I AM LIVID - advice appreciated

[Anonymous]

OP here. I've been a Fed for 16 years now and until this issue BCBS has been pretty good. It has always paid for everything as expected. I had some bleeding issues during that pregnancy and had something like 5 sonograms during that time and they paid for everything, no questions asked.

Honestly, it never occurred to me to check on what was covered and not covered when I got pregnant. Honestly, I am a lawyer, but I would have thought that "health of the mother" would have included my situation. Really, it never would have occurred to me that the insurance claim would be denied in that situation. I figured it would be treated the same as if they found no heartbeat. The pregnancy is not viable, medical intervention needed, end of story.

As far as how the stuff was actually coded, I can't say for sure. Someone at BCBS told me it was coded as a voluntary termination, but this was when I was checking on the appeal. I don't necessarily trust what I was told. In any event, I sent all my records from the pregnancy to BCBS so they could see the diagnosis. They said there was no danger to my health so they were not going to pay. For all I know it was coded correctly and they still considered it voluntary. For the record, I was told by BCBS that they couldn't release that information(how it was coded) to me because it was a HIPAA violation. I still don't understand that one, but that was repeated several times by several different people, so it's either true or their standard operating procedure.


From a purely economic point of view, BCBS makes no sense. The procedure, while expensive, is a fraction of what prenatal care and L&D costs. It makes no sense to me that they would prefer to have had me continue the pregnancy to term and deliver a stillborn or had me continue the pregnancy and had the fetus die in utero and then it would have been an emergency that threatened my health. From what I understand, that would have been a real possibility. It makes no sense from an economic or public policy sense to me.

Thank you to those that offered your condolences on our loss. It was very painful at the time and is painful again dealing with this BS.

[Anonymous]

Anonymous wrote:

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.

Me again. Also wanted to clarify that there are TWO kinds of numbers that will need to be clarified and possibly recoded:

1. The ICD-9 code number - which describes the diagnosis resulting in the procedure (see above).
2. The CPT code number - which describes the exact nature of the procedure.

See this website for an example of how a given CPT code for an abortion will be classified as "elective" (and not covered) unless it is accompanied by a given ICD-9 diagnosis, and therefore considered "therapeutic" and covered:

https://www.oxhp.com/secure/policy/abortions_for_commercial_1208.html

[Anonymous]

Anonymous wrote:OP here. I've been a Fed for 16 years now and until this issue BCBS has been pretty good. It has always paid for everything as expected. I had some bleeding issues during that pregnancy and had something like 5 sonograms during that time and they paid for everything, no questions asked.

Honestly, it never occurred to me to check on what was covered and not covered when I got pregnant. Honestly, I am a lawyer, but I would have thought that "health of the mother" would have included my situation. Really, it never would have occurred to me that the insurance claim would be denied in that situation. I figured it would be treated the same as if they found no heartbeat. The pregnancy is not viable, medical intervention needed, end of story.

As far as how the stuff was actually coded, I can't say for sure. Someone at BCBS told me it was coded as a voluntary termination, but this was when I was checking on the appeal. I don't necessarily trust what I was told. In any event, I sent all my records from the pregnancy to BCBS so they could see the diagnosis. They said there was no danger to my health so they were not going to pay. For all I know it was coded correctly and they still considered it voluntary. For the record, I was told by BCBS that they couldn't release that information(how it was coded) to me because it was a HIPAA violation. I still don't understand that one, but that was repeated several times by several different people, so it's either true or their standard operating procedure.


From a purely economic point of view, BCBS makes no sense. The procedure, while expensive, is a fraction of what prenatal care and L&D costs. It makes no sense to me that they would prefer to have had me continue the pregnancy to term and deliver a stillborn or had me continue the pregnancy and had the fetus die in utero and then it would have been an emergency that threatened my health. From what I understand, that would have been a real possibility. It makes no sense from an economic or public policy sense to me.

Thank you to those that offered your condolences on our loss. It was very painful at the time and is painful again dealing with this BS.

I know this makes no sense, but - again - your health records do not matter to the people at the managed care company. THEY ONLY CARE ABOUT THE CODING. You need to have your providers resubmit with the appropriate diagnosis. See the website I gave you above for an example of how this is viewed from their perspective. And, appeal, appeal, appeal. You will win this. The codes just need to be corrected.

Again, I am very sorry for your loss and wish you the best.

