Tuesday, April 07, 2009

How do I hate thee, insurance company? Let me count the ways

I am this close to divorcing my insurance company. What seemed like a fairly happy relationship has turned ugly. So, 8 1/2 months ago--basically as soon as we accepted this new job--I called to find out more about my maternity benefits since I was newly pregnant. I had already found the name of the CNM I am currently seeing, so I wanted to verify if she was covered, and whether she was in or out of network. Let's be honest--having insurance coverage for a midwife made me a lot more willing to consider that as an option. Of course if I felt that it was right to have a midwife, I would pay for one, insurance or not. But the fact that she was covered did make a huge difference for me.

So I verified last fall with my company that she was covered, although probably only as an out-of-network provider unless I petitioned for an in-network exemption. Since there are no other in-network home birth providers in my area, I hoped this wouldn't be too much trouble. My midwife's biller looked into this and obtained an authorization code for in-network exemption, which she re-verified at least once at a later date. The biller even did a test bill, which was approved and authorized back in November 2008.

So everything looks fine and dandy, right? I have my in-network deductible of $400-odd dollars, then I pay 20% of the remaining charges (compared to 40% for out-of-network). This works out to around $1,000 that I would pay out-of-pocket, perhaps less if they can bill for enough charges. My midwife's global fee is $3,600, although if you have insurance the numbers on the claims will be a bit higher than this.

Today I got a call from the midwife's biller, saying she just heard from my insurance company that the in-network exemption was a mistake and that they would only cover the CNM as out-of-network. Not the end of the world, but I decided to call and inquire about this change. Everyone I talked to said the same thing--the authorization code was a mistake, and that only physicians and specialists can be granted an in-network exemption.

I asked to speak to the person's supervisor to see if anything else could be done at this point. This is where it went downhill. This new person looked into my case and informed me that not only was the out-of-network thing non-negotiable, my CNM would actually not be covered at all by my policy! The specific insurance contract I belong to stipulates that a CNM must:
a) be directly supervised by a physician
b) attend births in a hospital or birth center (I think the wording was "in a health care facility")

Why didn't they tell me this 8 1/2 months ago when I called specifically to verify that she was covered? Why didn't they tell this to my biller when she submitted a claim back in November to verify that the insurance was working properly?

So now my insurance company totally refuses to cover the CNM I am seeing, even though for the past 8 1/2 months I had been assured that she was covered--after all, she is a licensed health care provider in my state. I spent a few hours on the phone talking to two more supervisors & managers and kept being told the same information: the CNM must work in a hospital or birth center, and must be under the direct supervision of a physician. Doesn't matter that they had told me, and my midwife's biller, multiple times that she was covered. Doesn't matter that they had already approved at least one claim from this midwife.

I refused to let them end the conversation. I kept asking if there was anything else I could do to petition this. They said that I could only appeal the claim after the birth. They would certainly deny the claim, and they said there was little to no chance that they would approve my appeal since my policy had those two stipulations written into it.

So after I kept asking who I could talk with to see if there was any hope of getting insurance coverage--keeping in mind that I had been assured all along that I did have coverage for this CNM--I finally got the 3rd or 4th level supervisor to tell me who wrote my policy's contract; she said it would be someone at my husband's college. So I called the college, found the right person, explained my situation: I am 8 1/2 months pregnant, had been told all along that I had coverage, and at the last minute was informed that my CNM would not be covered even though she's a legal, licensed provider in our state, because of certain technicalities written into the insurance contract. I asked her to look into changing the wording of the contract to cover any midwife or physician licensed to attend births, without the clauses mandating place of birth or physician supervision (since those are not required by our state by any means). She said, "oh, I know you--you're Eric's wife!" and seemed quite willing to look into changing the terms of the insurance contract. She said she'd look into it and get back to me tomorrow.

So I hope, hope, hope that this will work. I am glad I was obnoxiously persistent, because it was maddeningly hard to squeeze that bit of information out of the last supervisor.

Can I say it's just a tad stressful to find out, perhaps just a week or so away from giving birth (if I go into labor at 38 weeks like I did last time) that your insurance company suddenly will not cover your health care provider? And that it will not cover any CNM who works independently, despite the fact they they are fully legal and licensed? And that it mandates that I give birth in a hospital or birth center? (And of course there's no birth center in my town, so that's not an option anyway.)


  1. Argh. Can't live with'em, can't live without'em. I hope that you get this resolved in your favor! And soon. Sending peace filled vibes for the remainder of your pregnancy.


  2. Ugh. Hope this get's resolved the right way!

  3. ohh the joys of a universal health care system. what a bummer so close to birthing to have these issues. Hope it resolves soon and you can just focus on the job at hand!

  4. excellent post

    for more information about insurance you must visit


  5. There are ways around it, if your midwife can do some creative billing. I'm not saying you should defraud, or anything. I'm just saying that I might have known someone whose insurance company has an entire webpage devoted to explaining why homebirth is dangerous and will not be covered under any circumstances. And faced with that, my friend billed her prenatals through a clinic, and billed the birth as pediatric services to the newborn child. And it all went through seamlessly.

