View Full Version : Insurance company rant

05-15-2003, 09:48 AM
I just need to vent about the fact that my insurance has just informed me that they will not pay for my 20-week ultrasound (which I had on March 20, almost two months ago!) because the u/s lab is "out of network." (I have an Aetna PPO.) Well, the midwife practice is in-network and the u/s tech operates out of their office. I understand that they are a contractor, but still am I crazy for thinking that the tech working in their office would be covered? But of course, it's always the consumer's responsibility to know everything about their health coverage, even though finding that information is difficult since they negotiate deals with every individual company and everyone's coverage varies so widely. Also, if they had processed this claim in a timely manner, I would have declined the second u/s I just had (or rather insisted that they refer me to an in-network one). Now, I'm just nervous for all the things that they're going to tell me AFTER the birth that aren't covered. Has anyone ever called their insurance company prior to delivery and asked "How much is this going to cost me?" I'm sure they'd give you a bunch of crap about how it depends on the outcome, if you have certain surgery, meds, etc. They also have a policy of not paying for childbirth classes--which I know is typical but it irks me that they won't pay $275 for a natural childbirth class that prepares you to deliver without drugs, but they'll pay $1000 for an epidural.


05-15-2003, 10:19 AM
We just found out a couple of weeks ago that our insurance (Tri-care) didn't cover my ultrasound (which was back in January). We have Tri-care Prime Remote, which will mean nothing to anyone who's not military, but we went w/ that b/c they said they covered EVERYTHING pregnancy related. Didn't give us a list of what that was, just said that they covered everything. Apparently they don't consider an ultrasound pregnancy related. Doesn't exactly make sense to me. Called them and they won't budge. However, when I was pregnant for the first half of my last pregnancy I went to a military hospital and had ultrasounds, so I'm not sure why they aren't covered now. Yes, it makes me nervous to see what bills we'll be receiving after we have the baby.


05-15-2003, 10:27 AM
I had a similar experience - the insurance company covered the glucose screening test, but when I didn't pass that and had to take the 3-hour glucose tolerance test, I had to pay for that out of pocket. Then, when Aidan was born and was in the NICU for eight days, they paid for the delivery but denied the claim for his hospital stay (they eventually approved it...). I now know to call ahead of time to make sure something is covered, but it really is ridiculous. I hope you are able to resubmit your claim and get them to approve it. I just don't understand how they decide what gets paid sometimes...

Mom to Aidan Christopher 01/28/03

05-15-2003, 11:30 AM
My insurance company denied my csection because it wasn't preapproved. They didn't seem to care that it was an emergency, I guess Nathan's life and my life aren't important. They also didn't cover Nathan's NICU stay. Between the two its almost $20,000. Yes we are fighting it and the doctors have been really good about helping us.
Good Luck to you.

05-15-2003, 01:25 PM

Doesn't your PPO have out of network benefits? It should offer benefits for out of network care at a reduced reimbursement rate (that's part of the definition of a PPO). If your insurance refuses to pay, try to take it up with your doctor. They may pay some of the charges for you.

My epidural was out of network, even though my doctor and the hospital were in network - yeah, like I'm going to ask the anesthesiologist if he is in my network, and if he is not, wait for one who is... Fortunately, DH's insurance picked up the portion that my insurance would not pay.

And regarding the c-section that was not pre-approved - if you have an emergency procedure, you have time after the procedure to call your insurance and have it "pre-approved". This is definitely something that you need to know before you go into labor!

It is worth calling your insurance and knowing what they cover before you go into the hospital - some require preapproval for your delivery (like they don't know it is coming after all these pregnancy bills). And check your benefits summary (and all of your EOB's as you get them) to make sure that they are paying what they should - we have successfully argued quite a few denials in the last year or so!

05-15-2003, 01:29 PM
I also have Aetna PPO, and I may be wrong about this, but I thought that with a PPO it didn't matter if you were getting treatment within their network or out of network. I thought that you just had to pay a higher amount if you went out of network?? I would also mention this to the midwife's office, because they know who your insurance was with, and should have known if it was likely to be declined. Maybe they could lower the amount being charged to the contracted rate?

Also, what my OB's office did was submit an estimated cost of delivery to AETNA and then got something from them stating how much they would pay based on the estimate. I am not sure if this is something they routinely do, of if they just did it because DH switched jobs (and insurance - yikes!) while I was 8 months pg.

