I have a PPO with Blue Shield. I had a planned homebirth with a midwife. Blue Shield has paid out for some of the parts that they have been billed for the birth, but they have denied several claims for the labor, delivery, postpartum care, and newborn care. First, they denied them saying that they were all included in the "global fee" but they were not billed globally and did not pay globally. Now they are saying that the codes are incorrect because they are for a "facility charge". I have filed an appeal through Blue Shield and it was denied. I am mailing away an application for independent medical review to the CA Dept of Insurance tomorrow. Has anybody had these problems? Have any advice?
Good for you for fighting for your right to have the birth you wanted covered by your insurance company. This is a HUGE issue! You can connect with other mom's about this issue on our web site www.naturalbabypros.com and join the local community here in San Diego that is fighting for Natural birth to be an option for mothers! We have a meetup group that would be supportive to you as well www.meetup.com/naturalbabysd/
Good luck!!
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You have taken the right steps in appealing with the insurance company and now with the Insurance Commission. The other moms had some good advice too -- work with the midwife and the insurance co to make sure the billing codes are correct. To possibly prevent future problems make sure you read and understand the benefits available under your insurance policy; also, a good idea for major procedures is to ask for a 'predetermination' so that you know ahead of time what the insurance will and will not pay for. Stick with this until you get a satisfactory resolution -- and the insurance co does make it as hard as possible!!
be persistant! i watch our medical bills very closley and am constantly calling blue shield to fix one thing or another - sometimes its their fault sometimes its the drs, but either way i pay if its not resolved. there is a "rumor" that blue shield wont contest bills under $15000 if a lawyer disputes it on your behalf, it usually just requires a letter and they suddenly figure it out. i fought blue shield for 2 years and cigna for almost 3 years once - over completely legit bills that they finally paid - i completely agree with the previous poster, i think they just try to wear you down. good luck!
We had a somewhat similar issue in that when my son was born, he had pneumonia and spent the next week in NICCU. It was billed that we had a "private nurse". Huh???? Anyway, it all worked out, but it took a lot of phone calls and a lot of persistence. We have had many issues with insurance in which we have invested a lot of time. I'm sorry if I offend anyone in the insurance industry with this, but....I truly believe they keep you strung out, thinking you'll get frusterated and give up. I may be wrong, but that's the impression I get. If you check with whoever billed the insurance, I'm sure they'll change the code, it may just take a while. Be persistent and good luck!
Well, I don't really have an answer for you yet. I just wanted to let you know that I'm due in a few weeks and am also having a homebirth. My insurance is also a PPO through Blue Shield. My midwife told me from the very beginning that she knew for sure that Blue Shield will reimburse me for the costs. She said that it wouldn't be 100%, but she's never really had a problem with them. Please let me know how it goes, and congratulations on your new baby!
There are many great answers here from other moms, I just wanted to give some support to you too. I had both my boys at home with our midwife and had Cross/Blue Shield paid for them, not 100%, but we paid very little out of pocket. We're not in California, but my midwife does all of her own billing/coding and she's used to working with BC/BS so she may be used to just knowing what the insurance company expects for getting her bills paid. Good luck! Kudos for doing what's best for you and your family!!
I use to work for a Chiropractor and I did the Insurance Billing. You have to have the codes right if it isn't billed correctly they won't pay. Who billed it for you? I would call them and then I would call BS and ask them what code needs to be used or why it was rejected. Usually they are very helpful. I had to have a test run that wasn't something my insurance pays for so I called them before to make sure. They told me what I had to do to get it paid for by them so my Doctor and the Lab could bill it right. Good Luck I hope this helps you a little.
I agree with others, that the billing codes are the problem. Talk to your midwife about getting the bill recoded. She probably contracts billing out, so there may have been some communication problems down the line.
Good luck!
Did you only see your midwife for prenatal care? Did you have the same insurance for the entire pregnancy? Do you have on hand which codes were denied? I do billing for midwives, let me know privately these answers and I'll see what I can tell you! :)
the issue is probably with the BILLING(as in your midwife), not with the insurance company. with most BCBS PPO plans, maternity care is a global care plan, and has to be billed as such. talk to your midwife about properly submitting the claim and hopefully that will resolve it. good luck!
I also have a PPO with Blue Shield, and I checked with them before I started care with my midwife, and they wouldn't cover anything to do with her because she was a Licensed midwife, and they only cover 60% the cost of care under a Certified midwife, of which does not include the birth. We're paying for everything out of pocket which is ridiculous because we have insurance that covers 100% hospital birth which is over 3x the price and has higher infant fatalities. Keep on fighting, one day we'll win!
