Tuesday, November 03, 2009

At war with BCBS

I know I said that I'd have a post about the cutest lady bug ever today, but I'm going to have to delay that until tomorrow.

A few weeks ago I wrote about my ongoing fight with BlueCross BlueShield of Texas to get Elizabeth's delivery covered. Yesterday I went another round with the insurance company.

I received a letter in the mail telling me that my appeal had been denied because my situation didn't match any of the items on their list that would allow them to pay for the delivery. So I girded my loins and called BCBS. As soon as I got a human on the phone, I asked for a supervisor. I had the bad luck of being connected to Kelly C.

Here's where having a photographic memory for conversations comes in handy.

****

Me: I'm calling about my claim, which was denied.
KC: That's right. Your condition doesn't meet any of our requirements for being covered.
Me: Can you explain that please?
KC: We will pay for treating complications of pregnancy, but we won't pay for delivery.
Me: Did you get the letter from my doctor?
KC: Yes, we have it. But doctor's letters don't matter. Only medical records matter, and yours don't show that we should cover the delivery.
Me: When my son was born three years ago, you paid for his delivery because he was breech.
KC: We've gone back and reviewed claims, and it turns out the company paid for a lot of claims it shouldn't have. You son's delivery probably shouldn't have been paid, but we're not going to try and recover the payments.
Me: With this delivery, you paid for the claim from the anesthesiologist.
KC: That was a mistake, and if you ask for a review of this claim, we could end up reversing that decision.
Me: So I'd have to pay back the payment to the anesthesiologist?
KC: That's correct.
Yes, she did essentially threaten that if I pursued this they might make me pay more money.
Me: As my next step I'm going to be contacting the Department of Insurance, an attorney and my legislators.
KC: You can do that, but it won't do any good. No one in medical review is going to approve this claim.
Me: How can you work there and still sleep at night?
KC: If you're going to attack me personally, I'm going to terminate this call.
Me: Please put your supervisor on the line.
KC: There's no one higher than me.
Me: Bullshit. I want to talk to your supervisor.
KC: No one here is going to approve this claim.
Me: I don't care. Put someone else on the phone now. I'm finished talking to you.

After a few more back and forths where she claimed there was no one else to talk to and I told her I didn't care and that she needed to find someone immediately, she put me on hold. I sat there crying while listening to perky, cheerful hold music.

After about 10 minutes, Tanika got on the phone.

Me: Kelly told me that BCBS would pay to treat complications of pregnancy but not delivery. My complication was five weeks' pre-term labor with fetal distress. Now I'm not a medical person, but it seems to me that the treatment for that complication is to deliver the baby.
T: I'm not a medical person, so I can't explain why the medical section made this decision. But that seems reasonable.
Me: BCBS also paid for my anesthesiology bill without any protest. It was just paid automatically.
T: That's odd, because medical review says no claims from this date of service should have been paid.
Me: What do I do next?
T: You can file a second appeal - you're allowed two appeals. (Something KC never told me.) When you file your second appeal you need to include any other information that you feel is relevant, and have your doctor do the same. Anything you can give us that would help your case. After that, you can also contact TDI for help appealing this.
Me: Thank you so much for at least listening to me. Kelly C wouldn't even do that.

I felt like Tanika was sort of telling me, without actually telling me, how to get the claim paid. Kind of like the scene in "The Incredibles" when Bob Parr tells the little old lady exactly what forms she needs to file. And while Tanika didn't approve my claim, she did at least listen to me without being rude or telling me that the claim would never be paid.

*****
After I spent about 15 minutes sobbing on the kitchen floor with Campbell asking, "Why you sad mommom?" I pulled myself together enough to call my doctor's office. The woman who deals with the insurance companies wasn't in, so I left a message for her to call me today. Maybe she has some further thoughts.

After I got off the phone with the doctor's office I cried some more. This has just worn me out. I feel helpless and out of control dealing with this immense company. I know the medical review section is nothing more than pencil pushers going through checklists without putting any thought into whether their decision actually make any sense. There is no reasoning with people who can only see checklists.

But yesterday also made me mad, not angry, MAD. I'm going to fight this as far as I can. BCBS has stolen my time, energy and joy at having a new baby from me, and that's what really upsets me.

I also truly believe that anyone who thinks our health care system is fine the way it is has never had to pay for his or her own health insurance and has also never had a claim denied. Anyone who has had to fight with an insurance company should know that the system is broken.

Tomorrow, a cute ladybug. I hope.

9 comments:

Shelly said...

Hate, hate, hate insurance companies! I don't understand. Do they never cover the delivery of a baby? Or will they just not cover your c-section because they claim it wasn't medically necessary? Because we all want to run out and have unnecessary surgeries, especially when pregnant, just to screw the insurance companies.

knittergran said...

I'm with Shelly-I hate these companies too. The only way they can make their huge profits is to deny claims.
Shame on Blue Cross/Blue Shield.

hokgardner said...

Because B and I are both self employed, we are also self insured. We have no maternity coverage. I had to pay for all of my prenatal care out of pocket. However, BlueCross is supposed to pay for deliveries in emergency situations, regardless of coverage.

calicobebop said...

What an awful experience! I certainly hope that BCBS gets their head out of their ass - pronto! I swear, I think some of these "customer service" people are on a power trip. Can't even be bothered to be nice! What a piece of work.

Becca said...

god this is so stupid. anyone who doesn't get that the system is broken is also stupid.

Amy said...

Uh-oh, this is a hot-button topic for me. Long comment ahead!

Insurance companies are evil. They are driven solely and exclusively by their bottom line, which is ironic and bizarre because what they contend with day after day is human lives, and the quality thereof.

KC and her ilk are petty peons with a cruel streak. They often end up working for collection agencies, where they are lauded and rewarded for being mean and inhumane.

Fight the good fight. And good luck.

Baino said...

I don't understand how the health coverage system works over there. Is Blue Cross a government funded safety net? It seems ludicrous to me that you have to go through all this let alone be threatened by some little smarmy bitch who probably doesn't have health care her self. This is such a no brainer Heather. A public health care option should (I repeat should, if it's structured properly) pay for all of this. I can't even believe that you need health cover to deliver a breach baby! Unbelievable. I guess the lesson here is read the fine print and find out exactly what you're covered for when you take out your health insurance.

Cookie said...

Have you started looking for a new insurance company yet??
I hope you get this fixed. What a horrible thing to deal with.

Lisa Page Rosenberg said...

They are the devil. For real.

We carried our own insurance and also had insurance through my husband's new job - both Blue Cross, so BC was our primary and secondary insurance. Not only should we have been covered for the birth of our son by both plans, we should have been over-covered and gotten money back. Instead they over-paid our ob/gyn, who returned the money to insurance, and then overpaid the hospital, who did not return it. Not only did they not reimburse anything to us, they tried to bill us $5,000. for things that were covered and previously paid for. In the end, they said we didn't owe anything but we couldn't get the $2,500. out of them that they owed us.
After two and a half years, we finally did what Blue Cross wanted - we gave up.