[Anonymous]

OP here again. I don't know if I made this clear but the original claim was denied. I appealed sending in all my medical records from the pregnancy. They sent a letter today with a denial of the claim and oh, by the way, we are going after the money we erroneously paid to the anesthesiologist. You owe that, too. My next step is to appeal to OPM. At this point, I don't know how much difference it is going to make to recode everything. BCBS knows it was anencephaly and they said it was not a "health of the mother" situation. In my first appeal I didn't get a letter from my OB. I will now.

[Anonymous]

Anonymous wrote:OP here again. I don't know if I made this clear but the original claim was denied. I appealed sending in all my medical records from the pregnancy. They sent a letter today with a denial of the claim and oh, by the way, we are going after the money we erroneously paid to the anesthesiologist. You owe that, too. My next step is to appeal to OPM. At this point, I don't know how much difference it is going to make to recode everything. BCBS knows it was anencephaly and they said it was not a "health of the mother" situation. In my first appeal I didn't get a letter from my OB. I will now.

Would you consider talking to a lawyer at NARAL?

I have a sneaking suspicion that since you're a fed, this coverage reflects decisions of the previous administration that were heavily politicized and completely unfair to women in your circumstances. My guess is also that the choice lobbying groups are working on proposals now to fix all of this madness and focus on health and science again. Remember that the gov't negotiates these contracts, and what's covered. It will be renegotiated no doubt but in the meantime someone with that kind of access can figure out who the friendliest ear is. And if you are willing to compromise your privacy somewhat in order to threaten to raise hell, that could help.

Insult to severe injury-- I'm so terribly sorry that you have had to endure this.

[Anonymous]

http://rising-hegemon.blogspot.com/2005/08/well-send-your-husband-overseas-to.html

The unanimous ruling by a three-judge panel of the United States Court of Appeals for the Ninth Circuit came in the case of a 23-year-old woman who lives in Bremerton, Wash. Her name was not disclosed.

The woman terminated her pregnancy in 2002 after she learned that her fetus had no forebrain or cerebellum, a fatal condition known as anencephaly. Because her husband was in the Navy, the woman was covered under the military's health plan, the Civilian Health and Medical Program for the Uniformed Services, or Tricare.

But Tricare administrators said they were barred from paying for the abortion. Federal law prohibits payment for abortions except "where the life of the mother would be endangered if the fetus were carried to term." A regulation putting the law into effect specifically excludes payments for situations involving "fetal abnormalities" and mentions anencephaly.

Lisa M. Stone, who represents the woman, said she and her husband had an annual income of less than $20,000 and could not afford the charge of about $3,000 for the abortion. The couple sued, and in 2002 a judge ordered Tricare to cover the costs, allowing the abortion to go forward.

The government appealed to get its money back from the couple. Though lawyers for the Justice Department did not dispute the diagnosis of anencephaly, they argued that the Congressional restriction furthered the government's interest in protecting human life and warned against a "slippery slope" if courts tried to determine which abnormalities warranted an abortion.

Ms. Stone, the executive director of the Northwest Women's Law Center in Seattle, said the government's argument was "irrational at best and cruel at worst" because everyone agreed there was no chance that a fetus with anencephaly could survive or even attain consciousness.

[Anonymous]

Dear OP,
So sorry about this. Your baby, the insurance, everything. I am a Fed -- also on BCBS -- and the same thing happened to me several years ago. Ultimately, the claim was paid, but not after a lot of work on my end. I don't remember if you said you've already appealed or not, but agree w/the PPs who were helpful -- get a VERY detailed letter from your doc about how your health (even your mental health) was at risk from continuing the pregnancy. Our Dr's letter spoke clearly to this. I don't think we had to appeal to OPM. Also, agree about NOT paying the hospital bill. We did - under the assumption that nothing would be covered -- and then had one hell of a time (and had to get a letter from our US Senator) getting the money back (I'm skipping details here).

Good luck.

[Anonymous]

I am the 5:27 pp. I hadn't noticed earlier the post just above about the Bremerton WA woman. FYI, my termination was in 2001, so before the ruling came down. gl to you.

[Anonymous]

I'm sort of amazed at how a few people had politicized this issue, just because it's about termination.

Do you all know that BCBS does not pay anything at all for infertility? Or that it has a $5k cap on pregnancy costs in the District (for people who work for small companies or who are self-employed)?

Where is the outrage there? Hmmmm....

I just thought I would point this out. OP, sorry for your loss.

