I AM LIVID - advice appreciated

[Anonymous]

Anonymous wrote:

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.

Excuse me? I am the first poster you quoted. Why am I a "terrible human" -- because I pointed out that OP did not check these things with her ins co before she had the procedure? Like OP, I am also a lawyer, and we know firsthand how these contracts work - they are better at excluding claims than including them. As I said, I do sympathize with what she is going though, and I myself have experienced loss (and other serious illness resulting in fights with ins cos), but at the same time a contact is a contract, and that is what insurance coverage is -- we are not Entitled to get every procedure covered and see whichever doctor we choose. Do I personally think OP's situation should have been covered in this instance? Absolutely. But, at the same time, I also think that we have to be proactive and be our own best advocate, meaning do your homework and take whatever steps necessary in advance to obtain the desired outcome.

[Anonymous]

Anonymous wrote: 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.

That is ridiculous. HIPAA was set up to protect the privacy of consumer information. It should not prevent them from telling you your own information (UNLESS, maybe, MAYBE, it has to do with them not wanting to tell you things over the phone because they can't verify that it's actually you -- would they be willing to mail the information to the address they have on file for you?) They may have their own reasons for not wanting to release coding info to you, but they shouldn't be able to pin it on HIPAA. I have worked in the health care field and been trained over and over on HIPAA, and it's clear that companies are becoming paranoid about violations and go overboard in not wanting to release ANY information to ANYONE. It's frustrating to see a well-intentioned law get all twisted in its application.

I too have gone head to head with insurance companies on issues -- though nothing as traumatic as dealing with anencephaly -- where they are adamant they would have preferred I'd selected care that would have cost them thousands more to pay for, and they will not pay for the cheaper care I ended up with. Managed care companies are not only heartless, but often bizarrely brainless. This whole situation is grotesque, OP, and I am so sorry you (and others, apparently) are having to deal with it.

I think it is a good idea to get your elected officials involved on your behalf, if possible, and if you're up for it, consider contacting a Post reporter about this. It seems like one of those issues that's a no-brainer and would get fixed (for everyone) if enough attention were drawn to it.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

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.

Excuse me? I am the first poster you quoted. Why am I a "terrible human" -- because I pointed out that OP did not check these things with her ins co before she had the procedure? Like OP, I am also a lawyer, and we know firsthand how these contracts work - they are better at excluding claims than including them. As I said, I do sympathize with what she is going though, and I myself have experienced loss (and other serious illness resulting in fights with ins cos), but at the same time a contact is a contract, and that is what insurance coverage is -- we are not Entitled to get every procedure covered and see whichever doctor we choose. Do I personally think OP's situation should have been covered in this instance? Absolutely. But, at the same time, I also think that we have to be proactive and be our own best advocate, meaning do your homework and take whatever steps necessary in advance to obtain the desired outcome.

I'm the one who quoted you. You're a terrible human (at least acting like one above) by posting the way you did. You knew your post was inflammatory before you hit submit, otherwise you wouldn't have tried to squirrel out from under it with your qualifier "before you flame me..."

I don't think you need a law degree to know that a contract is a contract, but why would OP think that a medically necessary procedure that her doctor stressed was important would be denied? Most people don't even have any inkling how much crap an insurance company rejects until the shocking bills begin to roll in. And although I'm not one, I would bet many lawyers would agree.

Even so, there were many other ways you could have phrased your post here if you wanted to be helpful. In fact, you said nothing helpful at all. You've got an OP who is devastated and pissed and then you have some jackass stranger on a forum oh-so-helpfully telling her it's her own fault. Oh, but you sympathize and have suffered yourself. That makes it ok.

Sorry, but yuck.

[Anonymous]

16;13 poster. Please tell me what steps I should have taken. We received the diagnosis on a Thursday and was given the option of going in on Friday for the procedure(with another OB in the practice) or Saturday with my regular OB. My doctor's office set up the surgery appointment. No one gave any indication that they believed that this procedure would not be covered. Why would it ever have occurred to me that this would not have been covered? Why would it ever have occurred to me to even check my policy? It didn't. The doctor's office took care of the precertification.

I guess you are saying it is my fault for being naive or stupid. Should have just expected to pay out of pocket? Perhaps I should have just attempted to carry this to term. Yes, that is certainly the answer. I should have carried a baby whose death was certain upon delivery to term.

