How Tonya Should Go About Appealing Her "Elective" Miscarriage

I just read the story ‘Blue Cross Blue Shield Calls Miscarriage “Elective Abortion,” Denies Claim’, and I work for BCBS in NY. From what I’ve learned (and this is just from my experience working for a year there). The best thing for Tonya to do is appeal. She should write a letter explaining what happened that night. Go to the hospital get medical records/Doctor reports/emergency reports anything that shows 1) the medical necessity of the services and 2) what exactly happened. In NY there is a 180 day time limit from the last time the claim was adjusted (but that may be different in her state). Also, in NY, there are at least 2 appeal levels (three technically, and sometimes 4) Here’s how it works for the account I work for…

(again, definitely different for different plans, if you call the customer service number, they’ll be able to advise you on exactly how this works) A customer calls up, says they disagree with how a claim is processed. If there’s something I can do, I do it (call the dr’s office to get a different dx code, med recs, whatever) If it’s something that’s blatantly wrong, I can send it to appeals to have it fixed. If that doesn’t work, and the customer disagrees with what I’ve found, I can still send it to adjustments for the Standard Inquiry. (this is a proto-appeal) it takes 14 days (generally) The member is sent either a new explanation of benefits (if the claim is adjusted), or a letter saying (sorry, the claim is right). On to round two, which is technically Appeal-1. This has to be done in writing. It takes 30 days to process, and the member gets either the eob, or the letter, on to round three, Appeal-2, same idea 30 days to process, member gets the eob or the letter.

If that doesn’t work, the next step (at least for the plan I cover) is one last appeal, which gets sent, not to BCBS, but to the company that the member works for. They review it there, same 30 days for processing, and they send the member a letter. I don’t know if this is typical (there’s a lot of chances for claims to be changed here), but the general process is the same.

The best thing I can tell you guys, is send as much information as you can gather, ER records, pathology reports, doctor notes, peer reviewed literature, whatever you can find to prove the medical necessity of the service. I gather from the difficulties that are put up around it, that insurance companies don’t want people to try this, but it’s worth it, and it’s worth going through the entire process as well.

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  1. axiomatic says:

    Hey there Mr BCBS employee. Why don’t YOU just help her and champion her claim to your company. You seem genuinely concerned. Go “all in” why don’t you?

  2. bonzombiekitty says:

    @axiomatic: Maybe because the employee works in a different state with different plans? Outside of giving advice, the person who wrote the article probably has less of an ability to help Tonya than Tonya herself does

  3. enm4r says:

    @axiomatic: I work in commercial finance, and I have had one or two inquiries from friends asking if I could help with their consumer issue. Generally speaking, I could not. Even though the business card would be the same, big business is separated into such silos that it makes it almost impossible to cross…

    But good info all around, not to say it isn’t a huge hassle, because they’re definitely making you work for your money. Makes the complaint I have about redeeming my $50 ATA voucher seem meaningless…

  4. @axiomatic:

    Because 1: She doesn’t work in the state that the woman is having the problem with BCBS. Number 2: The BCBS employee here doesn’t work covering the same plan as the woman whose claim was denied.

  5. txinfo says:

    Why should she have to go through all of this waiting? 30 days here… 30 days there… Over and over. She had done NOTHING wrong. She should call the press have have the public get behind her.The more people(regular people and not some corporate stooge working for the company) who get on her side and complain, the more likely something will get done. Power is in the numbers.

    A few spots of bad press can take care of all this in no time. She has already suffered enough and shouldn’t have have to be forced to deal with BCBS any more than she has to.

  6. warf0x0r says:

    What she should do is call the press and get as much bad publicity for BCBS as possible so they have to do the work and either justify their labeling of her ER visit as an “Elected” Abortion. I’d love to see a higher-up try and explain that to the media.

  7. cashmerewhore says:

    3. Unles Tanya authorizes the author of this post to receive medical information (which is not the same as Tanya posting it for everybody to see), then the only people who can do anything for Tanya are her authorized contacts (herself, spouse, family if she approved it).

    Thanks HIPAA.

  8. bohemian says:

    An insured should not have to spend hours of research and footwork just to get an insurance company to cover and obviously covered expense.

