Anthem Blue Cross Won't Pay! - Mothering Forums
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#1 of 10 Old 01-09-2012, 08:12 AM - Thread Starter
 
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It has been 8 months since my beautiful homebirth and I am still battling my insurance to pay me back for my homebirth. I am in Los Angeles where the R&C charge for a homebirth is around $4000. I was told when I called the insurance during my pregnancy that they cover 80% of R&C charges after your deductible as long as you see a CNM. The first 3 times my claim was submitted they rejected/denied it with no explanation until I called and then they said it was various missing codes/other BS that resulted in that determination.

 

Finally the claim showed up as processing and just the other day it showed they were sending me a payment. When I looked at the details it came out to around 16% of the total cost of my care. Their determination of R&C charges was $2,240. I know that isn't right because I interviewed all the midwives in my area and know what they charge. My question is what do I do now? We used money saved for property taxes to pay up front for the birth and now we have gone into debt without getting any of that money back. But more than the money issue, it is the principal of the situation and how they are discriminating against home birth even though it saves them a ton of money.


Adriana, mommy to Klarity 9/06 and Grayam 6/08 and Zephyr homebirth.jpgMay 8, 2011
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#2 of 10 Old 01-09-2012, 10:02 AM
 
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I don't know what to tell you, other than, I was right there with Anthem BCBS after my home birth. I don't get why they are against it. They could pay my midwife, write me a check for a few grand JUST FOR FUN and still be out about 50% of what a hospital birth would have cost.

 

One thing that might work for you, if your insurance is through an employer, is to contact your HR department and ask them for help. It didn't help me, but my HR rep was totally incompetent. Also, I later wrote a scathing letter about the situation to my company's VP of HR, and the company switched from Anthem to Aetna this year. I'm not sure Aetna is any better, but I *do* think that Anthem lost a really big account because of my letter and a few others from women who had HBs and birth center births that year.

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#3 of 10 Old 01-10-2012, 08:04 PM - Thread Starter
 
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Thanks for your insight. It has been referred to my husband's HR at work so we'll see if they get anywhere. I also spoke to an insurance litigation lawyer who told me some helpful things regarding statute of limitations and rights. If the HR route doesn't work I will file a formal appeal.


Adriana, mommy to Klarity 9/06 and Grayam 6/08 and Zephyr homebirth.jpgMay 8, 2011
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#4 of 10 Old 01-24-2012, 10:47 PM
 
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I don't want to depress you, but I will tell you my experience:

 

We had Blue Shield when I got pregnant, which would have covered home-births as an in-network gap exception because Blue Shield did not cover any CNMs.  My husband's employer switched us to Blue Cross less than 3 months before I was due.  We are also in Los Angeles.  Blue Cross covers ONE CNM group based out of USC, which even though is 27 miles from our house, 30 miles is the cutoff - therefore CNMs were an option (they said) and our HB would be covered as out-of-network, meaning 60% after deductible and a $10,000 max for the year instead of the $2000 we'd budgeted for.  I applied for gap exception because the CNMs don't cover home birth.  I applied for a medical necessity for HB because my blood pressure plummets when I have needles, scopes, etc. inserted and I faint.  I filed an appeal, then a greivance when both were denied.  I applied for an expedited greivance because at this point I was due in a week and still didn't have in-network coverage.  I was denied the expedited appeal because it wasn't life-threatening.  I gave birth at home, and 2 weeks later received the letter that I was denied.  I filed another greivance because I would have gone to the hospital had I known I would have been denied.  It was rejected.  I went ahead and filed for out of network coverage to get back what I could.  They decided that a home birth's cost equaled roughly $1800 - after my deductible, that meant I got a check for $700+ after paying $4400 out of pocket.  I spoke to every supervisor I could - told them I had called every midwife in the LA area and NOT ONE charges anything close to that low.  They said too bad.  Anthem decides what they think a home birth SHOULD cost, and that's the figure they use, regardless of actual costs.  The only silver lining to the whole thing is that I noticed on the form Anthem sent that was attached to the check that they listed the birth as "Surgical" not Global Services, so I asked about that.  Apparently, whether you file for just the birth, or as global services (as most midwives do - including all pre- and post-natal appointments under the same umbrella), Anthem pays only for the cost of the birth ($1800 in their view) unless you file for those appointments separately.  So I filed for every pre- and post-natal appointment separately and was able to get back a few hundred more.  All told, I got back maybe $1300 - not nearly the 80% we'd budgeted for.  I'd like to have another home birth with this one, but I don't know if we can afford it under those circumstances.  I'm going to start filing my requests now, that's for damn sure.