[Anonymous]

OP, don't let this person get to you. She's got nothing helpful to say and should stop posting. Perhaps she got a perverse rise out of pointing out how this is somehow your fault. It's not worth your time to keep debating her, although it's hard to resist setting someone straight. Unfortunately, she's not going to listen. Nobody in her right mind could blame you for any of this. Keep your chin up, keep pursuing this with the good advice you've gotten from other posters, and do not let this fool upset you.

[Anonymous]

OP - I posted previously about having my medically necessary D&C denied by BCBS. I had a similar problem getting information. The EOB has some rubbish like "code 107 - this procedure not covered". There was no way to know WHY it was not covered. When I called several times, multiple BCBS reps said that I would need to speak with my doctor's office. Never did they say, "we are not covering your procedure because we think you had an elective abortion.". My doctor's office billing manager was amazing and was the one who helped me figure it out. At that point, when I called BCBS and said (very nicely and calmly), " I understand that you believe I had an elective abortion. I can assure you this baby was very much wanted. The baby died. My doctor said I needed a D&C. How did you want me to handle this? Have you ever had a baby die?". The rep was quiet for a few minutes and then said she was sorry, put me on hold, and then things seemed to move in the right direction. I think that the reps are instructed not to give reasons, but if you confront them with some facts (in a calm way), they can sometimes help.

Definitely get your OB to write a letter. You should definitely write to all elected officials you can.

This is so ridiculous! I am LIVID for you! I had thought about writing my Congressman and Senators, but had not yet. You are inspiring me to speak up about the agonly I went through. No one should have to go through this experience. These procedures should have contractually been covered. The situation that is not covered is an elective abortion, which neither you, nor I had! (So stop posting if you are not going to be supportive, mean, angry lawyer DCUM!)

[Anonymous]

OP, I am so very sorry you are dealing with this infuriating bullshit. In addition to all of the solid advice you've already gotten, I think it's high time BCBS got some serious public shaming.

[Anonymous]

I don't know about the public shaming. If I understand things, it seems as if the federal government has or had some kind of rule where, any insurance company that covered federal government employees could not cover terminations of pregnancy for any reason other than health of mother, and specifically could not cover termination due to anencephaly. That is, the mother is expected to carry the child to term, or else to pay for the procedure herself. (The slippery slope argument -- if we cover terminations due to anencpehaly, we'll have to cover terminations due to other reasons -- like Downs Syndrome, etc.)

It wasn't BCNS's decision not to cover these terminations; clearly it would be cheaper for them to do so. It was the result of the fedgov's contract with BCBS and presumably with all other carriers.

So OP can argue, protest, and attempt get the procedure recoded as much as she wants, but this procedure apparently simply isn't covered -- and by design. Or at least, that is what it sounds like to me. It isn't BCBS's fault, if the preceeding is correct.

OP, I am very sorry you are having to go through this.

[Anonymous]

Anonymous wrote:I don't know about the public shaming. If I understand things, it seems as if the federal government has or had some kind of rule where, any insurance company that covered federal government employees could not cover terminations of pregnancy for any reason other than health of mother, and specifically could not cover termination due to anencephaly. That is, the mother is expected to carry the child to term, or else to pay for the procedure herself. (The slippery slope argument -- if we cover terminations due to anencpehaly, we'll have to cover terminations due to other reasons -- like Downs Syndrome, etc.)

It wasn't BCNS's decision not to cover these terminations; clearly it would be cheaper for them to do so. It was the result of the fedgov's contract with BCBS and presumably with all other carriers.

So OP can argue, protest, and attempt get the procedure recoded as much as she wants, but this procedure apparently simply isn't covered -- and by design. Or at least, that is what it sounds like to me. It isn't BCBS's fault, if the preceeding is correct.

OP, I am very sorry you are having to go through this.

I work in healthcare policy and deal with insurance issues a lot - and this is poster is right. There are many flaws in the world of insurance, but many times, it is not the insurer - but the purchaser, in this case the government, that had this coverage policy in the contract. There are many complaints when insurance doesn't cover contraception and it is often the same deal - insurers have nothing against contraception, its the employer that doesn't want to pay for the benefit.

That being said, OP your situation sucks and I am so sorry for what you went through/are going through.

[Anonymous]

OP. I am sorry for you loss, and all the pain surrounding it. I'd be livid, too.

