I AM LIVID - advice appreciated

[Anonymous]

I don't know where else to post this question, so here goes.

I got pregnant during the summer of 2008. In August of '08 we found out that the baby had anencephaly. We were devastated. This would have been our first child. We terminated the pregnancy upon the advice of my doctor and due to the fact that we really felt that there really wasn't a choice. The pregnancy wasn't a viable one.

BCBS(Federal) denied the claim for my doctor, the anesthesiologist, and the hospital. I appealed the claim because I was told that it was coded as a voluntary termination. BCBS benefits state that they only pay for terminations when the health of the mother is at stake or in the case of rape or incest. I sent the medical records of my pregnancy to the appeal board. I believed that when they saw that it wasn't a viable pregnancy that it would fall into an exception. I got a letter today denying the claim stating that my health wasn't endangered by the pregnancy.

First, if anyone has any advice about how I should proceed, I'm all ears.(or eyes as the case may be) The letter states that I can appeal this to OPM but that the arguments must fall into the "health of the mother" exception. I find it astounding that BCBS would rather have paid for prenatal care and L&D for a child that was definitely going to be stillborn or for certain die within several hours of birth. In addition, adding insult to injury, I'm already pretty fragile because this Tuesday is what would have been my due date.

Right now I am so angry I can't see straight; however, I am also open to anyone out there who believes that I should just suck it up and pay for this out of pocket. My husband and I have the ability to pay it by using some of our savings. Am I wrong to believe that I shouldn't have to?

Thanks.

[Anonymous]

I'm sorry that you have to go through this. I suggest you talk to your Benefits department. If your company is self-insured, they can override BCBS's decision. Good luck.

[Anonymous]

I am so sorry for your loss. My friend had the exact same thing happen but it was covered by insurance (NJ). I would consult an attorney. If not paying the medical bills has a negative effect on your credit, etc... then I would maybe consider paying. I had a medical claim that kept getting denied for over three years. I explained everything to the collection agency and they worked with me on getting the appropriate authorizations from the hospital. Going into collections will not affect your credit as long as you communicate with the agency.

Not saying that collection is where you're headed but please know that if you pay out of your pocket it may take years for you to get your money back. I too was in an emotional state and was going to pay the $8K bill. My husband said no way and we fought it but it took years of calls, paperwork, etc... It never impacted our credit. Good luck!!!

[Anonymous]

You need to appeal to the next level. And you need to have your OB write a letter including STRONG and SPECIFIC language - even quoting the terms of your contract - about the medical risks and dangers to maternal health of a situation involving fetal death in utero and subsequent late term abortion.

VERY IMPORTANT: You also need to talk with your OB and the other providers involved and have them RESUBMIT USING THE CORRECT CODE NUMBER for termination in cases of pregnancy endangering the health of the mother. From my research, it looks like ICD-9 655.00 Known or suspected fetal abnormality affecting management of mother [central nervous system malformation in fetus, fetal or suspected fetal anencephaly].

See:

http://icd9cm.chrisendres.com/icd9cm/index.php?action=child&recordid=6416

Managed care sucks. I am very very sorry you are having to deal with this after such a loss.

The fault in this situation also lies with the care providers who should have coded the procedure correctly in the first place. Managed care workers are like monkey who can only do what your contract allows them to do - and it's all based on correct code numbers. And, a little known fact, is that more than 90% of people who persevere with their appeals to the final level end up winning. But it's horrific that it's set up this way at all.

Best wishes to you and GL.

[Anonymous]

Keep appealing and keep the hospital, etc. informed that you are appealing. Do NOT pay the bill. If you can get your doctor to help you by writing a letter in support of your appeal---try to frame the appeal as "health of the mother"---the potential dangers to your ability to have future children had you carried that pregnancy to term and faced complications during delivery, the danger to your mental health in having to complete the pregnancy and watch your child die. I would think that there are several "health of the mother" arguments that can be made in support of your claim. I am so, so sorry you are having to relive this through fighting with the insurance company. Best of luck to you.

[Anonymous]

Definitely appeal to OPM. I used to work as a benefits administrator for a self-funded government plan (not feds, but state). We would overrule the denial in that case. I can't promise that OPM will do the same, of course, but write a letter explaining your circumstances with the appeal.

[Anonymous]

Anonymous wrote:I'm sorry that you have to go through this. I suggest you talk to your Benefits department. If your company is self-insured, they can override BCBS's decision. Good luck.

OP said it's the FEDERAL BCBS.

[Anonymous]

Anonymous wrote:You need to appeal to the next level. And you need to have your OB write a letter including STRONG and SPECIFIC language - even quoting the terms of your contract - about the medical risks and dangers to maternal health of a situation involving fetal death in utero and subsequent late term abortion.

VERY IMPORTANT: You also need to talk with your OB and the other providers involved and have them RESUBMIT USING THE CORRECT CODE NUMBER for termination in cases of pregnancy endangering the health of the mother. From my research, it looks like ICD-9 655.00 Known or suspected fetal abnormality affecting management of mother [central nervous system malformation in fetus, fetal or suspected fetal anencephaly].