    It is ridiculous that they'd cover an elective cesarean without a thought, but balk at the much lower fees of a midwife. And it's impossible to find someone who can think rationally to talk to there.

    Good luck and keep us posted.

  6. Sounds like it is time to file some complaints against the insurance company. I would suggest complaints filed with the state Consumer Affairs Fraud and Protection agency, Better Business Bureau, and any agency you can think of that will cause them to have to fill out paperwork in response to a a complaint. Keep detailed lists of everyone you spoke to. My insurance refused to pay for my c-section hospital stay for my first birth because the baby was not pre-approved for surgery and did not have a social security number before she was born. They will do anything to delay payments of any kind in the hopes that you will give up!

  7. A friend of mine had something similar -- her insurance company said that they would reimburse them for their midwife charges; and then after the birth, they found loopholes that allowed them to get out of paying. Another friend of mine had constant difficulties getting her husband's treatment approved through her insurance -- one person would say it was approved, the next person would say it wasn't; a pencil-pusher would put in a wrong code, causing a rejection, etc. Ugh.


  8. The best thing to do is go through the policy/contract/certificate of coverage and read it for yourself.

    Our insurance company reps (HMO) are also remarkably ignorant about midwives. More than once, they told us "the midwife bills through the physician, and gets paid through the physician." Uh, no, she's a CPM, and THERE IS NO PHYSICIAN.

    We're waiting to see how the billing goes through, and whether they're going to reimburse us nothing, or just almost nothing. It is remarkably satisfying, though, to just pay for my health care myself up front, and know ahead of time what it will cost me.

  9. I petitioned my insurance company to cover my CNM's services. Not only did they decline, they sent me a letter saying that if I went ahead with the birth at home and needed to transfer, they wouldn't cover any hospital costs "resulting from home birth."

    I talked to a lawyer about it and decided to proceed as planned. It made things much more stressful, though.

  10. What a serious pain in the neck! I'm so sorry you are having to deal with this now of all times. I got this run-around twice, and finally gave up entirely. That's why I ended up having a pseudo-hospital birth with my 3rd and why I payed $2500 out of pocket for my 4th. I sincerely hope you don't have to do either of those two things. Anyway, I can't imagine you having a baby in the hospital when everything's fine in the first place.

    Good luck with all this, Rixa. You are persistent and insistent enough to get this done.

  11. I'm so sorry! How stressful, and talk about bad timing! Hopefully you'll get some good news today?

  12. I HATE insurance too Rixa. It gets my blood boiling so ferociously that I can't talk sometimes. I have had way too many encounters with insurance with my own situation and with other people who don't necessarily have the resources to be as persistent and it makes me furious that the people who are hurt are most often children, older people and really sick people who shouldn't have to be worrying about a bureaucracy that does NOT have their best interest in mind.

    I really hope it works out for you.

  13. I have a dream that one day, money will not be a factor in dictating the place she give birth for any woman! I hope this works out for you!


  14. I'm sorry. Insurance sucks! I am planning my second home birth right now and am having the same kinds of problems. We will end up paying out-of-pocket even though my midwife is a naturopath physician. The fact that she's a doctor doesn't help. My plan even covers naturopathic care with no limitations... except home birth. So frustrating.

  15. That sounds miserable! I've had a ridiculous time getting any coverage for this pregnancy (I'm 27 weeks now) and because of it, haven't seen the midwife yet, and will end up paying most of the cost out of pocket. Insurance can be a blessing, but more often than not, it's just a freaking hassle!

  16. Something similar happened to me: originally was told they would cover 80%, then denied it. We ended up paying out of pocket and then harassing them every week with phone calls and letters until six months later, they agreed to pay for half.

  17. Hey that is not acceptable they made the mistake and it shouldn't be your problem. they have to sort it to you need to be form with insurance people especially during this time.Shame its an unnecessary stress you need now. wish you all the best . irene

  18. I'm so sorry! I'm praying this will all work out for you! A very pregnant lady does not need any more stress in her life.

  19. We couldn't get insurance coverage of our CNM for homebirth. It was very frustrating. Hope you can be a trailblazer for other homebirthers in your state!

  20. Rixa
    Is it legal for CNMs to work autonomously in your state? If so, this insurance clause is a restraint of trade for CNMs, not to mention the limitations it puts on you personally in your choice of competent health care providers! Let us know how you make out...


  21. Yes, CNMs can work autonomously here--they just can't prescribe certain meds without a signed collaborative agreement. My CNM told me that NO CNMs here, even hospital based ones, work "under direct physician supervision" as my insurance clause mandates.

    Anyway I'm waiting to hear back if my college was able to rewrite the insurance contract. Hoping they were...the woman I spoke with was hopeful but couldn't guarantee she'd be able to get it changed it time.

  22. why are you using a medwife? I was a little disapointed in you for not UCing, and now it's like wow you must not really stay true to your word.


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