Baby's first insurance penalty

September 2, 2014 1:06 PM

We welcomed Baby NDG to the world just over a month ago and was added to my wife's insurance. Baby was admitted to the NICU (for monitoring) for four nights, which included one night after my wife was discharged from the hospital. The insurance (BCBS Platinum PPO in IL) is now sticking us with a $500 penalty for failure to "pre-certify" baby's inpatient stay. Is there anything we can do about this?

From what the CS rep told my wife, this is only an issue because she was discharged from the hospital before the baby, thereby retroactively turning the baby's NICU stay into a separate inpatient stay (or something).

I'm sure that this is buried in the (extravagantly priced) plan's terms somewhere, this is valid, and it's our fault for not being sufficiently curious about the appropriate times to call the insurance company while sorting out all of the other issues that were keeping us in the hospital. Fine.

Apparently we can appeal by writing a letter to the powers that be at BCBS. Has anyone had any luck doing this? I don't really have an argument for why the fee should be forgiven other than that it's a sleazy move and a usurious amount. Or should we just cough up the $500 and move on?

posted by ndg to Work & Money (15 answers total)

I think you should appeal it as an oversight in a frightening situation.

The hospital may also have someone able to help you on this appeal, so I'd speak to a case manager where baby was admitted. Sometimes insurance companies change their stories when a hospital staff member talks to them instead.
posted by zizzle at 1:11 PM on September 2, 2014 [4 favorites]

This does not even begin to pass the sniff test. See if you can enlist help from the hospital to appeal it. I agree with zizzle that they are less likely to try and strongarm a hospital person.

We have a BCBS PPO in IL, our infant was admitted from the emergency room to the PICU at a large hospital in the Chicago burbs, and at no point did we communicate directly with the insurance company. The hospital handled it.
posted by telepanda at 1:24 PM on September 2, 2014 [6 favorites]

The CS rep was grasping at straws. If they can retroactively change it to a seperate stay, then you can retroactively pre certify. Thinking you would have any idea you needed to precertify someone who was already in the hospital is really stupid. So NOt fine. I would make a couple other phone calls to someone higher up and with the power to make a change and explain that the infant never left the hospital after being born and to get a more logical explanation. The suggestion to enlist the hospitals help is a good one.

Save the letter for your last effort because if they deny on the letter you might not have another appeal.

Do they send you a bill for a penalty or deduct it from your payment to the hospital?
posted by domino at 1:32 PM on September 2, 2014 [5 favorites]

Response by poster: Domino - they sent a bill (to the baby). I really appreciate the responses so far.
posted by ndg at 1:34 PM on September 2, 2014

Also: do you get your health insurance through your employer? My (large, university) employer has an "insurance ombudsman" who deals directly with the insurance company about things like this. I understand that this is generally unadvertised, but not uncommon. Call your HR rep and ask, certainly, if they can help in this situation.
posted by anastasiav at 1:40 PM on September 2, 2014 [1 favorite]

Call the Illinois Office of Consumer Health Insurance (OCHI) at [phone]. They can help you understand if what the insurance company did was legal, if it was justified under your plan, how you can appeal it, and how you can file a complaint with state insurance regulators if necessary. OCHI is a government-funded citizen and consumer advocate that exists specifically to help Illinoisians navigate their health care plans and get accurate, complete information on insurance, laws, and their rights.

They are extremely, extremely helpful and knowledgeable and spend all day dealing with questions from "I don't understand which number is my premium" to "my insurer are denying my heart transplant, now what?" There is no question too big or small and they are very very used to people crying on the phone (just saying having had to call myself when I had a six week old baby and a LOT OF HORMONES). They are literally the exact people to give you an answer to each part of this question -- helping you understand your plan, helping you understand your rights, and helping you figure out what to do next.
posted by Eyebrows McGee at 1:48 PM on September 2, 2014 [8 favorites]

Good advice all around. Basically a screwup by the hospital and/or a greedy grab by the insurance co. Work thru the hospital and your employer's benefit dept.
posted by SemiSalt at 2:19 PM on September 2, 2014

Is the bill from the insurance company, or the hospital? If it's the latter, definitely make them eat it; they can't hold you responsible for what was their administrative mistake.
posted by ThePinkSuperhero at 2:37 PM on September 2, 2014 [1 favorite]

Appeal. Insurance companies pull these shenanigans all the time, as some people don't challenge it and just pay. An appeal should clear it up.
posted by vignettist at 6:43 PM on September 2, 2014

There is no way - no way - that a baby needs pre-certification for admission to the NICU. It does not pass the laugh test, because a NICU stay is obviously unpredictable. (Yes, my son spent 40 days in the NICU. Do you have a pre-certification requirement for admission to the ER after an accident? Of course not.)

