Read the entire article here: Insurance Industry’s Final Ad Blitz: Don’t Blame Us For Your High Costs

My husband and I want to thank everyone for their support. Lily’s story has been shared with so many people and we hope that it will help other families.

As Lily’s mom I would encourage other families to think seriously before purchasing or staying on their BCBSAZ plans… especially if you are self-employed and believe that your PPO insurance plan will cover you if you have to have a C-Section to protect your life and health or the life and health of your baby.

We believe that just because this is Blue Cross Blue Shields “policy”, it doesn’t make it right.

KTVK 3TV aired a segment about my fight with Blue Cross Blue Shield on Monday night. You can watch the video above. To clarify, Blue Cross Blue Shield has denied my claims because maternity is not a benefit of my plan and my C-Section did not fall within their current definition of “complications of pregnancy”. Thank you to all that watched the segment on 3TV. Hopefully it will encourage more people to go to the lengths necessary to understand their health insurance policies… and encourage them to fight back when insurance companies say “no”. Just because it’s your policy, it doesn’t make it right.

Interestingly enough, it seems that if I’d needed a cesarean section prior to October 1, 2008 it would have been covered.  The revision to Blue Cross Blue Shield of Arizona’s definition of “complication of pregnancy” to no longer include cesarean sections “during labor” seems to be a decision driven by the bottom line, not what is best for their patients.  If Lily hadn’t been delivered via cesarean it’s a definite possibility that BCBSAZ could be paying for Lily to have physical therapy right now.  Hmm… which is better for the patient, a cesarean section to avoid future complications or physical therapy for an infant?

BCBSAZ has offered me a meeting with their Medical Director.  That should be interesting.

Office of the Speaker
H-232
US Capitol
Washington, DC 20515

January 13, 2010

Dear Madame Speaker,

I am writing to you and enclosing my recent medical appeals because I wanted to bring to your attention the extensive and devastating effect that our current healthcare and insurance system is having on my family.  My daughter, Lily was born on August 10, 2009 via a medically necessary cesarean section because she was failing to descend and exhibiting non-reassuring fetal heart tones.  Blue Cross Blue Shield of Arizona (BCBSAZ) has denied the medical claims resulting from my cesarean section because my policy did not include maternity and only covered a cesarean section if they deemed it to be medically necessary.  BCBSAZ has maintained that my cesarean section does not fall within their definition of “medically necessary” and under their defined “complications of pregnancy”.  Therefore BCBSAZ will not cover the insurance portion of the claims associated with the delivery. BCBSAZ has also denied claims for visits to my hospital’s OB Triage unit that occurred pre-term (before 37 weeks gestation) because based on the BCBSAZ definitions, pre-term labor is not considered to be a complication of pregnancy.

I requested a Level 3 External Review asking BCBSAZ to overturn the previous denials, which in total are approximately $31,000.  My husband and I did everything right on our end, paying out-of-pocket $8,000 for my pre-natal care and a self-pay labor and delivery package with my hospital.  It was my intention to have a vaginal delivery.  My husband and I did agree that during the delivery we would rely on our doctor’s direction and medical expertise and if our doctor were to recommend a c-section out of medical necessity for Lily or me, that we would follow the doctor’s recommendation.

I believe that BCBSAZ has acted in bad faith and is attempting to make medical decisions for me that should instead be made by my health care providers.  I wanted you to be aware of my appeal because I sincerely hope that no other health insurance customers will have to go through what we have.  I have spent countless hours to appeal my denied claims and a significant amount of money printing and mailing documentation regarding my appeals.  It has become like a second job.  Both my husband and I are self-employed and my husband is a full-time education major at Arizona State University. I went back to working just four short weeks after the birth of my daughter so that I could help to contribute financially to my family.  My husband went back to work immediately following her birth and began a new school term the week following Lily’s birth.   My business and our livelihood is now suffering because of the hours that I am spending in the appeals process.  More importantly, as a new mother, I am losing precious time with my daughter that I will never get back.

