill-Cornell Medical College, New York, NY.
出版信息
J Oral Maxillofac Surg. 2021 Mar;79(3):672-684. doi: 10.1016/j.joms.2020.11.012. Epub 2020 Nov 24.
PURPOSE
The purpose of this study was to assess the validity of the medical insurance guidelines for orthognathic surgery used by the major American medical insurance companies.
MATERIALS AND METHODS
This study assessed the validity of the medical insurance guidelines for orthognathic surgery used by Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To evaluate the validity, we calculated the approval and denial rates of the 5 guidelines when we used them to assess the medical necessity for a control group of carefully selected patients. Patients were included in the control group if they met the criteria of a "prudent provider," crafted for this study. All rejected cases were analyzed to determine the root cause of the denials. The validity of the guidelines was also ascertained by determining their completeness and correctness.
RESULTS
The current study proves that no insurance guideline is in agreement with the criteria of a "prudent provider." When applied to carefully chosen patients, the requirements of BCBS, Aetna, Humana, and Cigna produce modest rejection rates of 6 to 12%. UHC is an outlier. Its guideline rejects 86% of patients, a rate about 7 times higher than its peers. Insurance guidelines disqualified patients for 3 different reasons: 1) no significant jaw deformity, 2) no demonstrable health impairment, and 3) the etiology of the condition is not a covered benefit. Additional evaluations demonstrate that the private insurance guidelines are incomplete, and at times, incorrect.
CONCLUSIONS
This study shows that the medical insurance guidelines for orthognathic surgery used by the major American medical insurance plans need revision. The most consequential flaw was considering etiology in judging medical necessity. Fortunately, only one company adopted this policy. Moreover, all guidelines have omissions and errors in the way jaw deformity is determined and how health impairment is determined.
目的
本研究旨在评估主要美国医疗保险公司使用的正颌手术医疗保险指南的有效性。
材料与方法
本研究评估了 Aetna、Anthem Blue Cross Blue Shield (BCBS)、Cigna、Humana 和 UnitedHealthcare (UHC) 使用的正颌手术医疗保险指南的有效性。为了评估有效性，我们使用这 5 个指南来评估精心挑选的对照组患者的医疗必要性，计算了这 5 个指南的批准和拒绝率。如果患者符合本研究制定的“谨慎提供者”标准，则将其纳入对照组。所有被拒绝的病例都进行了分析，以确定拒绝的根本原因。还通过确定指南的完整性和正确性来确定其有效性。
结果
本研究证明，没有一个保险指南符合“谨慎提供者”的标准。当应用于精心挑选的患者时，BCBS、Aetna、Humana 和 Cigna 的要求产生了 6%至 12%的适度拒绝率。UHC 是一个异常值。其指南拒绝了 86%的患者，这一比率大约是其同行的 7 倍。保险指南拒绝患者的原因有 3 种不同：1）没有明显的颌骨畸形，2）没有明显的健康损害，3）病情的病因不属于保险范围。进一步的评估表明，私人保险指南不完整，有时甚至不正确。
结论
本研究表明，主要美国医疗保险计划使用的正颌手术医疗保险指南需要修订。最严重的缺陷是在判断医疗必要性时考虑病因。幸运的是，只有一家公司采用了这项政策。此外，所有指南在确定颌骨畸形和确定健康损害的方式上都存在遗漏和错误。
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