French renovations, Day 30: Cleanup and ER visit

I slept terribly last night, thanks to my zombie finger. I finally decided to have it looked at this morning. Why? A) I'm a violinist and this finger is VERY important, B) I'm left-handed and I like being able to write and type with my dominant hand, and C) it really really hurt.

I had to remind myself that it's okay to see a doctor and even--gasp--go to the hospital. We're in France and even without insurance, healthcare is incredibly affordable. So off I went to the emergency room at the large university hospital.

(Why the ER? My family doctor didn't have any openings until next week, plus she doesn't have an x-ray machine in her office.)

So...just for fun, let's play a guessing game called "Rixa at the ER"

Question #1: How long did Rixa's ER visit take, from walking in the doors to walking back out? Some of the things Rixa did while in the ER:

• checked in at the front desk and took a number
• waited for her number to be called
• checked in at the nurse's desk and filled out all of the necessary paperwork and explained what happened
• walked to the trauma department and waited to be shown into a room
• was examined by a resident ("interne") and a medical student (they both looked like they were in HIGH SCHOOL!! Well, okay, maybe undergraduate...but still...)
• sent to the radiology department for x-rays
• went back to the exam room and waited for the x-ray results
• discussed the x-ray results (good news: no fractures!)
• had a supervising doctor poke holes into her fingernail to drain the blood
• got bandaged up
• went to the checkout desk for pain medication prescriptions (which Rixa doesn't need) and paid the bill

Question #2: What did the ER visit cost? (Remember, we are paying out of pocket at the moment as we still haven't received our medical insurance cards).

While I was having my ER adventure, Eric, Ivy, and Inga played a round of Skull King and then bagged rubble. They worked through about 1/3 of the remaining pile. I think we'll get everything bagged by this weekend. Then we have to haul everything down and out again!

 

This afternoon was filled with soccer pickups and dropoffs. I love that we can easily hop on the tram to get the girls to Cavigal, and Dio's is just up at the chateau.

During dinner we watched the US presidential inauguration. My favorite part was the poet laureate Amanda Gorman (Zari says "Yes, me too!") It's so refreshing to see values that matter to me laid out from the very start: compassion, diversity, inclusion, respect, empathy, environmentalism. And it wasn't just in Biden's words--it showed in every aspect of the inauguration ceremonies, from yesterday's Covid-19 memorial to the diversity of prayers/poems/speakers/presenters/artists.

My finger still hurts, but not nearly as much as it did before my hospital visit. I tried draining more blood when I got home, but the holes had already dried up. I don't have the guts to poke through my own fingernail.

Oh, during my hospital visit, the supervising doctor said, "I'm going to poke two holes into your nail." He explained to the intern and student why two holes worked better (one hole to let the blood out, the other to let air in, much like having two holes in a milk carton helps the liquid empty better). But then he proceeded to poke not 2, not 3, not 4, but FIVE holes in my fingernail! Aie!

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Money makes the babies come out

Our local hospital closed its maternity department in March, leaving a gap in OB coverage in our region. This came as a surprise to our community, since the hospital had recently renovated the maternity department and created new LDRP suites.

Newspaper articles cited financial issues as the main reason for the closure. I was talking with someone a few weeks back whose friend a hospital administrator. Here's the inside scoop:

55% of our hospital's maternity patients were on Medicaid. Medicaid reimbursements were so low that the hospitals' maternity department lost $500,000 last year. The administrators feared that the entire hospital would have to close if this trend continued. So they decided to close the maternity department, rather than risk shutting down the hospital.

Now, I'm not sad that this particular hospital closed. It had one of the higher c-section rates in the state (33.4% as of 2008). It also banned VBACs, another thumbs-down in my book. In contrast, a small community hospital 30 minutes away had a cesarean rate of 23.7% the same year. Both hospitals served nearly identical patient populations--only low-risk pregnancies and near/full-term babies--and did the same number of births per year.

But I am disappointed that I no longer have a hospital 5 minutes away. Granted, I'd only go there in an extreme situation where it would be impossible to travel to the other hospital (which does VBACs and is working on its Baby-Friendly certification).

Low Medicaid reimbursement doesn't just affect hospitals. Currently 60% of my midwife's clients are on Medicaid, 20% have private insurance, and 20% pay out-of-pocket. Although her global fee is $3,600, Medicaid only pays 15% of that amount per birth (a bit under $700). She cannot require her Medicaid patients to cover the rest of her global fee, which means that she actually has to pay to take Medicaid clients. Her birth supplies and birth assistant cost her more than she gets paid. She is currently deliberating whether to stop accepting Medicaid, since it is causing her practice to lose money.

A flip side of low Medicaid reimbursement is exorbitantly high billing for those with private insurance. A friend had her baby at our hospital a few months ago, before it closed. She had a spontaneous vaginal birth with no maternal or infant complications and no nursery stay. The total fees for her prenatal care and birth came to $25,000. The bill was negotiated down a few thousand dollars, coming to a total of around $22,000. Between her deductibles and co-pays, she had to pay close to $5,000 out-of-pocket to have her baby. 

Other reading on the topic:

• Will Your Hospital’s Maternity Ward Close? By Dr. Linda Burke-Galloway
• Lower TennCare rates for C-sections upset obstetricians (thanks to The Unnecesarean)
• Bye-bye babies: South Seminole closing its birthing unit today
• 2 VA hospitals closing maternity wards
• Hospital Maternity Wards Are Closing Across U.S.

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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.)

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