I hope you all had a wonderful Thanksgiving! I was finally able to relax and participate in a Turkey Trot 5k Run after taking my CFP exam last weekend. Now its wait game and I just need to wait for the exam results to come in 6 weeks.
I have more time to kill so let me finish the pending part on the Maternity Insurance. If you haven’t gone through previous posts, I recommend you check out Part 1 which introduces Maternity/Pregnancy Insurance and Part 2 discusses in details about important things to be considered. In this last post of the series, I will discuss about the money saving part, Claims process and Appeal process if you ever need to appeal.
Like any insurance, deductible is considered as the risk rentention part where certain amount of risk is retained by the insured by paying deductible first and later expect insurance company to cover the rest according to the plan. The deductible serves as the stopping gate for the insurance companies to make sure consumer won’t go to the doctor for anything and expect insurance to pay for it. With deductible, insured always have to pay the cost until they reach the maximum deductible amount.
It works the same way for maternity insurance (deductible plan only) as well where as you have Maternity deductible and Major medical deductible. Two deductibles run in parallel. So if you are visiting your regular doctor, its covered under Major medical deductible and when you visit your gynecologist for Maternity purpose, it will be covered under Maternity deductible.
Claims Process – Before Delivery
Anything related to the pregnancy like lab work, prescription all come under Maternity deductible. Don’t pay anything upfront. Let them process through your insurance carrier and they will send the statement after its processed. Match the statement of Claim from Insurance company and providers like labcorp and pay only the amount mentioned. These providers have standard agreed discount for each medical procedures so your insurance company will apply them and send you the final bill to be paid. You save money this way too when you have insurance. This amount is applied to your deductible.
Once you get closer to delivery date, your gynecologist office might ask to pay their charge for delivery if your deductible is high to avoid non-payment after delivery. Try to talk to them and pay may 1/3 of the charge. Also when you register in the hospital for the delivery, they also might ask you pay part of your deductible because of high deductible. Again talk to them and say you paid some to your doctor and can only pay certain amount. They will most likely work with you and accept it.
Don’t over pay or fully pay your deductible amount which might cause problem later because insurance company only process claims after the delivery is over and they process them accordingly how they recieve it. If your doctor sends their claim for $3500 as their delivery charge and they get processed first. You might have to pay $3500 to your doctor alone as part of your deductible. So if you paid $2500 to doctor and $2500 to hospital to cover $5000 deductible, you won’t have money to pay the doctor pending $1000 to satisfy the deductible. Hospital might refund your payment if they get paid by the insurance but it takes time. That’s why don’t pay all your deductible before delivery. You have lot of time to pay it after delivery so just talk to your providers ask them to hold for a bit.
Claims Process – After Delivery
After the delivery, if its normal process and you usually stay in the hospital for 2 days with your baby, then all charges are covered under Maternity deductible. If the delivery is complicated means C-Section and baby is normal, your delivery is covered under Major medical coverage and baby’s charges are covered under maternity coverages. That’s biggest unknown factor and you should hope for the best. If you previously delivered baby in normal delivery, you are most likely to have the future ones normal as well. You just need GOD’s grace and hope things goes well.
Otherwise, you will endup paying to cover both deductibles. You better be ready if you have bigger major medical coverage. Also you shouldn’t surprised to recieve bundles of bills from other providers like Pathologist, Anesthiologist and others apart from Hospital and Doctor’s office.
Medical Codes – Normal Vs Complicated
You might have heard about medical codes which are the important aspect of claim’s process. Your doctor or hospital has to send proper medical codes for their treatment for the insurance to process the claim properly and pay for the claim. If the medical codes were messed up, they might reject or apply the coverage under different deductibles. That’s want happened in our case. It is a normal delivery with little complication which is usual and they have different codes compared to strict normal delivery.
In our case, Doctor’s office sent a code as normal whereas Hospital intrepreted what doctor noted and sent code as normal with small complication. So insurance company processed exactly the way they sent and doctor’s claim went to maternity coverage whereas hospital cliam went to Major medical coverage even though its normal delivery. Medical codes can have big impact on the claim so be watchful on how the cliams are processed.
As I mentioned above, insurance company processed claims for the same delivery differently because of the medical codes. Because they processed the codes differently, deductibles are messed up. So I started getting bills from other providers to pay them. At one point, I got bills to pay total of $10,000-12000 which was a shocker. I never paid them. I immediately called insurance company to understand the problem and even conferenced with hospital to let them talk each other and same time find the underlying problem. After all that going back and forth 1 month, insurance company didn’t want to pay because the claims are done as per provider codes. Hospital don’t want to change because they were claiming correctly as per doctors notes. It ended up in deadlock situation. Meanwhile I had to call other providers and requesting them to hold on their bills, many of them put 30-45 days hold.
Only option given to me by Insurance company was to appeal the claim process. So I ended up drafting a detail appeal letter mentioning what happened and what was promised when the insurance was taken. They said any normal delivery is covered under maternity coverage and now they are changing it just because of codes sent by hospital and processing them as complicated. So I requested them to reprocess all claims as normal delivery because it not right to process some claims under normal and some as complicated. I know the appeal is worth a fight to save thousands of dollars.
It took almost 3-4 months for the appeal process to be completed and they finally accepted and reprocessed the claims which are wrongly processed as normal delivery. During this time, I had to call every provider to hold them off or just pay minimum amount to extend the due date. This way they won’t go to collection. Appeal process needs constant attention and follow up. You might have to contact hospital and collect documents and send to insurance company to speedup process instead of them waiting for months. You have to do as much as possible to get this process moving and help them make the decision so you can save money. This is the last route, if it didn’t work out I was planning to file a complaint to State Insurance Commissioner to take some action. But I am glad it didn’t go that far.
In summary for this 3 part Maternity Insurance, I want to say, Health Insurance is a must for a family and Maternity/Pregnancy insurance is very important for any family who doesn’t have group coverage to cover their pregnancy. If you want to face it without insurance, you might end up losing lot of your savings and have tough time with the providers which might worsen your financial wellness. So I strongly recommend to consider taken maternity insurance before planning to expand your family.