Financially this is a potentially devastating event for our family.  My husband and I are both very hard working, contributing members of our community and country.  After doing everything right, we are now left with tens of thousands of dollars in medical bills that we simply cannot afford and never anticipated.  It is also possible that due to these bills we won’t be able to have more children, because we cannot afford it.  We have been married six years and waited to start a family until we were financially stable and able to provide our family with a secure and comfortable life.  This is perhaps the most devastating part of all.  Because an insurance company is more concerned with making money and creating such limited parameters on what they consider to be medically necessary, my life, my husband’s life and my daughter’s life are forever changed.

When we bought our policy in May of 2008 it was our understanding that if I had to have an emergency cesarean section it would be covered.  On October 1, 2008 BCBSAZ changed our policy to no longer cover cesarean sections that are performed due to fetal distress.  If my baby is in distress and my doctor recommends performing a cesarean section, what could be more medically necessary than that?  In addition, how does a condition go from being medically necessary one day to no longer being medically necessary or a defined complication of pregnancy the next day?  It would seem to me that the change in definition is driven by one thing and one thing only, money.

I also find it abhorrent that an insurance company is allowed to change my policy after I have purchased it.  With what other major purchase does this occur?  My mortgage doesn’t change because my bank needs more money.  My car payment doesn’t change because the manufacturer doesn’t sell that model any more.  Why then can an insurance company change my policy after I’ve agreed to their terms the first time?  Again, the answer seems to point to the financial bottom line.

I received notice from the Arizona Department of Insurance on January 13, 2010 that our Level 3 External Review had found in favor of BCBSAZ because my claims did not fall within the BCBSAZ definition of “complications of pregnancy”.  We are now in the process of requesting a hearing with the Office of Administrative Services.

Madame Speaker, I am asking that you do whatever you can to help ensure that no other parent is told that protecting their child’s health, their child’s safety and that following their doctor’s expert advice is not medically necessary.  I’m asking you to stand up against insurance companies that are more concerned with making exorbitant profits than with their customer’s medical health.  I’m asking you to help ensure that other families like mine are not devastated and financially ruined because of an insurance company’s refusal to pay.  As a mother and grandmother I’m asking you to consider how you would feel if your child’s or your grandchild’s health, life even, was on the line and an insurance company told you it didn’t matter.

Sincerely,

Lily’s mom, Elizabeth Langford

This is of course not what we had hoped for, but we’re going to press on.  In addition to the more than 30 letters I have already sent to my local and state representatives I will now also be writing to Speaker of the House Nancy Pelosi and First Lady Michelle Obama.  I’m thinking for good measure I should also write to Oprah.

December 17, 2009

Vicki Roberts, R.N.
Medical Appeals and Grievances Coordinator – External Review A116
BCBSAZ
PO Box 13466
Phoenix, AZ 85002-3466

RE: Elizabeth Langford
Plan ID #: ——-
Group #:  ——-
Claim #: Multiple
Account#: Multiple

Dear Ms Roberts,

I am writing to you in response to a Level 2 Standard Formal Appeal letter of denial that I received from you on November 24, 2009.  I am requesting a Level 3 External Review by an external IRO as I believe my claims regarding a medically necessary cesarean section that was preformed by Dr. Sara Giali fall within the scope of medical necessity.

I was admitted to the labor and delivery ward of Mercy Gilbert Medical Center on Sunday, August 9, 2009.  It was determined that I was in active labor and after receiving an epidural and reaching full dilation of ten centimeters I began to push.  After pushing for an hour and a half my OBGYN, Dr. Sara Giali recommended that we proceed with a medically necessary cesarean section. Dr. Giali explained to me and three other people in the delivery room that a cesarean section was medically necessary to deliver my baby in order to pre-empt potential damage to the baby or to me.

Dr. Giali indicated that my daughter, Lily was exhibiting non-reassuring fetal heart tones and was failing to descend and that a cesarean section was “medically necessary.”

Dr. Giali performed a medically necessary cesarean section on August 10, 2009, delivering my daughter Lilian Belle Cobo at 5:05 am on Monday, August 10.  I have included the statement of medical necessity from Dr. Giali with this letter along with the doctor’s notes from the labor and delivery.  It is my belief that BCBSAZ should accept Dr. Giali’s professional determination of medical necessity and provide coverage for my cesarean section and related claims.

