Does anyone have experience with appealing insurance coverage for their maternity/prenatal care? My insurance is not covering any of my ultrasounds (or most of my blood work/labs) and 2017 will include the early ones, NT and anatomy scan = $$$$. I guess they're not usually covered since it's diagnostic testing BUT we're on a high deductible plan and I'm cringing at the thought of these costs going forward...
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@LindsayInNY: I work in the benefits department in our company. What exactly are you looking to appeal? If you're on a HDHP, all ultrasounds are going to be considered diagnostic. They aren't preventive as they are looking at pregnancy as a condition.
When you appeal, you're stating that the claim was processed incorrectly, and you're appealing the insurance company to process the claim according to additional medical necessity information. If the plan is written to say that all maternity costs are covered as diagnostic, you can appeal all you want...it's going to deny because the claims are processing correctly according to how the plan is written.
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In my experience with my past two pregnancies and being on a HDHP, you can pretty much expect to pay for everything out of pocket related to prenatal care until you hit your deductible. My last pregnancy required weekly non stress tests for the last 8 weeks at $300 a visit, but it just meant we reached our deductible quicker and when we had the baby ended up paying less than we would have if we hadn't met it yet.
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@2PeasinaPod: The insurance rep basically recommended arguing that it (tests, labs) should be covered as preventative care. It blows my mind that the NT and anatomy scans aren't considered preventative since the whole point is to detect issues.
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@HappyBaker: Ugh, I hate this plan. And insurance.
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@LindsayInNY: Yea now that I have kids I definitely assume we will end up paying the full deductible in the year when I make insurance plan choices and compare options! As a young healthy child free person I never even came close but every year since I had my first we've hit it without fail.
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When does your deductible reset? Jan 1? I assume most of the expenses will be in 2018 and you're going to hit your deductible with childbirth anyways....
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@LindsayInNY: I totally hear what you're saying. I have 2 kiddos myself and it's crazy that pregnancy is treated as a condition.
I think with the NT and other genetic tests...they're elective. You don't have to get them, so if you do, it's on you to pay for. In reality, a healthy pregnancy would be 2 ultrasounds (one at 8-10 weeks to confirm pregnancy, and the anatomy scan at 20 weeks). Beyond that, everything is elective.
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@lawbee11: Yes, Jan 1. But we'll change plans in anticipation of the birth. BUT the bulk of these costs are going to be 2017 it seems.
@2PeasinaPod: I would be fine if insurance just covered even those two!
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@LindsayInNY: Could you do one of the blood tests instead of the NT scan? Not sure of the difference cost-wise but I assume the blood test would be cheaper.
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@LindsayInNY: Diagnostic and preventative are not the same thing, so I don't think you'll have much luck appealing to have the ultrasounds and bloodwork covered. The bummer for you is that your pregnancy is going to span two insurance years so you have to start from zero again on Jan 1 in terms of meeting your deductible. Rather than fighting your insurance company, which I think would be a losing battle, I would see if you can work with your OB's office. My OB charged me one big bill for prenatal care when I hit my 3rd trimester. If you can get your OB to push off billing as much as possible into 2018 that will help lower your costs.
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We were not on a HDHP and all of my ultrasounds were still considered diagnostic. It's just a reality of US healthcare these days, unfortunately. We tried to offset some of the cost by contributing a large amount to our HFSA the year I was pregnant, knowing that we'd have a ton of out of pocket health expenses that year. At least we got a little break on taxes.
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@lawbee11: I looked into them before all these bills... I'm not 35 and no risks so insurance won't cover them. And they're $350+ I believe.
@Truth Bombs: My ob office was acquired by the NYU hospital system so I feel like there's no working with me on anything.
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That's so strange. I've had two different HDHP and two different practices. They've always included it in the all inclusive charge. The only thing I have had to pay for is some blood work.
