Wednesday, May 16, 2012

Health insurance is a pain in the butt!

As we all probably already know, the health insurance system in the U.S is pretty broken!  I have once tried to explain the concept of health insurance to my friends in the Philippines and they couldn't even wrap their head around how it works.

During my pregnancy, I had switched health insurance several times and it was all pretty annoying, ultimately ending in my health insurance refusing to pay for my 9 months of prenatal care!  Luckily, it is all squared away now, but it was all very frustrating!

It all started last summer when I was pregnant and needed an ob-gyn for my prenatal care.
At that time, I was on Jeff's insurance policy, which was with United Healthcare. 
We were on an HMO plan so I had to go to my primary care physician to "confirm" that I am pregnant, then get a referral to an ob-gym from her.  This meant that, the ob I was referred to is the one I was stuck with (oh the beauty of HMOs....) and I was referred to Plaza Towers Ob, which is a medical group, rather than 1 ob-gyn.  I ended up seeing 6 different obs during my entire pregnancy, and not 1 ob even bothered to remember my name.

Oh well, that part is not so bad, I already knew what I was getting into since we have an HMO.

In the Fall of 2010, Jeff switched jobs and the health insurance at his new company was Anthem Blue Cross.  When Anthem Blue Cross issued us our health insurance cards, I was not on the policy and all the information on the health insurance card was incorrect (such as, it said the co-pay was $15 even though it should have been $5).
After calling Anthem, it turns out that Anthem was confused because Jeff used to be an Anthem policyholder back in 2008 at his last job.  So when Jeff joined his new job and was back on Anthem again, they used his 2008 information, and that was also why I was not on the policy (I was not on Jeff's health insurance back in 2008 since we were not married yet).

Finally, we got every thing clarified with Anthem, but during that process, I had to delay my prenatal appointments with my ob-gyn, *AND* get another referral from my primary care physician to the ob-gyn.

On March 1, 2011, Jeff's company switched health insurance and automatically moved us from Anthem to Cigna.  Keep in mind I was 8.5 months pregnant at this time and I delivered 14 days later! With our Cigna insurance, it is an "open hmo" plan, meanng, we can just show up at our specialist's office without getting a referral from our primary physician.  And from what I recall, we were told that our ob-gyn (Plaza Towers ob) was in-network
Oh how perfect!
Or so we thought...

1 week after Caitlin was born, I got a call from Plaza Towers Ob saying that Cigna was refusing to cover the cost of my prenatal care, and possibly also not covering the cost of the delivery either, since they were considered "out-of network".  And I had to call  my insurance to appeal the decision.  Now, the cost of prenatal care was $6,300 and the cost of the delivery at the hospital was $14,700", so this was a lot of money we are dealing with!

That is so frustrating and it did not help that I had to deal with this so soon after delivering a baby!
I had to call Cigna and appeal their coverage denial.  I figured, worst case, if they still don't budge, then I am forking over the $20K bill over to Jeff's employer since they switched health insurance companies on us so late in my pregnancy!  We really didn't have much of a choice.

I called Cigna and drafted a letter of appeal with the rep on the phone.  My letter of appeal included arguments such as:
  • I have been using this ob-gyn for the entire duration of my pregnancy
  • The employer changed health insurance on me so late in my pregnancy
  • We were told that our ob-gym was in-network
  • My ob-gyn was actually "in-network" with Cigna until January 31, 2011, which was only 1.5 months before I delivered
The letter was submitted and would take up to 5 weeks for review.  The rep on the phone also informed me that the hospital we delivered at (St Johns Health Center) was indeed an in-network facility, so the coverage that was denied was only for my prenatal care.  That's great news!

A couple of weeks later, I got a letter in the mail from Cigna stating that after reviewing my letter of appeal, they decided to cover my prenatal care!

I'm glad that was all taken care of.  That was a big headache.