This is just a mistake by an under-prepared employee, and is easily fixed by calling and talking to a supervisor about what you're sure is a small misunderstanding on their part. If it isn't immediately sorted out, just let them know that you're thinking about calling around to the press and the state AG's office to see if it is acceptable to bill a newborn for not pre-certifying their fun vacation in the NICU. Really?

(If you want to go very new media, look up their corporate Twitter account and tweet them. I got stellar service from a major national consumer electronics provider because apparently they have a whole team in the head office devoted to addressing the concerns of people who might cause them trouble on social media. Seriously.)
posted by RedOrGreen at 8:04 PM on September 2, 2014 [5 favorites]

This has been bugging me all afternoon and I just came back to add a bit of righteous indignation to the thread because you sound kind of beaten down. Newborns'll do that to you. (It gets better.)

Intentional or not, this is an epically asshole move by the insurance company during what was a horrifically stressful time for you. Like, seriously, what the fucking fuck? Were you supposed to call them two weeks in advance and be all, "having a vanilla newborn is so passe; we think we'd like to spice it up and have a kid with [Problem] instead, so Baby NDG'll be hanging out in one of your isolettes for a bit. That cool with you? How's next Tuesday?"

I would just like you to know that I am livid on your behalf; and while I'm confident that you can resolve this with the tactics described in this thread, fuck those guys and the horse they rode in on. I barely managed to survive one trip to the store to purchase food for the rest of my family when Nanopanda was in PICU not breathing well enough to even be fed. You can bet your ass that calling the insurance company to ask for their permission was the last thing on my mind. As if it was elective. (Sorry, psychological wounds still fresh...)

Don't feel like you screwed up somehow. And good luck.
posted by telepanda at 8:41 PM on September 2, 2014 [7 favorites]

In my circle of friends and family members, BCBS has been NOTORIOUS for denying things they obviously cover, especially on the first billing. If the doc or hospital sends the bill again, the issue magically clears up and is approved. Sometimes it's because a box on a form is t ticked, sometimes it's because they didn't like where you put the zip code. I have had to precert psych hospital stays with BCBS before and some reviewers ask me info that is in no way relevant to the issue at hand, simply because someone decided we needed to know exactly how tall the suicidal man is upon admission. (Really.)

So definitely fight this. Call and talk with a supervisor, get the hospital to send the info in again, whatever. I think BCBS hopes people won't appeal their denials which makes them some extra money. Don't make their job that easy!
posted by MultiFaceted at 11:19 PM on September 2, 2014 [2 favorites]

Appeal. I had a planned C-section and my insurance denied the baby's inpatient stay completely. As in, we will take this baby out of you but we aren't paying for it to stay here! They do whatever to try to avoid paying for things. It was all worked out and we were 100% covered for the baby's stay.
posted by maxg94 at 6:37 AM on September 3, 2014 [1 favorite]

Response by poster: Thanks, everyone - these responses are really encouraging. Rest assured we won't roll over without a fight (with help from the OCHI office if we don't get anywhere with BCBS). We found a document from the insurance company that confirms that her admission to the hospital (a.k.a. "birth") was approved for the entire duration of her actual visit, so we hope that gets us some traction.

FWIW, in the event of an emergency, we were supposed to "pre-certify" within two days of discharge, LOL.

I will keep this thread updated!
posted by ndg at 7:09 AM on September 3, 2014

Response by poster: Good news! A sympathetic CS rep was able to roll my baby's pre-certification requirement under my wife's since she was only in the NICU one day after my wife was discharged. No one ever backed off of the claim that we were supposed to have known that our situation required a separate pre-certification but they decided to be nice in this case.
posted by ndg at 8:06 AM on September 3, 2014 [3 favorites]