After my husband and I purchased our policy in May of 2008 the “Complications of Pregnancy” and reasons for cesarean sections to be covered were significantly changed by BCBSAZ.  It is my belief that the narrow parameters for which BCBSAZ will now cover a cesarean section are too limited and not in the best interest of their policy holders.  The new guidelines do not take into account fetal distress and as a parent I cannot imagine what could be more “medically necessary” than to deliver a baby that is experiencing fetal distress and exhibiting non-reassuring fetal heart tones as quickly and safely as possible.

It seems reasonable that a doctor of obstetrics is better qualified than an insurance company to make a decision as to what is or is not “medically necessary.”  In a critical moment when my doctor is providing me with serious medical recommendations my concern and focus should be on what is best for my child and me, not what my insurance company will cover because of terminology or a matter of technicality.  I pay my insurance company for insurance coverage not for medical advice and I was devastated to learn that BCBSAZ had no intention of covering my cesarean section and related claims even though it was clearly medically necessary.

I never had any intention of having a cesarean section.  As our policy with BCBSAZ did not include maternity, my husband and I followed the advice of our insurance broker that sold us BCBSAZ policy and paid up-front, out-of-pocket for all of our pre-natal care, pre-natal ultrasounds and pre-paid our hospital for a vaginal birth, epidural medications and 48 hours of post-partum care.  In total we paid $8,000 out-of-pocket prior to the baby’s delivery in August.  We paid $2,750 for pre-natal care and ultrasounds to Valley Women for Women, $4,250 to Mercy Gilbert for their self-pay pre-paid vaginal delivery package and $1,000 to Mercy Gilbert Medical Center’s contracted anesthesiologist group for an anesthesiologist to administer an epidural during delivery.  My husband and I understood that our plan with BCBSAZ did not cover normal maternity or delivery but believed that in the event we had no other option but to have a cesarean section out of” medical necessity” that our plan would cover the cesarean section and related claims.

Had we wanted a cesarean section we could have requested that our doctor perform one and we would have paid an additional amount of money, approximately $1,000 to Mercy Gilbert Medical Center and would have had a scheduled cesarean section delivery.  We did not pay the additional money because we believed that our plan with BCBSAZ would cover a “medically necessary” cesarean section.  It was only after our delivery that we learned that BCBSAZ did not believe that “non-reassuring fetal heart tones” or fetal distress is a not a complication of pregnancy and does not make a cesarean section “medically necessary.”

My daughter is now a little more than four months old and I am continuing to loose precious time that I should spending with her, because I am instead spending it filing multiple appeals with BCBSAZ and speaking with representatives from Catholic Healthcare West asking them to place a hold on our outstanding accounts.  As a self-employed person my freelance business as a graphic designer and internet marketing manager is now suffering because continuing to file appeals and manage my accounts with the hospital takes valuable time on a weekly basis that I should be spending on earning an income to help with my family’s living expenses.

In denying my claim for a cesarean section that I believe any reasonable person would see as medically necessary to pre-empt serious medical complications and even the possibility of death for my daughter and me, it is my belief that BCBSAZ has acted in bad faith.

It is also my belief that BCBSAZ has not communicated with me in a clear manner.  The denial letter that I received from BCBSAZ dated November 24, 2009 stated in the header that it was addressing “multiple claims” and then noted that it was upholding it’s decision to deny the claims related to a July 24, 2009 OB triage observation services and August 9, 2009 primary cesarean section services. Upon further inspection I found that multiple parties had been carbon copied on the letter including Dr. Quentin Chan the anesthesiologist present during the labor and delivery that administered my epidural and Richard Lease the RNFA present during the cesarean section.  The letter from BCBSAZ indicated that they were upholding the denial of the “August 9, 2009 cesarean section, hospitalization and related services.”

I feel that grouping the other two claims from Dr. Chan and Richard Lease into one denial letter and not clearly designating them apart from the August 9, 2009 primary cesarean section is unfair, unclear and another example of BCBSAZ acting in bad faith.  Had I not identified that these other two claims were being grouped with the cesarean section claim I might have missed my opportunity to appeal those claims within the designed 30 day period.  While I understand that the claims were related, I submitted an individual appeal for each claim that was individually post marked and I believe that BCBSAZ should have extended me the same courtesy.

