I AM LIVID - advice appreciated

[Anonymous]

Anonymous wrote:OP here. Now I understand that this refusal is codified, I understand why it was refused. I spoke to my doctor and she is going to write a letter discussing all the potential life threatening things that could have happened had we not terminated this pregnancy. I am hoping that an Obama OPM has a broader view of health of the mother.

I am still angry. I resent that my healthcare is political. I should have known better. I have been involved in pro-choice causes for at least 20 years. I should have known that this provision had been slipped into an appropriations bill. I spoke to a friend of mine, apparently no one knew until it was too late. Now I get to direct my anger at Newt et al, as opposed to GWB. I can still be angry at him (GWB) just because.

Looking ahead, in the event that this claim does not get paid, does anyone know how I get a hold of what the negotiated rates for the procedures listed on my EOB form? I might try to negotiate with them to pay what they would have gotten if the claim was covered. I have to be realistic. An Obama OPM's hands may still be tied because this is federal law.

Thanks for all your support and ideas.

OP -- what confuses me is that you mentioned that your doctors contacted the insurance company for "precertification". Is that correct? Because if they did so, wouldn't they have been told that the insurance co wouldn't cover the costs?

[Anonymous]

OP here. I actually don't know if they did a precertification. I know that the office took care of everything. I was the first case of anencephaly my doctor had seen in 13 years of practice. I was so distraught at that point that I wasn't paying attention. I was just grateful someone else was handling things. The lack of precertification has never been mentioned as an issue, so I assumed they did something. They may have gotten precertification under some broader definition and then once the paperwork was filled out they denied the claim. I honestly have no idea.

[Anonymous]

I'm so sorry you have to deal with this.

I have BCBS fed insurance too. I've had a number of issues with them over the years. I wanted to mention a few basic strategies for dealing with them, since no one else has brought it up. Be sure to get a full name from everyone you speak to, and document the time of each call. (I keep a notebook/pad of paper handy.) I've gotten conflicting advice on more than a few occasions. The last time I called about something I knew what the answer was supposed to be, and it took 3 calls to 3 different people to get it. (The last person "apologized" for the different advice from persons 1 and 2.) Asking to speak to a supervisor will sometimes work, but you may need to insist "who can you connect me to who can help me with this?" -- until the person gets fed up and connects you up the chain. Faxing or writing them letters is better than asking things on the phone, but I've had them lose paperwork more than once. Keep copies of anything you write or fax. Best of luck. I'm rooting for you and for this law to be overturned.

[Anonymous]

Anonymous wrote:Looking ahead, in the event that this claim does not get paid, does anyone know how I get a hold of what the negotiated rates for the procedures listed on my EOB form? I might try to negotiate with them to pay what they would have gotten if the claim was covered. I have to be realistic. An Obama OPM's hands may still be tied because this is federal law.

I'm so sorry that your loss is being compounded by this BS. To address the question quoted above, it's my experience that the negotiated rates are pretty jealously guarded information; I doubt that BCBS would give them to you, but your providers might be willing to do so. You should def. try to negotiate with them, whether you use negotiated rates or something else as your baseline. I was uninsured during my pregnancy and daughter's delivery and was sucessful at getting a discount off of nearly all my services.

Take care.

[Anonymous]

I don't know if this will help you much, but if you are able to get your doctors to recode, couldn't they argue that your health was at stake? I mean, doesn't every pregnancy put a mother's health at risk? And this would be an unnecessary risk? I am probably not making this argument as clearly as someone more familiar with this area would be able to make it, but it seems like you have to work within the statute and I would think NARAL, or the National Women's Law Center, or some similar place might be able to advise.

[Anonymous]

Anonymous wrote: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.

OP, please stop. Don't do this!!! You don't have to justify anything to random people. I am the 3rd poster re: claim denied for 3 yrs. The reason my claim was denied was because we didn't obtain precertification. My 2 mo old DD was coughing and couldn't catch her breath and I thought she was going to stop breathing. It was 1:30am (first time mom), I was home alone (DH on a business trip) and HORRIFIED. The concierge called the ambulance. She was admitted, put on a nebulizer and released in less than 8 hours. Got a bill for $7800 for 15 hours in the hospital.

Guess what... only doctors and hospitals can obtain pre-certification. But everyone told me it was my fault for not getting authorization before she was admitted. Seriously??? Anyway, the rep at the collection agency was the one who explained all of that to me. It's ironic but the collection agency was the saving grace in my whole experience. The guy was so kind and understanding (partly because I was very nice to him, cried uncontrollably and explained everything). After three years, NUMEROUS phone calls, lots of stress, the hospital FINALLY relented that they were at fault for not obtaining the pre-cert.

