Clinical practice guidelines refer to current research based standards that govern the level and type of health care coverage provided for categories of diseases and conditions. These guidelines are in place to ensure that individuals receive care that is appropriate to their needs. Such guidelines also ensure that, should a patient have to relocate or travel, the standards can travel with him to ensure uninterrupted appropriate care and treatment.

Clinical practice guidelines are perpetually under revision based on emerging scientific research data and case studies. Health insurance companies, however, seldom move as rapidly as clinical research does. A health insurer has its own set of policies and guidelines that are followed to the letter when a claim is presented for payment. This explains the difficulty that frequently arises when either pre-authorization for treatment is required and the health insurer balks, stating non-necessity, or when medical care has already been provided and now it is time to submit for the reimbursement of the claim. As anyone who has ever had to fight with an insurer knows, it can feel a lot like getting a crash course in the legal system to go through the process of keeping accurate records, following the appeals process, calling in expert witnesses, and finally reaching a verdict.

The good news is that these guidelines are a claimant’s best friend in the instance of a disagreement between care recommended by a treatment professional and what an insurer may recognize as a medically necessary and thus covered expense. Since the sole purpose of these guidelines is to revise and refine the quality and effectiveness of health care over the long term, it is actually in the best interests of health insurance companies to learn about newly revised standards and revise their own coverage policies accordingly. By implementing health care measures to address problems in the most efficient and effective way, insurance providers avoid paying for unnecessary or ineffective claims, or paying too much for a course of care that is less or ineffective.

Insurers will caution medical professionals against using the guidelines as the sole source for recommending a course of care, and this too can be an ally in the patient’s corner. When current guidelines do not fit the course of care recommended by a treating professional, it is possible to make an argument for inclusion of coverage for new medical practices that are more effective. Ultimately, these guidelines aim to point coverage levels toward the most effective treatment modalities, and patients can feel reassured that, in following these guidelines, their insurance carrier is acting in good faith to provide the full range of coverage available to patients and their families.