CareFirst BlueChoice HDHP federal govt not covering prenatal!

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Leemiller
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CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Leemiller » Wed Oct 12, 2016 11:09 am

I'm hoping for some advice on how to deal with CareFirst. I'm a pregnant federal employee, and I'm an older mom. CareFirst is billing me routinely for prenatal care. Every visit there is a charge and in one case I was billed over $700!! In other cases I'm charged something like $7-25 for what should be a free visit. My doctor's office sent in additional information but got nowhere.

Any advice on dealing with this? Could my HR help me? Can I file a complaint? I'm at a loss when it comes to insurance companies.

Dottie57
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Dottie57 » Wed Oct 12, 2016 12:09 pm

Leemiller wrote:I'm hoping for some advice on how to deal with CareFirst. I'm a pregnant federal employee, and I'm an older mom. CareFirst is billing me routinely for prenatal care. Every visit there is a charge and in one case I was billed over $700!! In other cases I'm charged something like $7-25 for what should be a free visit. My doctor's office sent in additional information but got nowhere.

Any advice on dealing with this? Could my HR help me? Can I file a complaint? I'm at a loss when it comes to insurance companies.


If it is HDHP plan, you usually have to meet your deductible first, before the plan kicks in.

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dm200
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by dm200 » Wed Oct 12, 2016 12:33 pm

Leemiller wrote:I'm hoping for some advice on how to deal with CareFirst. I'm a pregnant federal employee, and I'm an older mom. CareFirst is billing me routinely for prenatal care. Every visit there is a charge and in one case I was billed over $700!! In other cases I'm charged something like $7-25 for what should be a free visit. My doctor's office sent in additional information but got nowhere.
Any advice on dealing with this? Could my HR help me? Can I file a complaint? I'm at a loss when it comes to insurance companies.


If you have not done so already, I would get or dig out the full details of your exact CareFirst coverage (as applicable to federal employees). Then take the EOB from these claims and any other documentation, and call CareFirst for an explanation. You may have to be aggressive in finding someone at CareFirst. It is probably in the EOB, but I would make sure the correct and accurate codes were used in the claims. There could be a "coding" error or confusion. There could be "issues" at such visits that are not covered as "free". In parallel with phone calls (or perhaps shortly after), I would put the question(s) in writing to CareFirst.

Depending on your doctor's office, sometimes (not always) there is an admin/billing/insurance person who might be able to help understand the claims "problem".

Years ago, my wife had claims denied for bone density testing her Primary care physician ordered that were rejected. (over and over). I finally was able to speak with a nurse at the BCBS insurance company who was able to explain (and fully justify to my satisfaction) that the test was not appropriate for my wife and the doctor should never have ordered the test.

Rupert
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Rupert » Wed Oct 12, 2016 1:01 pm

Leemiller wrote:I'm hoping for some advice on how to deal with CareFirst. I'm a pregnant federal employee, and I'm an older mom. CareFirst is billing me routinely for prenatal care. Every visit there is a charge and in one case I was billed over $700!! In other cases I'm charged something like $7-25 for what should be a free visit. My doctor's office sent in additional information but got nowhere.

Any advice on dealing with this? Could my HR help me? Can I file a complaint? I'm at a loss when it comes to insurance companies.


What does your insurance contract with CareFirst say? Start there. Taking responsibility for your own healthcare, which you must do to receive adequate care, means knowing what benefits you are entitled to under your insurance contract. It governs every single interaction you have with your insurance company. You should print a copy of your benefits booklet every single year, as insurance companies publish a new one every year. They usually also publish an easier-to-read summary of benefits, which I carry around with me just about everywhere and especially when I'm seeing a doctor for any reason.

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dm200
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by dm200 » Wed Oct 12, 2016 1:20 pm

What does your insurance contract with CareFirst say? Start there. Taking responsibility for your own healthcare, which you must do to receive adequate care, means knowing what benefits you are entitled to under your insurance contract. It governs every single interaction you have with your insurance company. You should print a copy of your benefits booklet every single year, as insurance companies publish a new one every year. They usually also publish an easier-to-read summary of benefits, which I carry around with me just about everywhere and especially when I'm seeing a doctor for any reason.