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Two things - first, I think whether or not ultrasounds are covered depends on your particular insurance plan. I was on two separate high deductible plans for each of my pregnancies, and the first covered all ultrasounds, but the second only covered one ultrasound per trimester (which I only found out after getting the bill for my NT scan, of course.)
Second, do you or your husband have access via your jobs to something like Health Advocate? It's included as part of our Employee Assistance Program (EAP) and they basically act as a go-between to help you navigate your healthcare situation. They were SO helpful toward the end of pregnancy with all the extra expenses that were coming our way (NSTs, iron infusions, etc.)
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I was on a high deductible plan for most of my 2nd pregnancy and it was awful to pretty much pay out of pocket. I had some success though to get some of the costs lowered. It was a pain to call each time I get a bill but it did help some.
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@Pollywog: Really? Are you in the US?
@raspberries: Ugh. So annoying. My husband works for a huge HR company too... I don't know if we have a Health Advocate type of service. I should have him check. Open enrollment comes up in a couple weeks and I'm sure it would be mentioned in the enrollment paperwork too.
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@snowjewelz: I'm trying to remind myself that instead of the premium, we're paying now. So it might just break even but it doesn't feel that way!
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@LindsayInNY: It literally hurt my heart everytime I had to pay a bill. So so awful. Then after birth I had unpaid maternity leave too. We also switched insurance before birth. At least I knew all of this going in so all the high bills weren't a "surprise".... But still!
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@LindsayInNY: yep, first birth with OBs at a major university hospital in DC and United. Second pregnancy is with BCBS in VA with midwives
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@LindsayInNY: I am so sorry you are dealing with this! I don't have experience with this, but I hope it works out. Try to talk to your OB's office. It's worth a shot.
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@LindsayInNY: That's crazy! I'm on a high deductible plan as well and ALL of my blood tests, ultra sounds (initial and at 20 weeks) were completely covered and I never received any sort of bill. To be quite honest, I didn't even get a bill until we had the birth and we had to prepay a portion of that, which was annoying.
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@NorthStar: I guess it's part of the plan documents, which, of course, I can never seem to get myself... It's so frustrating. It makes me want NO ultrasounds now!
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@LindsayInNY: Yeah, totally ridiculous. Have you tried to see if your doctor will recode as preventative vs diagnostic? I didn't get a chance to read all the responses above. Plus, I thought under the ACA, prenatal care was supposed to be covered! I would think the 20 week ultrasounds would fall under that as they are more or less required. Doesn't every doctor do those?
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I don't know much about high deductible plans, but can I ask how much your monthly premiums are? I wonder if in the end, you will end up "breaking even." For example, we pay $400 / Month for a family of 4, and to the best of my knowledge, everything is covered (or is subject to a nominal $20 copay), with $0 deductible. But over the course of the year, we pay almost $5k...
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@NorthStar: Insurance did mention primary versus secondary diagnosis codes so maybe. Apparently prenatal care only covers normal appointments - not tests or any issues that come up (like spotting, for example). Insurance suggested appealing and making that argument that certain scans are "required" by the OB.
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@LindsayInNY: yeah, i would do that. it doesn't hurt to try and if they require it, then I would think it would be covered. Sucks you have to deal with this.
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All of my prenatal care went towards my high deductible, except vaccines. My pre-natal care overall was charged to the year I gave birth, but I had to pay for all bloodwork and ultrasounds when it occurred. A non-high deductible plan would have cost much more overall. I went reached my deductible (and OOP max) in the year I gave birth, so my medical care was totally free for the rest of that year.
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You can certainly try to appeal, but the precedent appears to be that this billing and patient responsibility is normal. If you get some big bills (like I did for panorama/genetic testing) you can ask if there is a cash rate. I wasn't going to hit my deductible anyway (I have a HDHP) and I paid $200 for the test, cash, out of my HSA vs my "patient responsibility" of nearly $600. I roll over mid year, so the last 5 months of this pregnancy and the birth should make me hit the deductible. This was a similar experience as my first, except I had an oxford HDHP which I felt covered me a bit more and I paid less OOP
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