Moral... you can read all you want, select the insurance that seems best, but humans are idiots!!! FWIW... it was BCBS.

Hugs to you and DH!!!

[Anonymous]

I am doubtful that the doctor's office actually obtained a precertification. I terminated a pregnancy (same insurance) and was told specifically that the insurance would not cover it unless my health was in danger. I was initially going to argue it, because my health actually was in danger, but then I went ahead and paid for it out of pocket because I wanted to leave it behind me. It was a first trimester procedure.

BCBS specifically states that it does not cover pregnancy termination, unless the mother's health is in danger which is quite convenient for them, since it is less often the case. You should definitely talk to your doctor.

I am very sorry this happened to you. But unfortunately my guess is that you indeed will need to pay for the termination, unless the doctor can prove that your life was at stake.

[Anonymous]

OP here. My doctor was surprised at this provision. I was the first anencephaly case she had. I'm sure she's had many other cases where there was a "not compatible with life" situation, but they may not have had federal insurance. I am pretty sure that other health plans outside the federal system in the area, including BCBS, cover theraputic abortions. Why wouldn't they? Economically it makes way more sense.

I actually spoke to a bunch of my female collegues today. All of these women are strongly pro-choice and pretty active politically, none of them were aware of this provision in our insurance. They were all understandably as offended as I am at the provision.

Right now I am going to appeal to OPM with a letter from my doctor. I am hoping that an Obama OPM may be more open in their interpretation of "life of the mother." I fully recognize that their hands may be tied. I also contacted NARAL and the National Women's Law Center.

Thanks for your support.

[Anonymous]

Anonymous wrote:it's my experience that the negotiated rates are pretty jealously guarded information; I doubt that BCBS would give them to you, but your providers might be willing to do so.

I get an explanation of benefits for each doctor's visit, procedure etc. and it clearly states what the charges were and what BCBS paid (which would be the negotiated rate). I agree though that this information might not be available without the EOB. Perhaps the OP can even ask on this forum - there might be women who have had a termination who had BCBS who would know this info.

[Anonymous]

OP Here-Just an update for any of you who might be interested.

I've spoken to my doctor several times. Today I spoke to her and the letter she is writing is going to be very thorough. She told me that it is taking some time because she had to do some research and access some medical articles. I thought she was just going to write her letter about her medical judgement and her knowledge of the condition etc. I am thrilled with her level of attention to this letter. I have no idea if this will work or not, but I am going to see it through.

I've also spoken to several pro-choice organizations. I had a meeting with the president of the Center for Reproductive rights and told my story to her. She asked me if I would accompany her to the Hill to talk to members of Congress and tell them my story. I was happy to say "sign me up." I checked with my agency's ethics office and there is a problem with me lobbying the White House, so I won't be able to talk directly to the administration. She also asked me to write an Op-Ed. I said I would if I could do it under a pseudonym or anonymously. First, my husband is uncomfortable with the potential publicity. Second, there are crazy people in the world and I don't need the harassment. The Op-Ed is down the road.

I found out that the budget constraints not only affect the FEHB but also, women in the Peace Corps, under the Bureau of Indian Affairs, the military and medicaid. A woman in the military cannot recieve services in a military hospital for pregnancy termination even if she pays for it herself. That is outrageous enough if she is here in the States. Can you imagine if she is serving overseas? She would have to get herself out of the country where she is serving and get herself to a place where she can recieve services all on her own dime. Just think about the cost and how much enlisteds make.

In any event, I am directing my anger to what I hope will be a better outcome.

Thank you to all of you for your information and kind support.

[Anonymous]

Good for you for taking constructive action at such a difficult time - and doing something that will help not only yourself, but thousands and thousands of other families. Please let us know if there is action that others can take to help to change things - petition, write our congressional representatives, or anything else. All the best to you and your family.

[Anonymous]

OP, thank you for updating us. I think you are doing a tremendous service in sharing your story, especially during such a sad and difficult time. I think it is very unselfish and positive of you to do what you can to help other women avoid such a terrible situation. Please do keep us posted. I know many of us are interested in knowing how things progress and helping in any way we can. Good luck with all of your next steps and I hope you continue to feel better and better about everything.

[Anonymous]

OP, first, my condolences for your loss. I've been reading about your whole ordeal through this forum. The reason I'm writing is because I'm a producer at ABC-7 News, in DC. We're wondering if you'd be interested in sharing your story with us. Please contact me at either the number or e-mail address below. We can discuss your story further, and I can answer any questions you may have about what we're looking for. I hope to hear from you soon.
Sincerely,
Brandis Griffith Friedman
WJLA-TV, ABC 7
special projects producer
703-236-9396
[e-mail]