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.