    This is how corporate america keeps that bottom line profitable. Do whatever you want and force the customer to waste so much time that most will just give up.

    This is a standard practice in all lines of insurance and needs to be outlawed.

  9. Zaphâ„¢ says:

    Now I never advocate for the insurance company, though I work for one that is not in the heath business anymore, but it is possible that the hospital did send the wrong code on the paperwork. I have run into way too many stories where the person filing the paperwork to the insurance company effed the code by one digit or put the right code on the wrong patient file. While I think it is rediculous for the ailing patient or in this case grieving mother to do the leg work it might be the only way to get the claim paid.

  10. alk509 says:

    @txinfo: Absolutely! She shouldn’t have to waste any of her time fixing BCBS’s mistake. I say fuck ‘em, call the press.

  11. Cowboys_fan says:

    @warf0x0r: I think you’re assuming insurance companies even care about PR. With the bad name they already have, they do nothing to change that.
    This proves yet again, you can have insurance, you just can’t use it!

  12. blue_duck says:

    “Electiive?” Spell check! :P

  13. kc2idf says:

    When I have had unresolved problems (after several attempts) with insurers, I have found it useful to just show up in their front lobby with all of my paperwork.

    Now, if you do this, use some common sense. What you are trying to do is put a human face on your case.

    Don’t make threats.

    Don’t get beligerent.

    Remain calm at all times.

    Have all of your paperwork together and organised. You want to be able to pull out any sheet at any time in the conversation if it will help you make your case.

    Be polite. Tell the receptionist, what you need (keep it short — ten words is a good length) and who you have spoken to in the company. Remember, the receptionist is mostly there to answer the company phones, so let her do her job. She can’t help you directly, but she is the one who will be able to find someone to help you, so you need her to be your friend.

    If the person you were speaking/writing to is unavailable, ask politely for that person’s boss.

    If the boss is unavailable, ask for anyone who can help.

    If they ask you to leave, do so (this has never happened to me).

    On the occasions when I have had to do this, I have invariably left satisfied, and with an unsolicited apology from the claims handler.

  14. A customer calls up, says they disagree with how a claim is processed. If there’s something I can do, I do it (call the dr’s office to get a different dx code, med recs, whatever) If it’s something that’s blatantly wrong, I can send it to appeals to have it fixed.

    Hopefully, that will be (and should be) it. If the agent at the insurance company calls the ER then getting proof it wasn’t elective should be a simple matter. From Tonya’s comment in the previous thread it sounds like they got the right information in the first place so I don’t know how/why the hospital faxing the same information to them again is going to fix this.

  15. Hawkins says:

    BCBS isn’t a company. It’s an association. They try to look like a single entity, mostly for purposes of contracting with providers, but each plan is a completely separate company. See [www.bcbs.com] .

    Mr. CowboysFan is right: Shenanigans like this are now so common that they’re beginning to lose the power to shock people.

    Mrs. Clinton’s plan for health care is starting to make sense.

  16. warf0x0r says:

    @Cowboys_fan: Okay, get the press and the religious right. Do you have any idea how pissed they would be that an insurance company would tell someone they had an abortion when they didn’t. Insurance companies will start to care then.

  17. mcrbpc says:

    She’s in KC, KCTV5 always does those “Call for Action” pieces on the local news when businesses are behaving badly. I’m sure they’d love this.

  18. SadSam says:

    While this is good advice from the BC/BS employee, why does insurance need to be so darn complicated. These insurance companies pay all these people to deny health care, nickel and dime doctors and make everyone involved in the process miserable (patients, doctors, hospitals, the company paying for the policy, etc.) we would be so much better served if we had some other system, non-profit, government run, etc.

    The patient in this story (noted in prior posts) confirmed with the hospital that the proper code and paperwork were provided to BC/BS. She should not have to waste her valuable time discussing an emotionally unpleasant event in her life with one BC/BS customer diservice rep. after another.

