Train potty

The cost of a loss

Has anyone out there had the pleasure of dealing with medical insurance drama before? If so---you might totally feel me on this post. And if not, you are incredibly lucky and maybe you should read this anyway in case you are ever in a similar situation. I feel like SOMEONE has to learn something from this horrible journey we've been on since April and I'll gladly share my story in the name of helping someone else beat the bad guys and come out on top. Where to begin? This might get long. And maybe a little sad.

Well, first of all, Nate and I have always felt very strongly about always having medical insurance no matter how expensive or inconvenient it may be. It's just not worth the risk of having a catastrophic accident wipe us clean of our savings because we didn't opt to pay for a policy, assuming that since we are healthy we don't need insurance. That's just our mindset and I know not everyone thinks like us, but even after all of this ridiculous drama with insurance I still vow to always carry a policy no matter what.

Earlier this year, when I decided to change companies with my job, I knew that there would be a gap from the time I left my old company in March to the time when my new company would qualify me for benefits in July. We were planning on Nate carrying all of the benefits for our family when he began his new job, and that would get us insurance by June 1---so we still had a good few months when we needed to patch in a policy for our family.

Enter the confusing world of an internet 'self' policy, not provided by an employer! We found Anthem Blue Cross Blue Shield online and figured it would work out just fine for those few months, although the premiums weren't cheap at all (about $300 per month for our family) and the deductible was high ($5,000). We knew it would cover any major catastrophe past the 5k mark and it was really the best we could do without employer coverage. The one catch was that it did not include maternity coverage---something we knew way back in February when we selected the policy. But we were not planning to expand our family or 'try' to get pregnant and I personally figured that if I did happen to get pregnant in those few months before Nate's employer kicked in, it would only be one or two office visits before his coverage, which we could handle if we were blessed enough to be in that position.

And then, of course, I got my surprise BFP at the end of March and immediately called the OB's financial office to figure out how much one office visit and one ultrasound would cost us out of pocket. I had calculated that I'd only have to see her with Anthem for those two early appointments, and then by the time I hit 14 weeks we'd have Nate's policy and I'd be due for regular maternity visits and they'd all be covered. If I had only known then what was about to unfold.

If you've been reading my blog since April you know that during that 'out of pocket' ultrasound at 9 weeks we found out the worst news possible. I remember saying to Nate, while we waited for the doctor to come into that wretched ultrasound room, 'What if they want me to have a D&C? That is going to be SO expensive and not covered by this stupid policy!' He reassured me that we'd figure it out and my health was most important but I couldn't help but wonder if maybe somehow I could postpone any interventions at all until June 1, when Nate's policy would cover the surgery. I was just praying to pass the baby naturally, fully, and without the need of any help from my OB. But those prayers were definitely not answered and we began a horrible journey full of many complications.

I remember the day before I went in to finally get the Cytotec placed, to force my body to begin the bleeding it refused to do on it's own. I spoke with our insurance company on the phone and discovered that although our policy did not include maternity coverage, lucky for me it DID include 'pregnancy complications' for coverage. I really felt that God had to be making this happen for us, because there was no way for us to have known that we'd need this little clause in our policy more than ever.

Of course it's never that easy. I had a total of 4 more ultrasounds, medication placement that didn't work, multiple blood draws, a particularly nasty ER visit and hospital stay, then switched to a different OB and finally got the surgery I should have gotten from the beginning. If you are like me, you just read that last sentence and started hearing 'CHA-CHING' in your head as you pictured the enormous bills to follow such a complex course of care. But hey, lucky for me my policy covered 'pregnancy complications,' right? Ha.

As the bills started rolling in, we noticed that not one dime was covered by Anthem. And the grand total for the entire nightmare? Brace yourselves: $17,000.

GULP.

I knew in my heart that we should not be responsible for these bills. I knew that our policy clearly stated they cover miscarriage, and 'therapeutic abortions' (don't even get me started on this term for a D&C). I had the policy itself circled, highlighted, and practically memorized. And so I began to call Anthem at least twice per week for months. Every time I spoke to a rep, I tried my hardest to ask questions and get answers. And every time I felt like I was banging my head into a wall. They kept telling me that the diagnosis code used by my doctors was not covered under my policy. They would not TELL me what the freaking code was, so I had to talk to my OB's office a few times to figure it out, and after discovering that it was 'missed abortion' I felt more disgusted than ever. I mean, really? The 'A-word?' Talk about a shock to my heart--as if I purposely chose to lose this baby.

I did more research and discovered that there is NOT a code for 'miscarriage' as that isn't the technical medical term. The doctor's offices were using the correct code, then (as sad as the word was to me)----but my insurance still wasn't budging. There were even more phone calls to them, including one time when I couldn't take it anymore and just burst into tears saying something about 'Please stop treating me like I'm a number or a code---I just lost a baby should not be paying for thousands of dollars in bills, according to your stupid policy!' Not my finest moment but there just aren't words to describe the sadness and stress of paying hard-earned money for the loss of a child. It's one thing to pay for the birth of a child. But it's quite another to come home empty handed, with a broken heart, and more bills than I could have imagined.

There were definitely times during this struggle with Anthem when I really felt like giving up because I just wanted to move on with my life. Most all of the doctor's offices and hospitals had 'self pay' policies for patients who don't have insurance, and if mine wasn't paying a dime I could probably qualify for those discounts (which were only about 25% at the most, by the way). So we figured that if Anthem really didn't pay we were looking at about $13,000 or so out of our pockets. Technically we could pay this giant sum but only because we've been working so hard for the past four years to save up a 'down payment fund' for our first home. I realize that not everyone would be able to even fathom paying this amount of money and it might set some families back by years. Of course I'm extremely grateful for our financial situation, but that money was not supposed to go towards a loss of a baby. Especially not when our policy clearly stated, in black and white, that they'd have our backs in this case. And isn't this type of 'catastrophe' exactly why we wanted medical insurance? To cover us during a horrible, unplanned event? The more I thought about that idea, the more angry I got with Anthem and I refused to go down without a major fight.

I sat down and created a huge Excel spreadsheet with every single claim listed, so that I could keep track of everything. I documented every single call I made to Anthem and the doctor's billing offices. I asked to speak to supervisors and I tried to remain calm. I had already written a formal 'grievance letter' back in May, after one of my calls to Anthem's fabulous customer service department lead me to believe that would be the only way I could dispute my bills. I didn't really think too much about this letter, since I thought it would take months of ambiguous decisions made by faceless people behind the scenes. I really preferred to speak to someone in person about this issue because I believed that would be my way to convince them all that I was right. But finally, I asked my husband to take over calling Anthem for me because I could no longer mentally handle the stress of dealing with them. He agreed when he saw I was teetering on the verge of yet another breakdown.

And two things happened: First, we got a letter in the mail stating that my grievance letter had been reviewed by a committee and they thanked me for bringing my case to their attention (gee, three months after I wrote the darn thing). They said that they were reversing their decision to reject my claims, and agreed that everything should be covered under their policy. HALLE-freaking-LUJAH!!! And secondly, my husband can be a badass when we wants. When he called Anthem for his first time, he simply told the lady that he would not get off the phone until she personally figured out how to fix this problem, since she admitted that she was confused about why everything was being rejected. Turns out that our policy is basically the only one they have that covers pregnancy complications. Nearly every other policy does not cover them and therefore the computer automatically rejected my claims, because almost all of the time they don't cover 'missed abortions'. And it only took four months for them to figure that out, you guys. Nobody in the dozens of calls I had made before bothered to really look at the problem and figure out they needed to manually override the computer system. It wasn't the doctor's office using the wrong code---it was the insurance company not recognizing a correct code.

Even though we still have a 5k deductible to hit before Anthem really does pay for claims, it's amazing to me how each bill has been drastically reduced because we now have insurance 'covering' the claims. For instance, the total bill for the ER visit and brief hospital stay was almost $7,000 before insurance. And after the bills were 'adjusted' for allowable claims? Only $2,200 will be paid by us, going towards our deductible. Isn't that just insane? That doesn't mean that our insurance paid the difference (because they didn't pay any part of it), but the hospital just had to eat the rest of the total cost that nobody is paying. I could go on and on about how messed up insurance coverage is in America today but this is already ridonkulously long.

And according to my most recent calculations, after everything has been re-processed, I think we will pay the deductible and that is about it. We'll still need to recover financially from this big hit on our savings but nothing like what it could have been if we didn't fight for our coverage. Although I really considered giving up the fight just to move away from the pain much more quickly, I'm so glad we stuck by our guns. And I'm so glad my grievance letter worked---it must have been the two glasses of wine I downed while typing it. Oh, and of course my heroic husband's phone call didn't hurt, either.

If you made it through this whole post, I commend you. I guess I just had a lot of pent up thoughts and stories about this process. And I just want you to know that if you are banging your head against a wall with your insurance company you are not alone. But stay strong, go through whatever formal processes they suggest for a grievance, and keep meticulous records of all bills and all interactions on the phone.

This whole craptastic situation is yet another reason why I'd consider moving to Canada, if it weren't for the pesky fact that it's even further north than Milwaukee (and therefore colder, and past my limit of frigid weather). Not only do my lovely Canadian friends get a whole year of paid maternity leave, but they also wouldn't be paying a dime for this stupid fiasco. Love ya girls, but SO jealous right now.

Suffering a miscarriage is bad enough for anyone and I'd never wish it on my worst enemy. Throw a little financial drama into the emotional mix and you have a recipe for a serious breakdown. Just ask Nate---he's seen the effects first hand and it wasn't pretty. But I suppose it taught us a lesson in persistence and if we are EVER in this type of situation again, I'm having Nate make all of the calls from day one:)