 

So if they deny everything, at least go back and refile for each appointment separately.  And if they pay, please please tell me how you got that to happen.

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#5 of 10 Old 01-25-2012, 10:07 AM
 
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Hate to say it, but I think you're lucky to get what you got.  I've discussed this in depth with the MWs I interviewed because I knew it was going to be an issue.  But we budgeted to pay it out of pocket entirely, and if we get reimbursed that's just a bonus.  Basically, the insurance gets to determine what they're going to pay, like they do with everything (this is not HB specific, talk to any doctor's office, and they'll tell you they get a fraction of what they bill out of the insurance companies).  And then they'll take the percentage they pay off that number.  Like the pp said, you will probably be able to get more out of them by billing separately for every individual appointment, both pre and post partum, plus the birth, than if they're billed one fee for global.  But I still wouldn't expect anything close to full coverage.

 

My MW gave me a list of questions to ask my insurance company that helped me determine what I might expect for reimbursement.  Their global fee is $2052.  That's all they'll allow for L&D.  I have a 50% copay and a $3000 deductible that has to be met before they'll even pay that much (because it's out of network).  So even once I meet the deductible, I still have to pay 50% of the fee before they'll pay anything.  Basically I might get a couple hundred dollars back at the end, but I'm not counting on it. 

 

It sucks that you didn't realize this, and are now in a budget crunch, but I doubt you're going to get the full 80% that you're hoping to see out of them. 


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#6 of 10 Old 01-25-2012, 10:32 AM
 
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One thing I recently learned is that you can use a Health Savings Account (HSA or FSA) to pay for a home birth. That's pre-tax money, so depending on your tax bracket, it could be up to a 30% or so savings (not that high for US, but still...it would only be 15% for Mitt Romney! :)  )

 

It's kind of inconvenient because there's usually just one time in the year when you can determine how much you're putting in an HSA, and if you aren't pregnant at that time, it can be kind of a high pressure situation...but if you *are*, then it's a good idea.


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#7 of 10 Old 04-17-2014, 08:42 PM
 
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hi do any of you know if anthem blue cross covers certified midwives? 

 

I have insurance through my so's work insurance, and it's anthem blue cross? 

 

I have tried to find this out and looked and looked online and on the website. Can anyone please help me?

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#8 of 10 Old 04-17-2014, 09:26 PM
 
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I am pretty sure it was anthem that fully reimbursed me for my first home birth. But, I would not recommend calling and asking. That puts you on their radar. I've had midwives who require a certain amount of payment upfront that will be reimbursed if insurance pays, and midwives who just send a bill after the birth for anything not covered. could you ask any midwives you're considering if they've received payment from your insurance? With home birth, it seems like you never really know how the coverage will be until after the birth when the claim is submitted. I pretty much brace myself for the possibility of paying all of it, while hoping insurance will pay up!

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#9 of 10 Old 04-18-2014, 06:03 AM
 
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Well i didn't have a baby under this insurance yet.. I am just trying to see if this insurance i am currently under covers 'alternative birthing', like birthing center, a midwife instead of a obgyn (unless the obgyn is friendly to vbac since that is what i want instead of another c-section), and water birth?

 

And no, i haven't called and asked because i have heard they will turn you down or can lie over the phone, or immediately say no to the slightest mention of 'homebirth'. i'd rather my 'doctor/midwife/whatever' can see and call for me. lol

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#10 of 10 Old 04-19-2014, 08:10 AM
 
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I have Anthem BCBS California as well- and got back $2750 of a $5000 midwife bill. My midwife is not a CNM, and all the midwives in my area charge between 3500-5000. I spent many hours on the phone (probably 10 hour long phonecalls total and lots of written appeal letters/forms) just to get that 2750 back. When i originally filed for pre-approval- they also told me they'd pay 80%.... but they don't tell you clearly that they pay 80% of the "customary reasonable amount" which is pretty much a bullshit way of them saying "however much they want". They pull those numbers out of thin air- because the customary reasonable amount that midwives charge in my area is stated above-- and maybe the 3500 is 80 percent of that but MY midwife with all her prenatal and postpartum care above and beyond that the cheapie 3500 newbie midwives charge is definitely worth 5000 and that's more than reasonable.

 

insurance companies suck- and we will never win with them. I think you've just got to budget to pay $5K per homebirth because when insurance companies cover that.... pigs will fly. 

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