It is still unclear to me which appeals the letter I received from BCBSAZ dated November 24, 2009 is responding to.  The letter clearly mentions claims for July 24, 2009 and August 9, 2009.  This would lead me to believe that the other claims I appealed have been overturned in my favor.  If however BCBSAZ intended that the letter dated November 24, 2009 be a comprehensive response to all of my appeals I ask that this letter, dated December 17, 2009 act as a request for a comprehensive Level 3 External Review of all my appeals filed with BCBSAZ in 2009.

This review should include an appeal that I submitted to BCBSAZ for a well-woman exam that was performed on December 31, 2008.  My benefit plan clearly covers an annual well woman exam and being pregnant should not negate my right to that exam nor hold BCBSAZ exempt from paying their responsible portion.

I believe that denying my well woman exam claim is another example of BCBSAZ not applying careful consideration to my claims and once again acting in bad faith.

The other appeals that I filed were for claims from pre-term OB Triage visits in July and August of 2009.  As it was my understanding that BCBSAZ would cover a medically necessary cesarean section, it was also my understanding that pre-term labor was considered a complication of pregnancy and would also be covered in the event that I experienced pre-term labor that required medical treatment and observation.

In reference to the cesarean section claim and related claims, my doctor and I acted in my best interest but most importantly my child’s.  My cesarean section was not done out of laziness, a lack of motivation to continue to push, convenience or any other reason besides what was medically necessary to ensure that my daughter was delivered healthy.  It is my belief that any parent would have done the same.

The alternative to having the cesarean section could have been devastating and potentially life threatening to both of us.  What could possibly be more medically necessary than that?  Had I not followed my doctor’s recommendation my daughter could have been born with any number of types of physical and/or neurological damage, resulting in lifelong numerous claims filed with her medical insurer, BCBSAZ.

I am asking BCBSAZ to reverse their previous denials and pay their portion of all of the claims associated with the cesarean section that my doctor performed out of medical necessity on August 10, 2009. In an effort to be absolutely clear about what claims I am appealing I have listed the claim numbers below. Thank you for your time and assistance in this matter.

Sincerely,

Elizabeth Langford

Claim Numbers Being Appealed

1. XXXXXXXXXXX3900 – Provider, Richard A Lease RNFA ($1,725.00)
2. XXXXXXXXXXX2400 – Provider, Mercy Gilbert Medical Center ($17,454.70)
3. XXXXXXXXXXX9600 – Provider, Quentin Chan MD ($3,561.60)
4. XXXXXXXXXXX5300 – Provider, Laboratory Corporation of America ($341.00)
5. XXXXXXXXXXX8100 – Provider, Mercy Gilbert Medical Center ($2,073.98)
6. XXXXXXXXXXX8100 – Provider, Mercy Gilbert Medical Center ($1,531.33)
7. XXXXXXXXXXX8900 – Provider, Chandler Regional Hospital ($3,405.60)
8. XXXXXXXXXXX2000 – Provider, Valley Women for Women ($3,774.00)

Enclosures:

1. Statement of medical necessity for cesarean section from Dr. Sara J. Giali
2. Operative Report from Dr. Sara J. Giali

cc:
Arizona Department of Insurance

Sara J. Giali, D.O.

Mercy Gilbert Medical Center

Denise Belise, M.D.

Richard Lease, RNFA

Mia Van Eken, D.O.

Quentin Chan, M.D.

Heather Wunderle – JDH Insurance

Amy Anderson – Patient Financial Services for Catholic Healthcare West

Michael O. Adkins, MD – At-Large Director of the Arizona Medical Association

Suresh C. Anand, MD – Maricopa Director of the Arizona Medical Association

Dr. John H. Crothers, MD – At-Large Director of the Arizona Medical Association

Howard B. Fleishon, MD – Maricopa Director of the Arizona Medical    Association

Philip E. Keen, MD – At-Large Director of the Arizona Medical Association

Sheldon P. Kottle, MD – Maricopa Director of the Arizona Medical Association

Marilyn K. Laughead, MD – Past President of the Phoenix Obstetrical & Gynecological Society

William R. Martin, III, MD – Maricopa Director of the Arizona Medical Association