I agree. It amazes me how many folks I know that complain about what they have to pay for relating to health and medical expenses (in the same plan/provider that I have), BUT do not have a clue about the details of what is and is not covered, how to obtain care at the lowest (net) cost and not sacrificing quality of care, etc. In my case, for example, even the "type" or "category" of appointment with my PCP can make a BIG difference. When I encounter someone who complains about being charged for something, and I ask what kind of appointment they made/had -- they seem to get angry at me -- seeming to believe that the health plan and/or their physician can "read minds" about this. I rarely am charged for something that is supposed to be "free" and in the one case where I was charged, a simple call to the billing office (with details) cleared it up immediately.

Big Dog
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Big Dog » Wed Oct 12, 2016 1:34 pm

If it is HDHP plan, you usually have to meet your deductible first, before the plan kicks in.


Bingo. While preventive services (annual physical) are not subject to a deductible, I would guess that pregnancy care would be.

If your delivery date is next year, suggest you switch out of the HDHP into a normal PPO or HMO during Open Enrollment so you don't get hit with a large hospital bill. (This is what our broker did when she was pregnant.)

btw: the HDHP also may come with a Health Savings Account. If so, are you contributing to that on a pretax basis so you can cover the current medical expenses?

Mako
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Mako » Wed Oct 12, 2016 1:38 pm

Agree with those that said look at the plan brochure.

I have GEHA HDHP from the federal govt. They pay everything maternity related after you hit the deductible. Prior to meeting the deductible I have to pay their negotiated amount. When I had GEHA standard (i.e. non-HDHP) they paid all maternity stuff regardless of the deductible, so this is a case where the HDHP benefit is not as good. This is all fairly clear in the brochure. I wouldn't be surprised if Carefirst is the same.

Leemiller
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Leemiller » Wed Oct 12, 2016 4:24 pm

:dollar The plan is supposed to cover routine prenatal 100% for in-network, which I am. I did read the plan's terms.

First a representative told me items were miscoded so my doctor's office sent in additional information (and said the items were not miscoded). CareFirst has denied it again.

The terms of the plan are clear, what I'm asking is how to appeal in the Byzantium world of health insurance so that I might be efficient in my next steps. I've already spent hours on this. I was also wondering if anyone happened to have this particular plan.

SuzBanyan
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by SuzBanyan » Wed Oct 12, 2016 6:19 pm

Has the insurance company clearly communicated why it was denied?

Are you really covered for "routine" prenatal or just "preventative" prenatal? There may, or may not, be a difference.

You posted that the coding was correct, but do you know if a non-preventative code was added which might justify coding for an office visit for which there is a charge? This sometimes happens with preventive non-prenatal exams, when the patient asks about something such as "Doctor, as long as I'm here, I've been having an issue with ...". Not sure if it also applies to pre-natal.

Or is this a case where it is coded as a preventative prenatal exam, but that the insurance company believes you need to meet your deductible or pay a copay under your policy?

malabargold
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by malabargold » Wed Oct 12, 2016 6:46 pm

You said you're an "older mom" -if so are you AMA-
"advanced maternal age" and seeing a maternal-fetal-medicine
specialist for high-risk pregnancy?

Anina
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Re: CareFirst BlueChoice HDHP federal govt not covering prenatal!

Post by Anina » Thu Oct 13, 2016 4:35 pm

Insurance is tricky.

When you saw your doctor, did you complain of something? Nausea, vomiting, aches, pains? Did you want that addressed? If so, then they code those as problem visits. It is no longer a routine prenatal visit. What does your insurance say about problem visits?

I am an OBGYN. I spend considerable time explaining this to my patients. When I hear about a complaint during a routine visit, I ask them if they are just venting or do they want me to evaluate it. I then have to discuss possible co-pays or possible bills.

Another issue is ultrasound.....Oye vey! Read your policy regarding ob ultrasounds. If you want an ultrasound before you start ob appointments, it will be billed as a GYN ultrasound which is different for insurance purposes. You may have to meet a deductible. Once I explain it to my patients, they sometimes elect to wait on ultrasounds until they have designated ob appointments.

Very confusing...and constantly changing this insurance system of ours.

Congratulations on your pregnancy! Parenthood...it's the best.

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