But, everything did work out fine - I just had to pay the copay/deductible. My only problem is that they keep referring to DS as a DD, and they spell his name 2 different ways, but besides that...

Hope everything works out for you!

05-15-2003, 02:52 PM
Well, they do have out-of-network benefits, but there's a $500 (per person) annual deductible, and then everything after that is reimbursed at 70%. This is better than nothing, yes, but I certainly would have asked to see an in-network u/s person had I known.

I just have to deal with this part; I understand that is the official coverage of the policy. I am just irritated. Also, a bit mad at the midwife's office for not alerting me to the fact that their u/s tech might not be covered the same as them (surely this is not the first time they've had a patient with Aetna, one of the largest insurance companies in the U.S). Also, I told the customer service rep that I have already met my deductible by paying for mental health services and I submitted this claim in late April. She said "Well, it hasn't been processed yet, so you'll have to pay for the u/s, the remaining deductible up to $500 will come out of what you paid for mental health, and then we'll start reimbursing you at 70%." Yeah, but I want all my deductible to come out of mental health, because I was going to be paying for that anyway, and this way, the 30-visit per year cap doesn't begin until I've already paid for about five of this year's visits. It's not my fault it takes you this long to process a claim.

05-15-2003, 04:30 PM
...fight it with the doctor!!!! how in the world would you have known...they should delter the excess charge and soak it up. By the way that is tax deductable for them. You also should suggest tot hem that they have a sign in the US room and maybe for someone to sign pre sono that says the tech is a differnt billed item!!!
Fight it with the Doctor!!!...they'll write it off I bet...threaten to leave the practice they makes tons off of pregnant women!!!! tons!!!!

August Mom
05-15-2003, 04:41 PM
I agree that it does seem like lab facilities/techs operating in the same building/office as your in-network doctor would be in-network as well, but I learned that's not true the hard way as well. My blood work was processed in the lab connected to my doctor's office, but I didn't learn until the bill came that it was out-of-network. The next time I had lab work, a different nurse noted my insurance company and said that my previous lab work shouldn't have been processed by that lab but should have been sent to another lab in my network. Live and learn, I guess. Our biggest insurance problem was coverage for DS. We added him to DH's policy rather than mine and DH's company didn't like it. His company, Anthem, said that DS's birth should be covered by my policy because his birth was intimately connected to me and therefore the mother's policy controlled. My insurance company didn't think so. Of course we didn't learn that there was a problem until after 30 days past DS's birth and therefore too late to add him to my policy anyway. We finally got it resolved, but Anthem couldn't get it to register that I was not on DH's policy but DS was.

05-15-2003, 10:11 PM
I also had Aetna PPO when I was pregnant and gave birth (company has switched ins. plans twice since then) and I also learned the hard way that Aetna would only pay for lab tests done by Quest Diagnostics. I had no idea until bills for blood tests started coming in! No longer could I just skip down the hall from the doctor to the lab, I had to drive across town to the nearest Quest lab. Plus they wouldn't accept just any form, it had to be a Quest form, and for my glucose test I had to wait around while they faxed a form to my midwife for her to fill out and fax back >: Another annoying thing was having to call Aetna's "Little Appleseed" line and get their approval for EVERY lab test. That Mother-May-I routine was a total pain, and when I had to have a 2nd ultrasound because they didn't get a good look at the spine the first time, Aetna would only pay for the first one.

On the bright side, it was only a $20 copay for the hospital, even though I ended up having a c-section. (Later it was jacked up to $500) Aetna also reimbursed me $50 for childbirth classes. I guess that benefit too has been whittled away.

Sorry about your experience, but these days I wouldn't count on doctors or midwives to know every little quirk about every insurance company, since they change practically by the day. I don't envy the many hours they must spend on the tangled web of insurance paperwork.

05-16-2003, 04:08 PM
Odds are the OB isn't make much off this at all. It needs to be read by a separate radiologist, and that might be the person who is out-of-network. In terms of OBs making "tons" off of pregnant women, I think this is an exaggeration. Have you seen the cost of malpractice for OB's, particularly in NY? I agree that this is very frustrating, and that one should be informed upfront if a particular procedure is unlikely to be covered, but please don't blame the physician for pocketing all of the loot at the patient's expense. Most physicians are just as frustrated by health insurance companies as patients are, and aren't looking to swindle their patients.