Insurance Frustration

Discussion in 'General' started by Beth*J, Aug 13, 2007.

  1. Beth*J

    Beth*J Well-Known Member

    Arghhhh. I've posted this in an IVF forum I frequent, but I thought I would also post here in case someone has additional advice for me. After our IVF (and after my BFP actually), I was hospitalized with severe late onset OHSS. I was in the hospital for 4.5 days. I didn't go to the ER, but it was basically an emergency situation. I went to the doctor. He told me to go straight to the hospital. I asked if I could go home first and get some things and I was told no. So I went to the hospital and they didn't even check me in first, they put me in a room and started the check in process while they were starting my IV. Anyway, it never occurred to me that my insurance might not cover the hospitalization. We just got a bill for $10,266 and insurance says they won't cover any of it. The EOB just says "not covered services." I've read my insurance coverage booklet from cover to cover and it does not say it won't cover OHSS. It does say it won't cover most infertility treatments except for a lieftime maximum of 6 IUIs. Well, this could have happened with an IUI too, so I don't see why it won't cover this. I know that IVF is an elective procedure, but I keep thinking about how many people elect to ride motorcycles without a helmet and insurance covers them if they end up in the hospital. I do plan to appeal this and I found out what I need to do to do that. I'm also planning to talk to my OB at my appointment on Wed. since she oversaw my care while I was in the hospital. My RE is 3.5 hours away and since I was pregnant, it was decided I should just stay at my hospital here. I'm so frustrated. My poor babies don't need their mommy to be this stressed. I hope we can get this resolved. I have no idea how we will come up with that kind of money. DH is discussing selling our farmland (not the house and yard). I hate to have to do that since the land has been in the family since his grandfather owned it and he worked really hard to be able to get it.

    If anyone has experience with this and has any suggestions for me, I would love to hear them.
  2. butterfly02

    butterfly02 Well-Known Member

    :hug99: I have no advice, but just wanted to say i wish you luck and i hope that everything works out for you!

    Try not to make any hasty decisions right now...I know tha finacial stress can really play with the mind.

    I agree, talk to your doctor and hopefully they can help out.

    Good luck with everything!
  3. ladybenz

    ladybenz Well-Known Member

    Ah Beth, this stinks. Some things you can do in addition to appealing your insurance's decision:

    Call the hospital, as soon as possible, and ask to speak with somebody in the financial services department--get the name of whoever you talk to, and ask if it would be allright for you to call that person directly in the future--this way you have someone "on your side" at the hospital. Explain the situation, that you are starting the appeal process, and ask them if they can delay billing you until this is resolved. (to avoid negative action against your credit while you are in the appeal process). Next, ask them to double-check the way your hospital visit was coded, and see if they can find any mistakes and refile. If there are no mistakes, refiling probably won't help, however, they may cover some of it if there were coding mistakes. And the hospital may be willing to re-code it in such a way so the insurance will cover it.

    If you still end up having to pay it, ask the hospital if there is anything they can do to reduce the amount owed. They may very well do this--and substantially. If necessary, ask to be put on a payment plan or put the charges on a no-interest credit card if you have one.

    Good luck!!!
  4. tammygb

    tammygb Well-Known Member

    QUOTE(ladybenz @ Aug 13 2007, 06:59 PM) [snapback]367309[/snapback]
    If you still end up having to pay it, ask the hospital if there is anything they can do to reduce the amount owed. They may very well do this--and substantially. If necessary, ask to be put on a payment plan or put the charges on a no-interest credit card if you have one.

    Good luck!!!

    this is good advice. also, ask your insurance carrier to point to the place in the booklet that specifies this isn't covered. for instance, they may not be covering it because it wasn't 'pre-certified' and you may be assuming it has to do with the IVF. i've worked in benefits and i don't think the associated with IVF is the reason it's denied. but it's a crazy industry, so you never know.

    try not to stress until you get all the facts. also, if your employer (or DHs) has a helpline for this sort of thing, you may want to try to solicit their help.

    good luck!
  5. Jennie-OH

    Jennie-OH Well-Known Member

    I have worked in billing for a physician and for 2 different health insurance companies. I think the PPs gave great advice regarding (1) talking to your ins co to find out specifically what is triggering the denial, (2) working with the hospital account rep to figure out what ways they can help, and (3) that it probably doesn't have anything to do with the fact it was related to IVF. If there were the case, they could deny paying for many of the things that resulted from that IVF cycle (pg tests, u/s, etc).

    I think (and hope) what you are going to find is that the hospital/physician either didn't pre-cert your stay OR that the hospital is billing some diagnosis that they shouldn't be. Both of these are easily corrected in most cases. If it somehow is a medical benefits issue, by all means, appeal - appeal - appeal! Unless you have a major medical plan only, I cannot imagine how they would be able to justify denying a medically necessary hospitalization. If necessary, involve your benefits administrator (either your DH's or your company would have the name of this person - depending who is carrying the insurance) and/or your state's department of insurance/insurance commissioner.

