- Pregnancy
- Baby & Toddler
- Parents
- Getting Pregnant
- Baby Names
- Product Reviews
-
Registry
- Community
-
More
Want a personalized experience?
Download the free app
Success after IF
IBackBevo
member
May 2014 January Siggy Challenge:
Insurance appeal - Mostly a vent
IBackBevo
member
So even though it has been forever, I am still dealing with denied insurance claims from IF and pregnancy. (As an aside, we paid OOP for all IF treatment, but diagnostic tests and procedures are covered under our insurance policy. And maternity definately was covered.) Our insurance company has been the biggest PITA - you have know idea. Literally, they initially paid about $6k out of a $25k for my delivery and stay and I had to fight them tooth and nail for the rest. They have acted (IMO) so eggregiously in some of their denials, that I probably could sue them for deceptive insurance practices, but, alas, I digress.
I'm now to the point where I've succeeded on all of my appeals and all is resolved except for 2 claims. One is for about $600 and the doctor has never pursued me for it so I have not pursued the appeal. (Trust me, I've had a half dozen others to pursue.) The other is about a $2600 claim and I am being pursued for it. I've gone through about 3-4 levels of appeals. I've exhausted all appeals with the insurance company and now am appealing directly to the employer--who is my husband's former employer and a major academic institution. The only appeal after this one will be the outside appeal.
There is little doubt in my mind that I am in the right and the insurance company is in the wrong--I'm an attorney and DH is a physician so between the two of us, we know how to read an insurance policy. However, I have spent SOOOO much time on this. The insurance company has been so dishonest (it truly has been absolutely horrible) and deceptive in everything from not disclosing who to properly appeal with to, not disclosing that we even had a right to appeal and now is not turning over medical records/docs I have a right to despite 5 verbal requests and 3 written requests. Not only do I know my claim has been wrongfully denied, but I am pretty darn sure that the insurance company is also in violation of the Texas Insurance Code and the Texas DTPA (Deceptive Trade Practices Act) which is a tie-in statute to the Texas Insurance Code and would enable me to damages.
However, I'm getting to the point of wondering if this is worth it. It is $2600, but between DH and I, I bet we have spent 40-50 hours just fighting this one claim. If you valued our "time" by what we bill in our respective professions, we have now spent way more than the initial $2600 fighting this thing. I'm pissed as hell, but I feel like at some point I cannot continue to invest 5-10 hours a week fighting with these people in what seems to just be a never ending battle...not over $2600. And the way the law works, I still have to go through 2 more appeals before I could bring suit anyway...not that I would bring a lawsuit over $2600 anyway. In my legal practice, we rarely even have a claim under 6 figures because the cost of litigation is so high.
I figured there might be someone else out there who has fought with insurance...did you eventually win? Or at some point did you just decide to walk away?
Edit for typos.
IF DX: DOR & Fragile X pre-mutation carrier
2011: FSH 13.3 & E 99; AMH 0.54 2nd FSH 6.2 E 40's AFC: 8
BFP from Clomid/IUI ~ Pre-e and IUGR during pregnancy ~ DS born 9/4/12
Feb./March 2013: AMH less than 0.16 (undectable) and AFC = 4;
BFP from supps ~ DS#2 due May 2014
2011: FSH 13.3 & E 99; AMH 0.54 2nd FSH 6.2 E 40's AFC: 8
BFP from Clomid/IUI ~ Pre-e and IUGR during pregnancy ~ DS born 9/4/12
Feb./March 2013: AMH less than 0.16 (undectable) and AFC = 4;
BFP from supps ~ DS#2 due May 2014
May 2014 January Siggy Challenge:
This discussion has been closed.
Re: Insurance appeal - Mostly a vent
Unexplained Infertility
After two Clomid cycles, three injectable IUI cycles, two IVFs, two miscarriages, and one lap surgery, IVF #2 has brought us our little boy!
TTC #2
After months of being postponed or cancelled, FET #1.3 (Natural FET) brought us twin girls!
Anything less than $100, I'd just pay and walk away. But, $2600- that's a whole lotta diapers! We are still having issues with our bills from the hospital and OB. The OB owes us $800 and we had all sorts of issues because the insurance company denied Baby B's bills (they thought they were getting the same bill 2x. The rep said this happens all the time with same gender twins).
