stupid anthem BCBS NONSENSE

[nilatti]

In case you couldn't tell from my subject line, this is a rant.

I live in Virginia, and I have Anthem BC/BS. In my area, CNMs do not deliver babies at home. I had my baby in September, at home, with a CPM. I tried to apply for a gap exception (because there are no in-network CPMs or anyone who attends home births) months before the baby was born, and this paperwork mysteriously disappeared. They ended up paying my CPM as an "out of network provider," which, after deductibles and such, wound up being about 10%. I appealed, explain that homebirths have similar safety and much lower medical intervention, and that, since my city just moved our hospital 20 minutes FARTHER from my house, and through a high traffic area, if I had planned a hospital birth, I would probably have had an automotive birth (my whole labor was 3.5 hours long...and I didn't realize that OMG I should call the midwife RIGHT NOW until about an hour into it). My appeal was, unsurprisingly, flatly denied because "there are in-network providers that offer this service." So, I called (just now) to ask who they meant. The lady started listing CNMs, and I said, "Yes, but they don't do out-of-hospital deliveries. It's not the same thing." I then went into all the facts about the lower incidence of medical intervention, etc., etc., and just before I got to the part about how there was a 30% chance that if I had gone to the hospital, Anthem would have had to pay for a C-section (!), she said, "Yes, but there are nurse midwives and gynecologists [I'm sure she meant obstetricians??] who could have delivered your baby. It doesn't matter that you wanted a home birth."

So uhm...it doesn't matter that I wanted to have my baby where I believed it would be the safest? Really? So I have to choose between putting myself and my son in danger, or ponying up the money to be safe? It sounds kind of crazy when I put it like that, doesn't it?

My employer's HR department just hired a service called "Health Advocate" whose job is to fight with insurance companies for employees (they also offer other services, like finding specialists and stuff). Isn't it crazy that they're spending money on fighting with another company whose services they pay for? We have access to that starting today. So, here's my plan of action:

1) Email Health Advocate, including links to studies on HB safety (and the debunking of the recent ACOG study), asking if there's anything I can do.

2) Email my HR department explaining the situation, and past situations (this isn't the first time I've had a really hard time getting Anthem to pay--we also have to argue with them about paying for my husband's seizure medication EVERY YEAR, even though it's the only thing that makes him employable).

3) Send a snail mail letter back to Anthem, to the specific "Grievances and Appeals Analyst" (oh, btw, she introduced herself on the phone as working for the "Grievances and Denials" department. I just noticed that as I was looking at her letterhead. WTF? Is that what they jokingly call it around the office?) explaining that I know of other insurers that cover homebirths via a gap exception--thank you for posting your successes with those companies so that I can say specifically that United Health does this! I will note that my company has increased its employee rolls by a factor of 10 in the past five years (going from only 200 employees to over 2000), and I anticipate further growth along those lines. And I will state that I am recommending to my Human Resources Department that they look into working with other insurance providers.

I kind of doubt this will help much--and I'm ok with that, I guess. It was absolutely worth it to have my baby peacefully, at home. We could afford it. We saved and saved to be able to do it. And if we have to pay the same amount for our next baby, we'll find it. It's worth it. I'm just frustrated that EVERY time the medical profession has actually helped us, Anthem has either refused to pay for it or given us trouble. They wouldn't pay for the naturopath who diagnosed my food intolerance, after three GPs insisted I had migraines (haven't had one since!). They wouldn't pay for the neurologist who diagnosed my husband's seizure disorder, even though the in-network doctor insisted there wasn't anything wrong with him. I'm just terribly frustrated. It's enough to make me consider moving to a civilized country like...you know, practically anywhere else.

Does anyone have any ideas about what I should add to my list? Are there any things on here that I definitely should NOT do?

Thanks.

[Chamomile Girl]

I don't have any ideas for you.  I just wanted to say YOU ROCK!  Greviances and Denials indeed.

[StellaNuova]

Sounds like you have a good plan, good luck. Is there any consumer watchdog type of reporter on a local news station in your area? If they won't work with you despite your efforts, that could be someone to consider turning to, i.e. "I'd hate to be forced to bring this to the attention of so and so"...or better yet is there a national entity that does essentially the same thing for health insurance companies? They probably wouldn't like the publicity and it might help pressure them into paying. 

[MegBoz]

Originally Posted by nilatti 

It's enough to make me consider moving to a civilized country like...you know, practically anywhere else.

Yeah, I've joked for years that I'm moving to the Netherlands if I really get tired of it here - and that was years before I ever had a clue about the abysmal state of American maternity care & the comparatively fantastic Dutch system!
 

I have, what I think may be fantastic news for you! I have Anthem BCBS out of Virginia (where my employer is based) and they told me:

1. They DO cover HB

2. They will cover my CPM at the "in-network" rate since there are no in-network providers who provide HB services.

No one once said anything about not covering HB!!! It was actually surprisingly easy. And ironically, CPMs are illegal in Maryland (although my MW is licensed in VA) and there ARE a couple CNMs up here who provide HB. Thankfully I think they're out-of-network anyway so I could get in-network coverage for my CPM, otherwise I was going to hope they were already booked up, since we switched to this insurance when I was already about 18W along & the one Baltimore CNM does book up quickly.

Anyway, I have my letter! I'm not due until March but it states they will cover my CPM at the in-network level. I'm wondering if it will help if I send you a copy. While I don't want to jeopardize my own chances of maximum reimbursement, I'm not too worried about them going back on their word now that I have the actual letter.

And I would imagine it would help tremendously to be able to say, "REALLY?! You don't cover home births. Really?! Then why are you doing so & offering gap exception for this particular woman?"  

It just confirms what I've heard time and again regarding insurance that the more you call, the more people you talk to, the more different answers you get.

[nilatti]

Oh, wow, could you? That would be incredibly helpful! I don't want to talk with the same person again, but I probably could just get someone different at random, and being able to say, "Here's this other person to whom you said YES" would be great. I'll PM you with my address and such. 

Thank you

Thank you.

Thank you.

[gemasita]

OMG, OP, I am in the same boat as you.  We have BCBS but it's the NC State Employees' Health Plan.  They told me to request a gap exception so I did.  They denied that saying there were in-network providers available.  I called and they told me to do a search and show them that none of the CNM's in my area do homebirth.  Did that.  They denied again but this time, said "not medically necessary.  Homebirth is a patient's choice!"  So now I'm where you are in that I guess I have to call this Patient Advocate person and I agree with you - it's strange to pay someone to argue with the insurance company that THEY pay for services from!  I also know people first-hand who have had their homebirth covered by my plan so I am going to ask about that.  I can't imagine they can pick and choose who they cover this for.

Oh, and like you, in my letter, I argued that there's a 33% chance that they will have to pay for a c-section if I go to the hospital and a 5% chance if I don't.  So they are guarenteed to pay thousands more if everything goes perfectly in the hospital and they have a 33% chance of paying way more than that!  Guess they are not interested in saving money.  I love that a hospital birth with a surgeon is defined as medically-necessary but a lower-tech service is not?  That's not even possible, by definition.