We have been struggling with our insurance company since the very beginning. It all started back in 2009 when I was still pregnant with Connor. When my doctor first saw a heart abnormality on an ultrasound in December of 2009 he immediately sent me for a level 2 ultrasound at our local hospital, Lawrence General where Connor would be born. From there, we were sent to Tufts Medical Center in Boston for a Fetal Echo where the heart defect was officialy diagnosed. That was about a week after the first level 2 ultrasound. Shortly after that I received a statement from insurance indicating that the level 2 ultrasound was not covered as the Doctor who perfomed it was out of network. First of all, we were not given a choice when we were sent for the testing and the test was done at a hospital that was covered by our insurance. We called our insurance company and were informed that even though the doctor came to Lawrence General he was from Tufts Medical Center which is not part of the network covered and the equipment used was technically the Doctors and therefore not covered. We had been told that Connor should be delivered in Boston due to the high risk pregnancy, but that it was still an option to deliver at Lawrence General if we planned to induce the one day of the month that a cardiologist from Tufts would be on duty at Lawrence General. We found out that either way we would not have insurance coverage for any of this. After many, many discussions with the insurance company we discovered that there would be coverage if the delivery was an emergency situation such as if I was transported in an ambulance or if Connor was born at Lawrence General and then trasported himself in an ambulance as an emergency. We spoke with my doctor as well as Connor's future pediatrician's office to see if they had any more information. The office manager at the pediatrician was fantastic and called our insurance company on multiple occasions explaining the situation. The only problem was it is impossible to get through to someone who can help. The doctors can only talk to specific departments, the patients can only talk to other specific departments and no one on their end communicates with each other. As if we didn't have enough to worry about with the heart defect, we now had to worry about how we were going to pay for it!
During all of this arguing we also recieved a bill for $585 Makayla's nebulizer that was medically necessary and given to us at the pediatrician's office. Again, we weren't given a choice as to where we could get this nebulizer. It turned out that the medical supply facility was not covered by our insurance. After fighting for this one they changed the billing code to have it come from our doctor's office so the claim was paid in the end.
On January 12, 2010, we were scheduled for a second level 2 ultrasound at Lawrence General. At this time the High Risk doctor informed us that we needed to go to Tufts Medical Center immediately for them to induce labor and deliver. We explained our insurance situation and he was outraged. He actually called our insurance company himself and spent over an hour and half trying to get through to the correct person to insure that there would be coverage for the delivery of Connor in Boston.
I remember the whole process being such a nightmare. How could they not want us to have the best care for our baby? There were no other pediatric cardiologists in the area so it wasn't like we really had much of a choice. The only one actually covered in their network was about 2.5 hours away.
Thankfully it all worked out in the end with the help of an amazing doctor and the office manager at the pediatrician's office.
I have since learned that you literally have to fight for coverage on many different things. They will try to reject as much as possible just to see if you will pay. Hospitals, doctors, etc. submit under incorrect codes a lot and insurance will not accept the claim. We were triple billed our deductible for Connor's birth. We were billed by the hospital, by the specific doctor that delivered, and again for Baby Boy Murphy. It took months of phone calls to clear this up. The hospital even sent us to a collection agency even though we kept trying to explain that they were billing us for Connor Murphy and for Baby Boy Murphy. I believe that this situation has finally been resolved. I think I got my last bill for Baby Boy Murphy about 2 months ago and insurance finally paid the bill. I can't be certain about that but hopefully I will not receive another bill as it is now 21 months later!
As soon as we were introduced to Early Intervention, we were told to apply for Katie Beckett Medicaid which in the State of NH is not financially based, but based only on Connor's medical needs and his finances. We were told that due to his mulitple Diagnoses he would automatically qualify and they would reimburse up to 6 months in previous medical bills. They would cover deductibles, co-pays, prescriptions, etc. that the primary insurance did not pick up. Sounded perfect to me since we were already spending a ton on our medical bills. Turns out it was not so easy. After waiting over 4 months to hear anything from them we received a rejection letter stating that Connor was not eligible because he had already had his heart surgery at this point. This really would not have bothered me but after everything else we had been through with insurance I was ready for another fight and since I had been told he would automatically qualify I had to understand why he didn't. So I decided to appeal the decision. Several of his doctors wrote letter to Medicaid showing why Connor should qualify as he had also been diagnosed with the Ocular Albinism. Once they received this paperwork we received a letter within 2 weeks advising that Connor did qualify.
I guess my moral of this story is to always question the bills you get from doctors, hospitals, etc. if you are unsure. They really do try to see what they can get away with. It is certainly a pain to fight them on the claims, but if you keep at it and keep calling you may just find that there really should be covereage.
In the end it all worked out for us, but has certainly been stressful along they way!
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