We were all geared up to fight a $1200 bill for the first assist during my c/s. The insurance rep said the hospital had selected an out of network first assist because I went into spontaneous labor. She said if I had made it to my scheduled c/s at 37w, I would have not been charged. Such nonsense! When I approached the issue with my OB, she said they didn't have a choice about the first assist since it is the only practice the hospital uses. I spent hours on the phone with the insurance company and my OB's billing office to be told the first assist practice usually ends up dropping the bill once the insurance company denies the claim. Insurance companies are full of d**che canoes.
12dp5dt: 765; 15dp5dt: 1979; 17dp5dt: 3379...TWINS!!!!!
Our perfect baby boys were born at 36w1d!!
The one I am currently fighting is for my HSG. They say it is is infertility treatment. Not IF diagnosis or testing (as that is covered), but treatment. I want to ask them to point me to one person who has ever gotten pregnant by virtue of an HSG.
The biggest issue right now is that the B I am dealing with won't even turn over my records. I think we are now up to seven verbal requests and three written requests. Did I mention that this is required by law? The next letter is going to come in the form of a demand letter.
2011: FSH 13.3 & E 99; AMH 0.54 2nd FSH 6.2 E 40's AFC: 8
BFP from Clomid/IUI ~ Pre-e and IUGR during pregnancy ~ DS born 9/4/12
Feb./March 2013: AMH less than 0.16 (undectable) and AFC = 4;
BFP from supps ~ DS#2 due May 2014
May 2014 January Siggy Challenge:
That is crazy! I didn't have coverage for HSG because it was considered diagnostic, and my insurance didn't cover IF related diagnosis or treatment. But I was only charged 750 dollars for the HSG since I was OOP. But get this twist my HSG showed that I had a whole lot of adhesions. I convinced my dr to submit for coverage since we were now dealing with endometriosis and not strictly IF. They covered it retroactively.
Your insurance company should not have a leg to stand in. I would be over fighting too. There are only so many hours in a day.
IVF #1 ET 1 d3 embryo 10/30/11 BFP
3 Embryos frozen (1 d5, 2 d6)
DS born 07/29/12
FET #1 ET 1 d5 embryo 02/10/15 BFN
FET #2 1 d6 embryo didn't survive thaw, transferred last d6. CP
Well, I did not have a blocked tube and it wasn't done for that reason. It was 100 percent diagnostic. They filed it as the code for infertility diagnosis. And the insurance company told us ahead of time it was covered. And they told the hospital it was covered. And they also told my RE's office that my hysterscopy was covered. They denied that, too, but my RE isn't pursuing me for the money.
2011: FSH 13.3 & E 99; AMH 0.54 2nd FSH 6.2 E 40's AFC: 8
BFP from Clomid/IUI ~ Pre-e and IUGR during pregnancy ~ DS born 9/4/12
Feb./March 2013: AMH less than 0.16 (undectable) and AFC = 4;
BFP from supps ~ DS#2 due May 2014
May 2014 January Siggy Challenge:
SMH. Sounds like my situation. I think you hit the nail on the head when you say that they deny claims and make things difficult just so people will give up and pay instead of fighting with them. They have denied legitimate claim after legitimate claim.
I also had this same company deny my room charges for my entire hospital stay after my c-section because I was in a "private" room - only, the hospital I was at was "in network" and ONLY had private rooms. It is one of the major hospitals in the world for labor and delivery of babies - pretty much all they do. So I know my insurer, who probably insures hundreds of thousands if not millions of people, has had people in this hospital before. Do you know how it was finally resolved? Not by the insurance company paying it, but by the hospital agreeing to write off the bill! They have denied other stuff, too, that I have fought and prevailed on.
2011: FSH 13.3 & E 99; AMH 0.54 2nd FSH 6.2 E 40's AFC: 8
BFP from Clomid/IUI ~ Pre-e and IUGR during pregnancy ~ DS born 9/4/12
Feb./March 2013: AMH less than 0.16 (undectable) and AFC = 4;
BFP from supps ~ DS#2 due May 2014
May 2014 January Siggy Challenge: