Congrats on the baby — now pay up | Opinion

‘Only you and your doctor can decide what’s best for you,’ the letter read.  Funny, because it doesn’t feel that way.

(Getty Images/The Minnesota Reformer)

By Jasmine Winter

Here’s a notice a new mom shouldn’t receive:

“Your doctor ordered a test to see if the membranes around your baby were leaking.  The procedure is not approvable under the plan clinical criteria because there is no proof or not enough proof that it works as well as other tests to check for ROM.  For this reason, the request is denied as investigational and not medically necessary.”

Let’s start at the beginning: On Jan. 4, I went to an ultrasound appointment with my midwife. I was 38 weeks into a high-risk pregnancy, having spent my third trimester with twice-weekly appointments to monitor me and my son’s health. I had two days left of work. I’d worked retail full time through the pregnancy, and an induction was scheduled for a week later.

My midwife was concerned about the amount of amniotic fluid I had been leaking, and wanted me to immediately go to my hospital to be checked for signs of labor. I called my husband and warned him to be on standby should I need him to meet me at the hospital. I was quickly shown to a room, and tested for amniotic fluid leakage.

My mind raced as I laid waiting on the test results. The year before, I lost my first pregnancy when my water broke at 19 weeks. My body went into labor within 24 hours and my daughter was stillborn on my 25th birthday. This was a major factor in my high-risk pregnancy status, as well as my midwife’s concern.

Finally, the results came back: I was not in labor. I was sent away with instructions to take it easy until my induction on the 11th.

On Jan. 11 we welcomed my son into the world. It was my husband and I in face masks — no visitors were allowed in the hospital. We brought him home and entered a new chapter of sleeplessness, joy and lots of poopy diapers. We were tired but we were together.

Of course, the bills eventually rolled in. We were prepared for that: It cost us over $2,000 after insurance to lose our daughter at the hospital, and even more for the anesthesiologist. Several bills took additional back-and-forth with the hospital and the insurance company to get them settled. Sometimes not enough information was on file, sometimes the insurance company made mistakes. So I was tasked with combing through every bill and explanation of benefits that came in the mail.

Eventually, for my son’s birth, we paid well over $4,000, meeting my individual deductible and approaching our family deductible.

One bill, however, bounced between the insurance company and the hospital several times and was still not yet covered.

The leftover bill was for Jan. 4, the day I was tested for “rupture of membrane” — or as the rest of us call it, my water breaking. The insurer — called Anthem Blue Cross Blue Shield — repeatedly said they needed more information, and eventually denied the claim due to lack of proof that the test was necessary. That’s the note I got above.

I filed an appeal and had my midwife’s office send over the notes from the visit that spurred the hospital followup.

A notice from my insurance company dated Sept. 17 arrived on Sept. 23. It stated that on Sept. 22 a meeting would be held to review my appeal. The notice said I could attend the meeting via phone to present my grievance and answer any questions from the committee, as long as I reached out by Sept. 20. I would have loved to have stated my case, but that letter arrived on Sept. 23.

The committee deemed the procedure unnecessary, which meant we were stuck with the bill.

This isn’t the biggest claim we’ve had to pay; without insurance this bill is $675. That loss won’t destroy my little family, but it makes a difference. I still saw red when I got the verdict in those big professional words.

I want to know what they think I should have done when my midwife expressed concern and told me to go to the hospital. Should I have just gone to work instead?

When I got to the hospital and was told we were going to do an “evaluation of cervicovaginal fluid for specific amniotic fluid protein,” should I have said that wasn’t the correct test to perform?

Should I have just forgotten that I had an extremely unlikely premature labor before?

I’m going to do another appeal before biting my tongue and paying the bill. This year I’ve had to spend so much time with deductibles and billing summaries, and checking the work of people I don’t know, on bills I don’t understand, because each decision results in hundreds or sometimes thousands of dollars out of our pocket.

I’ve spent countless hours on this while breastfeeding on my couch.

This is not my first time dealing with bills that don’t feel fair. I once had a former apartment property manager contact me two years after moving out, claiming my roommate and I owed $1,200 in repairs. Once, after paying off a hospital stay, I was billed $900 over a year later for the physician who asked me inappropriate questions and prescribed me medications for diagnoses I did not have. That doesn’t even come close to what my student loans are going to get out of me.

I don’t even know any names of the people who decided that my claim was unnecessary, so maybe I shouldn’t take it personally.

But it’s hard not to, because this was my health and my baby’s health on the line.

In the final paragraph of the letter detailing their decision it says, “What’s next? This decision means this service isn’t covered by your health plan. It doesn’t mean that you should stop getting medical care. Only you and your doctor can decide what’s best for you.”

Funny, because it doesn’t feel that way.

Jasmine Winter is a queer mom and retail sales manager. She wrote this column for the Minnesota Reformer, a sibling site of the Pennsylvania Capital-Star, where it first appeared

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Capital-Star Guest Contributor
Capital-Star Guest Contributor

The Pennsylvania Capital-Star welcomes opinion pieces from writers who share our goal of widening the conversation on how politics and public policy affects the day-to-day lives of people across the commonwealth.