See:

http://icd9cm.chrisendres.com/icd9cm/index.php?action=child&recordid=6416

Managed care sucks. I am very very sorry you are having to deal with this after such a loss.

The fault in this situation also lies with the care providers who should have coded the procedure correctly in the first place. Managed care workers are like monkey who can only do what your contract allows them to do - and it's all based on correct code numbers. And, a little known fact, is that more than 90% of people who persevere with their appeals to the final level end up winning. But it's horrific that it's set up this way at all.

Best wishes to you and GL.

[/quote

Forgot to add that I used to work in managed care, fwiw. Again, appeal, get the providers to resubmit using the correct code, get a supporting letter from your physician speaking to maternal health endangerment issues, and you should be fine. GL.

[Anonymous]

dear OP -- I just wanted to say how sorry I am for your loss. I remember how sad I was when my twins' due date came around, the ones I lost, and can only imagine how hard it would be to be dealing with something like this on top of the sadness of their due date passing. Wishing you kind thoughts.

[Anonymous]

Sorry for your loss. Sounds like your OB's office is at fault. They should have used the code that would have covered you.

However, that's your health insurance's policy. Lots of us don't like our insurance policy exemptions - most don't cover infertility for example. Since you're a federal employee, you had a lot of choices re: plans. You chose this one. I can't imagine that you will win a lawsuit if you chose a policy with this exemption.

Your best bet is to resubmit with correct code. Good luck to you.

[Anonymous]

OP, I had the same thing happen to me when I lost my son to multiple birth defects that doctors called "inconsistent with life". It was the final insult to injury when I got that denial of benefits letter, and I delivered him as a fetal demise! (We saw another OB for an injection of KCl and had to pay cash to get around insurance details).

I called my OB in tears when I got the letter and he wrote the HMO a sternly worded letter citing the codes and giving them his case notes on me. It worked but I was so fragile it was outside of what I could deal with.

Definitely appeal and ask your OB to give you a letter to include in your records going forward. Best of luck! It does sound like the ins coding was wrong, or like something your OB's wording might be able to provide the final bit the HMO needs to qualify.

Good luck and so sorry this is compounding your pain.

[Anonymous]

Try your congressional office, they actually will intervene on insurance issues. We had friends who were told their son needed a helmut to correct plagiocephely and the insurance denied it as cosmetic. Some insurance will cover it because if severe enough is considered disfiguring. They contacted their congressional office who interevened with letters. The political leanings of your congressman or woman may play into this but MD and DC should be supportive.

[Anonymous]

While I do sympathize with the OP, part of the fault lies with her for not checking with her insurance what was covered or needed pre-certification before she had the procedure. Before I get flamed, I recently miscarried late and even though I was upset, I called my insurance company to find out what would be covered/required pre-certification and what did not. I would have loved to have had the placenta tested but they refused to cover it. In any event, OP can't demand that the terms of her insurance contract be changed - best bet would be to try to get it recoded by your Drs and have your Drs directly appeal to the ins co as to the medical necessity of the procedure.

[Anonymous]

Anonymous wrote:While I do sympathize with the OP, part of the fault lies with her for not checking with her insurance what was covered or needed pre-certification before she had the procedure. Before I get flamed, I recently miscarried late and even though I was upset, I called my insurance company to find out what would be covered/required pre-certification and what did not. I would have loved to have had the placenta tested but they refused to cover it. In any event, OP can't demand that the terms of her insurance contract be changed - best bet would be to try to get it recoded by your Drs and have your Drs directly appeal to the ins co as to the medical necessity of the procedure.

Agree 100 percent. And my health insurance plans have put me through the ringer for issues ranging from infertility to a vanishing twin to pregnancy. I paid $12k out of pocket to have my second child because my husband is self-employed and we live in the District (this means that NO plan will cover more than $5k for maternity costs).

Her plan has limitations. She chose the plan. It sucks, but that's what she chose. Agree too about changing the code, though it will probably look very fishy at this point, and if you get caught doing something like that, they can yank your insurance from you and make you pay back all your recent costs.

[Anonymous]

OP - don't listen to the mean people. You got screwed. I had both my ultrasound to indicate that my baby died and my D&C denied by BCBS after I miscarried. It was very upsetting to go through. Be nice to your OBs office; they can help you! My OB used the same codes they always use, but for whatever reason, BCBS termed my procedure an elective abortion! There was a special diagnosis code that it seems that the case worker misinterpreted. I called BCBS and explained the situation and asked nicely to speak with a supervisor. It took many calls and my doctor resubmitting claims to get it resolved. I would definitely take advantage of your appeal. Definitely keep your OBs office in the loop so that they know you are working on this, but do not pay.

I am so sorry for your loss! I am coming up on my due date for the baby I lost and am feeling a deep sense of loss, too. Take care of yourself while going through this!