[Anonymous]

To the PP = I agree with you on alot of levels. First, I offermy condolences to the OP - difficult to go through and then to be denied on top of it.

But on a larger note, the real injustice is the state of health care in this country. If you have not watched Michael Moorer's Sicko, it is being replayed alot now on cable, try to catch it. We have to do a better job of taking care of our health needs in this country.

To the OP - fight with all you have. Do not pay the bill. Let everyone involved know that you are fighting!

[Anonymous]

Anonymous wrote:OP here again. I don't know if I made this clear but the original claim was denied. I appealed sending in all my medical records from the pregnancy. They sent a letter today with a denial of the claim and oh, by the way, we are going after the money we erroneously paid to the anesthesiologist. You owe that, too. My next step is to appeal to OPM. At this point, I don't know how much difference it is going to make to recode everything. BCBS knows it was anencephaly and they said it was not a "health of the mother" situation. In my first appeal I didn't get a letter from my OB. I will now.

Again, the words in your medical records mean nothing if the coding does not indicate that the pregnancy interfered with the management of your health.

You have to have the providers change the codes. And also write a letter using the language that the company specified it needed.

And I agree with the political aspect mentioned above - this wording in your contract is a highly politicized issue.

However, if you work the system to your advantage and use the appropriate codes and appeal all the way to the end, you can win.

[Anonymous]

OP chose her plan well before she knew she'd conceive a baby with a condition that was incompatible with life; did any of us choose a plan with the idea that we might have to terminate a fetus because of anencephaly? Come on, people. This is not on her; it's largely on her providers, and she needs to put it back on them. They didn't code properly, and they should be advocates for her in this situation. OP, please follow up with your OB; appropriate action from him/her should give you a much better chance of success in your appeal.

[Anonymous]

I had a D&C due to fetal demise, first pregnancy, it was awful. I can't imagine also having to deal with all this crap. and I thought it was horrible that the D&C takes place in the MATERNITY area of the hospital.... sometimes the insensitivity of the systems and procedures in health care is astonishing....

Agree that you should continue to appeal, and I like the idea from a PP about talking to NARAL. You probably are feeling the effects of the last Administration.

And as for your logic about the economics.... I have always been baffled by this. For example, it used to be that plans would pay for pregnancy and delivery, but not birth control pills. Um hello? Or pay for Viagra but not contraception. Makes NO sense.

[Anonymous]

Anonymous wrote:

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.

OMG! These two terrible humans who posted this should be disregarded. I'm sorry for your loss, OP. I don't have much to add. Hang in there. And this is NOT your fault. Not even slightly.

[Anonymous]

OP here. Thanks for all who replied. Tomorrow I am going to get a hold of my OB to ask for her help. I spoke to her when the claim was originally denied and she was appalled. She offered to write a letter then, but now I am going to take her up on her offer.

I honestly don't have any idea how the claims were actually coded. From looking at the way the denial of the appeal was worded, the claims could have been coded correctly and they considered the termination voluntary anyway. My OB did not consider this termination voluntary. I asked BCBS how the claim was coded and they told me they couldn't tell me because it was a HIPPA violation. I don't understand how it is a HIPPA violation. I'm still going to try to get that information.

I actually did think about going to NARAL. First, I am going to go through the last channel of appeal and then go to NARAL if I have to. As is evident from this board, I'm not the only woman who has gone through this or something similar. I'm still a bit incredulous that the claim was denied. Like I said, I would have believed that anencephaly fell into a "health of the mother" exception. I live in DC and I'm willing to go to Rep. Homes-Norton. I might also go to VanHollen or Moran. They might be willing to hear me out since it is a Fed insurance issue.

I reread the letter this morning. The medical review board actually said that carrying the baby to term would not have posed a threat to my health, so they weren't going to pay. Apparently, they would have preferred that I attempt to carry this baby to term. I know the court in that Bremerton case said they didn't want to go down the slippery slope of deciding which conditions they would pay for. There is no slippery slope here. There are "conditions incompatible with life." For the record, there is not one person in our lives from our family, to our friends to our bosses who were not 100% supportive of us. We received many many condolence cards and flowers.

For those of you who said I should have checked my benefits, what exactly should I have done? Should I have called BCBS with a list of potential fetal abnormalities and life threatening conditions during pregnancy and asked how they covered each one of them? Seriously, it never occurred to me that this problem would not have been covered.