  19. sassypizzazz says:

    First of all, let me state that I am in NO WAY condoning the actions of BCBS. That being said, I am a claims adjustor for a different health insurance company, but I can still speak with some authority on the subject. Unfortunately, I have seen this situation before. And I think that BCBS is getting criticism for what may not be their mistake. What I have inferred from the story is that the HOSPITAL did not bill correctly. If the HOSPITAL did not bill correctly, then the claim cannot be adjusted. However, Tonya has many different ways to appeal this claim. Because Tonya is the member and not the provider, she cannot change claim data; this must come from the provider. Some providers, and this is due to federal law, must correct claims in writing, a phone call won’t do the job. What Tonya can do in this situation is contact the Billing Department at the hospital and have the hospital appeal as well. Because abortion is so controversial, and plans vary widely on coverage, the hospital may not realize that there is a mistake on the claim. Since this is group health insurance, Tonya can also contact the HR department and have HR make an executive complaint. The company’s HR representative has a contact at BCBS (before I became a claims adjustor, I was that HR contact at BCBS) and can expedite the issue.

  20. CurbRunner says:

    It can really be amazing how quickly an insurer can solve problems that they would otherwise lead you to believe need to first enter the black hole of appeals when the right level of media coverage (Michael Moore’s skills come to mind) and public pressure are applied to expose their denial of coverage practices.

  21. CumaeanSibyl says:

    @sassypizzazz: Read the original article before you make inferences. Tonya checked with the hospital and found that they used the correct coding and described the event as a “spontaneous miscarriage,” and she did not receive a D&C or any similar service that might be miscoded as an elective abortion.

    The hospital also informed her that the BCBS in the area had a history of denying miscarriage claims as elective abortions.

  22. hills says:

    More advice from a fellow BCBS appealer (I’ve got 5-10 under my belt!) – Send your appeal with delivery confirmation or it will probably be “not received.” Write down the name of everyone you talk to, date, and important info…. follow up (ask for phone extensions) and make them stick to the 30 days.

    Unfortunately, I don’t think going to the press is going to be very newsworthy (no offense) – It’s just that this literally happens every day – It’s just the first time for Tonya. I just finally got a claim paid earlier this month that was originally filed in May 2006 – it is a long and time consuming process, but I personally wouldn’t expect to find it on the nightly news.

    My favorite was when I stayed in the hospital for 4 days, and BCBS covered my first & last days, but not the middle two – according to them I could have had a home care nurse?! That was sorted out and paid, but just another example of the hoops you have to jump through….

    FYI – Wellpoint, parent company of BCBS has huge profits at our expense – net INCOME of $731.8 MILLION, for the first QUARTER ending March 31 2006

  23. timmus says:

    The system is going to collapse. The people that are being hurt the most by this medical mess are the same kinds of people that put Bush in office, and if they can do that twice, then they have some clout. Bring on the billing mistakes. I’ve chose to remain insured and go out of the country if I need some major procedure.

  24. timmus says:

    (remain uninsured, I mean)

  25. Red_Eye says:

    @sassypizzazz: yep because its the hospitals fault there are thousands of CODES that are used to describe items. Its the nitpicky friggin insurance companies who demand the ability to reject every piece of friggin bed lint they dont want to pay for, that they dont want to approve of, that they can weasel their way out of.

    See insurance should work like this. I the customer pay you to insure me. You set the flat amount youre willing to pay for a service and a lifetime cap your willing to pay. After that NOTHING should be contested. It should not go before a ‘peer’ review of the insurance companies doctors, it should not be debated by the insurance company as to the necessity unless its glaringly obvious. How obvious? I cant set that limit but in this case the insurance company should have called the doctor for answers if they didnt like what they heard or got a lack of response they should have called the patient. Not just say oh it was all coded wrong, so no soup for you.

    I swear some of them just do this so that the time limitations that are part of their contracts with the health care provider run out and they cant be billed. This happened to my kids pediatrician once, miscoded a single immunization, the ins co denied the claim and the ped ran out of time to file the new claim and was out over $300.

  26. hills says:

    You’re kidding right? I’m the type of person being hurt be this medical mess and I can guarantee that I didn’t have anything to do with Bush being in office.

    You’re uninsured on purpose? Good luck with that!

    PS-I really hope you are joking!