    On a personal note, as an example, I recently received a denial for my 1st trimester screening u/s to the tune of $800. I was panicked! (I know it doesn't compare to $10k.) I called my insurance company to ask specifically why it was being denied. When the customer service rep looked more closely at the claim, she noticed the provider had billed a "routine preventative care" diagnosis. Nothing about pg mentioned in the dx at all! Once I was finally able to get the provider's biller to comprehend what could possibly be wrong with that and get her to rebill, it was magically paid. A simple coding error had me totally freaked out for a whole day. I hope your issue is as easily resolved and that you are able to put this behind you very soon.
  6. 2each

    2each New Member


    Ask your hospital billing dept. to help you appeal. They have a vested interest in getting the insurance company to pay, since most hospitals only collect about $0.05 on the dollar for "self pays." Make sure that the insurance company has officially denied payment first - sometimes hospital bills go out before claims settle. If you haven't called your insurance company yet, do that too. Make sure you understand why they are denying payment. If it is for lack of a precert, you shouldn't suffer for this. You came in an emergency situation and followed your doctor's advice.

    If nothing is in your policy, you probably stand a good chance of getting this resolved in your favor. Don't give up easily.

  7. twoplustwo

    twoplustwo Well-Known Member

    I agree with PP's. DON'T STRESS OVER IT!!!
    I would call your insurance comp to see why they denied first, so you know where to go from there.

    I had a ER visit denied when I had a cyst burst. The hosp billed incorrectly and it took 2 years to get straightened out. It happens.

    If it was a pre-cert, you don't pre-cert emergencies. hence the name emergency. They would get in big trouble for denying you immediate medical care for a life threatening situation if they required you to pre-cert emergenies. You are supposed to call after the fact but by then the hospital has already done that so it's redundant.

    BTW, Congrats on your BFP!!
  8. greengirls

    greengirls Well-Known Member

    I hate that you are having to deal with this. I had OHSS also after a round of Gonal-F and an IUI. My doctor was able to code it differently and it was paid by our insurance. I hope that you are able to get some answers soon. From my experience with insurance companies, my daughter has cerebral palsy, if you are a bug in their ears or a squeaky wheel it can help... be persistent!
    You are totally right that insurance companies pay all kinds of money for other people's stupid mistakes and having OHSS is no walk in the park!!
    I feel for you!
  9. tammygb

    tammygb Well-Known Member

    Beth, Please post back when this is resolved and let us know what happened.

  10. JDMummy

    JDMummy Well-Known Member

    Oh how awful! Beth, please try to enjoy your pregnancy and try to not let this stress of this bill take over the joy of a BFP! :hug99:

    Let us know how things go!
  11. Jennie-OH

    Jennie-OH Well-Known Member

    QUOTE( @ Aug 13 2007, 11:11 PM) [snapback]367660[/snapback]
    My doctor was able to code it differently and it was paid by our insurance. I hope that you are able to get some answers soon.

    Ok, I think alot of us who have dealt with IF have benefited in one way or another from "creative" billing but I just want to put it out there...."coding it differently" for the purposes of 'tricking' the insurance company is potentially insurance fraud.

    Beth - Please keep us posted and let me know if there is anything I can do to help research your options. Feel free to PM me.
  12. 4jsinPA

    4jsinPA Well-Known Member TS Moderator

    Did your insurance cover the drugs alone? Forget the IVF part, but if they covered the drugs than they should cover the side effects the drugs gave you. The IVF didn't give you OHSS, the drugs did. Definetly appeal. I had to appeal something and it took a long time to research and write the letter but it was worth it. Lots of loopholes, you just have to find one....good luck!
  13. Beth*J

    Beth*J Well-Known Member

    Well, here's where we are at this point. I told my OB about the situation at my appointment yesterday. She was perplexed about why the hospitalization wasn't covered because she said it was "a complication of pregnancy." The doctor said she is happy to write a letter, but wants to know exactly why the claim was denied so she knows what parts to emphasize in her letter. I went to the hospital and the cashier said that it looked like there was some infertility coding involved. They gave me a copy of my hospital records and an itemized bill. So, today I emailed our company's contact at BCBS to find out what my next step needs to be. I'm waiting to hear back from them.

    Thanks for all your support. I'll try to keep you all updated as I learn more.

    ETA: Oh, and no, nothing was covered by the insurance for the IVF. They did cover my IUIs though.
  14. Beth*J

    Beth*J Well-Known Member

    Good news about my insurance dilemma with the OHSS. It caused quite a bit of stress and we've been worried about how to deal with this. We spent all day last Sunday getting documents together for the appeal: written naratives from DH and me, a letter from my OB, hospital records, itemized bill, etc. etc. On Wed, I received a call from the insurance company. They received my appeal, but had paid the claim the day before. What?!?! I called the hospital the next morning and they knew nothing about it. They did some more searching and found that someone at the hospital had filed an appeal and that it had been paid, so we owe $0! Woo hoo! I wish we hadn't given up a good portion of a weekend worried about this when we didn't even need to file the appeal, but I guess I'm just happy it appears to be solved. We have received written confirmation from the hospital, but nothing written from the insurance company yet. I wish I knew why they suddenly changed their minds.

    By the way, if anyone else ever deals with something like this, our hospital was willing to decrease the bill by 38% if insurance wouldn't cover it. We would have had to prove we didn't qualify for medical assistance and had to go on a payment plan, but that would have helped significantly.
  15. greengirls

    greengirls Well-Known Member

    That is great news!! I'm so happy that the bill was paid and you owe $0.. what a relief!
  16. summerfun

    summerfun Well-Known Member TS Moderator

    Beth-that is great news! :clapping:
  17. cclott

    cclott Well-Known Member

    I'm so glad it got all worked out! Dealing with insurance companies can be such a headache!! Hopefully that was the last of your worries during this pregnancy!!!
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