PPs who talked about insurance contracts - I do not think you were out of line in what you said at all. In fact, it is good solid advice that may help one of the other readers at some point. It may very well be that the problem stems from how the doctor coded it, or maybe it isn't covered. I know how hard it can be to get info about insurance out of doctors, and my bet is that this is where some of the problem lies.

[Anonymous]

OP, I really admire your strength and will to fight this. I had a similar situation (different medical condition) and we did have our doctor call and we were able to get some coverage but did end up paying some of the costs out of our own pockets...I did not have the energy to fight because it was all taken grieving for the baby I lost (at 21 weeks)...

I am sorry for your loss and I hope this all works out in your favor.

[Anonymous]

Anonymous wrote: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.

It's politicized because it is the Federal health care system. Run by the government as directed by the executive branch. We had problemsp related to an accident and multiple broken bones (so not pregnancy related) under the same plan years ago, lost an appeal and only after contacting our congressman--got a complete reversal!! It's political for sure.

[Anonymous]

Anonymous wrote:

Anonymous wrote: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.

It's politicized because it is the Federal health care system. Run by the government as directed by the executive branch. We had problemsp related to an accident and multiple broken bones (so not pregnancy related) under the same plan years ago, lost an appeal and only after contacting our congressman--got a complete reversal!! It's political for sure.

Have you read the past several posts:

I don't know about the public shaming. If I understand things, it seems as if the federal government has or had some kind of rule where, any insurance company that covered federal government employees could not cover terminations of pregnancy for any reason other than health of mother, and specifically could not cover termination due to anencephaly. That is, the mother is expected to carry the child to term, or else to pay for the procedure herself. (The slippery slope argument -- if we cover terminations due to anencpehaly, we'll have to cover terminations due to other reasons -- like Downs Syndrome, etc.)

It wasn't BCNS's decision not to cover these terminations; clearly it would be cheaper for them to do so. It was the result of the fedgov's contract with BCBS and presumably with all other carriers.

So OP can argue, protest, and attempt get the procedure recoded as much as she wants, but this procedure apparently simply isn't covered -- and by design. Or at least, that is what it sounds like to me. It isn't BCBS's fault, if the preceeding is correct.

OP, I am very sorry you are having to go through this.


I work in healthcare policy and deal with insurance issues a lot - and this is poster is right. There are many flaws in the world of insurance, but many times, it is not the insurer - but the purchaser, in this case the government, that had this coverage policy in the contract. There are many complaints when insurance doesn't cover contraception and it is often the same deal - insurers have nothing against contraception, its the employer that doesn't want to pay for the benefit.

That being said, OP your situation sucks and I am so sorry for what you went through/are going through.

[Anonymous]

PP, I was the poster who posted one of the above posts. I said that IMO, BCBS isn't covering the procedure because it has a contract with the federal government that specificies that it not cover the procedure for yes, political reasons, stemming from the fact that this procedure is a termination of a pregnancy. I do not mean to politicize anything.

Personally I am pro-choice, and personally, I have opinions about what types of contracts the federal government should enter into with its carriers. However, those opinions are not important to this discussion.

If OP is going to try to fight this she needs to understand what she is dealing with. If the above situation as described is correct (and I'm not sure it is -- but I think it is) then BCBS doesn't cover the procedure. It isn't that the company doesn't WANT to cover the procedure. Very likely the company would be very happy to cover the procedure as it would be more cost-effective for them than the alternative -- they just can't because they are forbidden by the contract with the federall government from covering procedures which carry certain codes. This is simply a fact, and anyone in this situation needs to be aware of this fact, as it may help her chart a course of action.

[Anonymous]

OP here. What the PP said about the insurance contracts for us Feds rings true to me. These contracts were probably negotiated under the previous administration. W is still making us Feds miserable.

I am going to talk to my doctor about the appeal to OPM. I am hoping that she can write a letter framing it as a "health of the mother" issue. I am also hoping that I may get a more sympathetic ear in an Obama OPM. I am also planning to call the reps in the area that would be sympathetic and who have lots of feds in their districts. (VanHollen, Moran, Holmes-Norton) I have no idea if I will be sucessful, but I am going to try.

I understand the slippery slope argument; however, it is BS. There are conditions "incompatible with life." It is not a difficult line to find. Doctors should be making these decisions, not insurance companies and certainly not the Gov't.

Thanks to all of you who have offered your advice, words of wisdom and support.