    @timmus:

  27. BrockBrockman says:

    It is VERY insulting to call a miscarriage an “elective” procedure, especially as a rote BCBS policy.

    While I don’t doubt that BCBS will eventually pay for the procedure, where is the apology to all women who have had to suffer the tragedy of a miscarriage but are denied by BCBS (emphasize “BS”) by calling the procedure “elective”? Compounding the family’s heartbreak and sorrow and essentially blaming them for the miscarriage is morally reprehensible. BCBS failure to pay for the procedure is just another slap in the face.

  28. LionelEHutz says:

    This is why the insurance industry should be drowned in the bathtub.

  29. nardo218 says:

    The scholarly journals suggestion is interesting, I’d never thought of that.

    You can get abstracts on pubmed.gov. If you know anyone in college, you can ask them if they’ll print out or email you the full article. (A doctor or professor friend could also help you – anyone who has reason to keep up to date on medicine or biology.) If you’re really dedicated or have money to burn, you can subscribe to a journal for a few thousand a year.

    If you find the process of searching scholarly journals confusing — it *is* a byzantine system — go to your local university library and ask the librarian for help. Aside from special collections, as far as I know, the public is welcome in a univ library; you may even be able to obtain a library card, possibly for a fee.

  30. scoobydoo says:

    What SHE should do? SHE shouldn’t have to do a damn thing. BCBS should read the article here, pay the damn bill, send her flowers, pay her for damages and take their collective heads out their backsides.

  31. Uh oh... Cleveland says:

    For all of you who said she shouldn’t have to do anything, you’re right–but if she wants something done, she better pursue it herself.

    One small bit of advice to add to the others above. If you write a letter, make sure you state exactly what you want to happen and why it should happen. If you can point to a part of your medical records that supports it, all the better. But don’t just send a letter saying “Please review my claim again.” Honestly (and unfortunately), the more you can do for the person reviewing your appeal, the more likely it will end in your favor.

  32. Nytmare says:

    @scoobydoo: Great advice. She should just sit back and wait for the problem to fix itself.

  33. chickymama says:

    I have read the orginal posting, the update and now this one and nowhere does it say that the hospital is going to appeal as well. It is all well and good that the hospital confirmed that the dx is not elective abortion, but the next step would be for them to tell her that they are appealing as their documentation supports the dx of spontaneous miscarriage.
    I work as a an account follow up specialist at a hospital. On our team there is one person whose job is to appeal. Her job is to appeal for dx that are covered by the insurance plan, procedures, admits that were covered then denied, contractual obligations, etc. We have provider reps who are liasons between the hospital and the insurance companies. Normally we can just contact them, forward the info, then they will have the claim reprocessed. If the hospital in this case has a contract with BCBS of Kansas, then they need to be appealing or contacting their provider rep.
    It upsets me when I read other commenters postings that their providers did not get their bill in on time and therefore it was denied. Most insurance companies there is a timely fiing limit of one year from the date of service, then 90 to 120 days from the date of denial to appeal. This is plenty of time to get things done. These providers just do not have their act together.
    Tonya should appeal in writing, certified mail, return receipt and contact the hospital as well do this. She shouldn’t talk to customer service but somebody in their department who talks to insurance companies every day to resolve unpaid claims. Most people in customer service have only basic training in insurance denials and have to forward it to the appropriate department anyways.
    As a side note…I would be glad to appeal this for Tonya. I have done many appeals for insurance companies and have won many.

  34. ceejeemcbeegee is not here says:

    @hillsrovey: Oh, it’s great! You’d be amazed at the red carpet treatment you get when you pay cash.

  35. axiomatic says:

    @enm4r: I’m sorry but I still fail to see why you could not champion the call (warm transfer her to the correct BCBS employee) in to the other division (in the other state) for this lady. It just seems to me like you’ve already committed to helping her in this blog. Go the “extra mile.”

    Sorry but at my company, I constantly break the procedures for customer satisfaction. It’s the right thing to do.

    Unless the reason you can’t is that it might get you in trouble. I’m not suggesting you sacrifice your career to help this lady. But if there is no repercussion from corporate, then just do it.

