Insurance Denials for Pregnant Moms

I work in an OB/GYN practice and am fortunate to provide prenatal care to women. Here's a peek behind the scenes that might explain why 67% of physicians surveyed favor insurance reform and a public option.

This is not covered. This is the common sentence in the numerous faxes from insurance companies informing me and the physicians I work for, that what we in the OB/GYN community consider standard of care for high risk pregnant women is not covered. Let me repeat, Not Covered. Here's a common scenario in the prenatal care setting:

When a pregnant woman becomes high risk from high blood pressure or diabetes, she often needs to have more ultrasounds, non-stress tests and biophysical profiles, which are evidence based treatment algorithms that help prenatal care providers determine how to care for the mom and when to consider inducing labor, performing a C-Section or allowing her to go into labor spontaneously. Many prenatal providers have the equipment necessary in the office and do the testing there. We rely on these tests to help us increase the likelihood of a healthy mom and a healthy baby, while trying to prevent an extremely premature birth. To rephrase, we follow a very specific plan of assessment every 3 days which replicated research demonstrates increases the likelihood of a healthier baby. We don't do the tests because they're fun or we have an extra 45 minutes in the schedule. We do these tests because they help us help moms have healthy babies.

If I had a nickel for every time an insurance company told my office that they would not cover these test, I could retire.

Here's the problem. As health care providers, we are obligated to provide this care. #1, It's the right thing to do. #2 It's evidence based. #3 We're liable for negligence or malpractice if we don't and there's a serious consequence, because these tests are Standard of Care. Standard of Care means that if you asked any OB/GYN what they'd do in this scenario, they'd all say the same thing.

Now, the insurance company has no liability or risk if they chose not to cover the tests. And since health care providers must do these tests, whether they are paid for or not, OB providers and hospitals absorb the cost. It's called a "write off." So lots of doctors and hospitals provide the ultrasounds, the non-stress tests and biophysical profiles without being paid for them. That's right, we end up subsidizing the insurance companies. Patients get the care they need and the insurance company may or may not have paid for it. I don't think this is right.

While I agree that insurance companies are a business and they have a right to make money, and have responsibility to their shareholders, I think that they have a bigger responsibility to their customers. And if you say, you're going to provide coverage for prenatal care, you ought to live up to your promise.

What can you do? Well, I for one, would like to see health insurance reform.

 

 

Comments

[ESerafina42]

Where are the "family values" crowd when you need them? Oh, yeah - they're off pocketing money from those very companies.

[Enjay 1]

Once again, our heath care system needs drastic reform.
In addition, the insurance industry has proven they can't be trusted
- so they need oversight.

What many people don't seem to understand is that those of us WITH insurance are already paying the price for the uninsured. The Drs / Clinics & Hospitals that aren't paid - they have to make up the difference somewhere - and they pass those costs on to the all patients; insured, uninsured and the poorly insured. Even considering legal costs, malpractice insurance, etc., $110 for an Ace Wrap is like those $900. hammers and $4000. toilets the government bought back in the Reagan days.

Also, bite my tongue for saying this but Medicade & Medicare have to admit THEIR contribution to the rising cost of health care. They set their "governmnet reimbursement price" per procedure - (just tossing numbers here as an example) break a leg $1500 / the hospital cost may actually be $2500 - break a hip $18K / and the hospital costs may be $29K.

The hospital has to make up that payment difference by increasing their procedure prices - on people who can or be forced to pay..... the insured, the working people with a paycheck ( they can attach or bank account they can seize) the homeowners (a lien against the home)

The more the hospitals, clinics & dr's get stuck with limited payments or no payment - the more the costs will rise. It's a vicious cycle.