  36. Euglenas says:

    I’ve always hated health insurance providers, now we all do because the stories are getting out. Tonya’s story is a bad one; it really shows how little the people in charge of our health care about us. A friend of mine ([asecondchance.us]) had a far, far worse experience with BCBS, and it didn’t end well. BCBS only agreed to provide coverage when the Washington Post started running a story on him.

  37. Hawkins says:

    @axiomatic: Warm transfer? You’re still not getting it. They are completely different COMPANIES. Your suggestion is equivalent to: I have a problem with my Toyota; why can’t the Chrysler guy help me fix it?

  38. paranoia2mb says:

    I work for BCBSMA and I have to tell you, these comments are really getting out of hand. Again, nobody understands how these companies work, and that’s no fault of the companies because they are constantly educating–just look online at websites–medical policies for your individual states are littered on BCBS websites. Everyone keeps saying insurance should ‘do this’ and ‘cover that’, etc. First: all the BCBS companies are different. One company cannot help another unless the policy that the member has requires it (out of state coverage, or if your insurance company is in a different state than the state that you are in), and you can only speak to the state where your policy originates. Second: they don’t have to cover anything they told you would not be covered or have in print that it would not be covered. Have you ever stopped to think that they break their own contracts that are legally binding to beable to pay things that shouldn’t be covered? Third: the HOSPITAL says they coded it right, and you BELIEVE them??? do you know what the code is, and do you have a book of them, to describe what it defines? The hospital is going to tell you what you want because they don’t want to get yelled at, and of course they’re going to back it up by saying it’s happened before. I’m almost positive that they mean they have billed it incorrectly before. It’s always easy to blame the insurance company. Did you also know that insurance companies did not invent the codes in which are used for hospital/provider billing? We just USE the system for the medical billing. Anyone can buy a coding book for use in medical billing, they’re around $8.95–there are no secrets.

    And as for the comments about the 30-day periods, that is just foolish. Everything has a process–just because they are an insurance company doesn’t mean they are any exception to having periods to review information to make a decision.

    To be honest, anyone speaking negatively needs to be educated. If you think that you ‘shouldn’t have to know how insurance works’–there is your problem. You’re paying for something every week and you don’t know how it works. Whose fault is that? I’ll give you an example: BCBSMA insures MIT. MIT educates ALL of their students and faculty/staff with their policies, and spend money doing so. Do you know who never has to call the insurance company? MIT students, faculty and staff. They know how it works, things RARELY deny because of that, and if they do, they understand why and if it warrants a call to the insurance company. More and more employers are doing this, and instead of rallying against insurance companies, why don’t you talk to your employers, read your contract, or do your research? This is why call centers for insurance companies are thriving–we just can’t seem to stop getting phone calls from uneducated people.

    Take some time and do your part and you’ll be fine. And if you need help, you need to ask nicely, specifically ask for it, don’t give an attitude and we will WANT to help you! I DO IT EVERY DAY.

    Oh, and does all the above sound moronic? Everyone seems to think that people working on the phones for these companies are stupid. I’m sorry to say that it’s simply the other way around. It’s that attitude that is going to push us to not really care what your problem is. If you get someone that you get pushback from, ask for a supervisor! And again, just because you get one, doesn’t mean you can speak down to them.

    If you are even college-level educated, the above will completely make sense to you.

  39. almondwine says:

    I still think that Tonya needs to spend more time thinking about a good lawyer than thinking about a good letter. I’m no fan of meaningless litigation, but it seems to me that by accusing her of opting for an abortion BCBS has done more than commit a simple mistake that can be corrected on appeal. They have caused a woman who lost her child serious emotional pain and distress. They have exposed her to the possibility of serious financial injury and have potentially committed slander.

    Just my thoughts.

  40. hills says:

    @paranoia2mb:

    Yes, everyone needs to know how their insurance policy works and what it covers. However, I am offended by your position that uneducated people are the ones having issues understanding their coverage. I am a well-educated person, and the reason I have had so many approved appeals with Anthem BCBS is precisely because I am educated – I understand my policy – I understand what I am entitled to – I am aware of when Anthem BCBS has issued a denial that is undeserved – Those are the denials I fight, and I have won every single one. Why? I know my plan, policy, and rights.

    If I had a dollar for every idiot at BCBS that I spoke with about my claims I could afford to pay for my treatment myself! That said, when I do find a helpful agent (rare!) I am sure to express my appreciation – There are some helpful agents, but you have to work hard to find them!

  41. …they don’t have to cover anything they told you would not be covered or have in print that it would not be covered…

    @paranoia2mb: Irrelevant in this case. The problem is that the insurance company is calling her miscarriage an elective abortion.

    the HOSPITAL says they coded it right, and you BELIEVE them???

    Is there a reason not to? At best there’s a fifty/fifty chance it’s the hospital that screwed up but that’s ignoring the fact that they’ve denied ALL of Tonya’s claims up to this point.

    To be honest, anyone speaking negatively needs to be educated.

    Saying that everyone who disagrees with you is stupid doesn’t exactly make you endearing.

    Everyone seems to think that people working on the phones for these companies are stupid. I’m sorry to say that it’s simply the other way around. It’s that attitude that is going to push us to not really care what your problem is.

    It’s your attitude that makes people hate the CSRs answering the phone. Assuming that everyone calling must not have read their contract and is uneducated is ridiculous. As hillsrovey said, legit claims do get denied by the insurance company. If you start from the position that the customer must be wrong, it’s no wonder that the customer thinks you’re the one who doesn’t know what’s going on.

  42. dedi says:

    Most insurance companies are corrupt. I had a friend that worked for a BCBS. He was hired to write a new computer program for their claims. He said the way the system was set up, there’s only certain codes the computer will accept, this could be why her miscarriage was coded as an elective abortion. The only way to correct it (as far as your benefits go) was to persistently contact BCBS to fix it, maybe eventually you’ll get someone or someone will read your appeal and actually do something to change the coding but most of the patient communication was ignored. Also, the computer system was set up to automatically spit out a denial letter b/c most people won’t take the time to fight it. People who are stuffing/mailing the letters don’t know what’s legit so no one fights this.
    My friend was writing a software program to “fix” these inaccuracies however he was pretty much forced to write it off of his personal computer b/c the computer they issued him didn’t have the adequate programs/memory to handle the building of the program. Once he got close to finishing the program and needed to test it to make sure it would function properly they fired him.

  43. Eruntano says:

    Ok, I’ll defend myself. BCBS is not a homogeneous organization, it’s fragmented into smaller groups. If this were a BCBS in CO, CN, ID, KY, MA, MI, NV, NH, OH, VA, WI, GA, CA, NY I could help. After I sent the comments in here, I forwarded the link to a president in my company, to see if there was anything that could be done. Since it’s not our plan, the most I can do is advise how to appeal. I realize it sucks to have to wait 30 days here, 30 days there, but if the hospital refuses to change the cpt codes they’ve used (sometimes they’re willing to change, and listen to what they’re being told, sometimes they’re not) and the insurance refuses to consider the charges there’s not a whole lot that can be done without an appeal.

    Here’s how a claim is processed. There are two codes that are involved here. The first is a CPT code, or current procedural terminology. These describe the medical procedure being done, and there are very fine distinctions between them (for example, the difference between 99214 and 99213, is 10 minutes of the doctors time.) You can look up cpt codes on the ama’s website [catalog.ama-assn.org]

    The other involved code, is the diagnosis code. These describe the condition that made the cpt necessary. Ok, so here’s the fun part, there are certain cpt codes, that will pay with most any dx code. There are cpt codes that will initially deny for medical records, or more info from the dr, or because they’re not medically necessary, or experimental. (Yes, boys and girls, medical insurance policies are based on medical necessity, if a service can be proven to be medically necessary, they it can be covered). There is another set of cpt codes, that require specific dx codes to process (I’ve seen them be as specific as _one_ code, if this cpt code isn’t billed with this dx code, it’s not getting paid. The added layer of complexity is added by the individual company that is buying the policy. They can change the basic processing, so some cpt codes that weren’t covered (for whatever reason) will be, and some that were covered, aren’t.