Rober Orford, MD – Vice-President of the Arizona Medical Association

Beth A. Purdy, MD – President of the Arizona Medical Association

Carol S. Taylor, MD – At-Large Director of the Arizona Medical Association

A. Judson Tillinghast, MD – Maricopa Director of the Arizona Medical Association

Robert O. Wilson, MD – At-Large Director of the Arizona Medical Association

Kelly Pile – Executive Director of the Phoenix Obstetrical & Gynecological Society

Michael Hibner, MD – President of the Phoenix Obstetrical & Gynecological Society

Gerald F. Joseph Jr, MD – President of the American Congress of Obstetricians and Gynecologists

Congressman Jeff Flake – U.S. Congressman for Arizona’s Sixth District

The Arizona Medical Board

Dr. Douglas D. Lee, M.D. – Arizona Medical Board Chair

Terry Goddard – Arizona Attorney General

Jan Brewer  – Arizona Governor

Todd W. Van Sant – President of the Arizona Insurance Claims Association

Jon Kyl – United States Senator, Arizona

John McCain – United States Senator, Arizona

My husband and I had been married five and a half years ago and had waited to start a family until we were ready to take on the lifestyle and financial changes that come with children.  We are both self-employed and therefore had to purchase our insurance on our own.  In May of 2008 we purchased a PPO policy from Blue Cross Blue Shield of Arizona.  The policy did not include maternity and we understood that if we were to become pregnant we would have to pay out-of-pocket for the cost of pre-natal maternity care and a vaginal delivery.  It was estimated that this would cost around $10,000.  The policy did however cover “emergency cesarean sections”.  If a pregnancy resulted in a medically necessary cesarean section then BCBSAZ would cover the cesarean section and related medical claims.  We purchased the policy knowing that the only reason we would ever have a cesarean section was if it was “medically necessary”.

After owning our policy for less than six months, BCBSAZ changed our policy and their definition of “complications of pregnancy” to cover a narrow list of eight reasons for a “medically necessary” cesarean section.   Unfortunately “fetal distress” is no longer considered to be a “complication of pregnancy” by BCBSAZ and they will not cover a cesarean section even though it is deemed “medically necessary” by an OBGYN.  Sadly, for my husband and I we did not understand this change in our policy.  Like so many other insurance customers, the language and manner in which changes to policy’s are made can be confusing, overwhelming and daunting.

When Lily was born at 5:05 a.m. on Monday, August 10, 2009 she was delivered via a medically necessary cesarean section.  My OBGYN had recommended that Lily be delivered via cesarean in order to avoid potentially devastating medical complications that could occur by continuing to push and attempting to delivery Lily vaginally.  After an hour and a half of pushing Lily was failing to descend and began to exhibit non-reassuring fetal heart tones.  My doctor became concerned because Lily was not “perking up”.  It also seemed that Lily’s head was not going to fit through the birth canal.  The doctor suggested that even if she was able to deliver Lily’s head there was a possibility that Lily’s shoulders would get caught and she could be born with a “bum” arm.  When your doctor tells you your child might be born with a bum arm… or worse, as a parent your first instinct is to do whatever is necessary to protect your child.  My husband and I had agreed that we would follow our doctor’s recommendations and when she advised us that a cesarean section was medically necessary to ensure Lily’s health, and my own, we followed her directions.

Several weeks after Lily was born I received our first “Explanation of Benefits” statement from Blue Cross Blue Shield that stated that the patient owes the provider $17,454.70.  The reason given was that “THIS SERVICE IS NOT A BENEFIT OF YOUR BENEFITS PLAN.  PLEASE REFER TO OUR BENEFIT PLAN BOOKLET UNDER “WHAT IS NOT COVERED” FOR ADDITIONAL INFORMATION.”  After the initial shock of seeing the amount, I immediately thought it was all a big misunderstanding.  My policy covered “medically necessary” cesarean sections.  What I would find out later was that BCBSAZ no longer considered fetal distress as a complication of pregnancy and had no intention of covering any of the costs related to my cesarean section.

In total, my husband and I have approximately $31,000 in outstanding bills with our hospital.  The bills include the cesarean section as well as a handful of OB Triage visits (some that were pre-term and I believe also should be covered by BCBSAZ).  Up to this point, the hospital has been very reasonable in granting “holds” on our account while we pursue the appeals process with BCBSAZ.  $31,000 is a devastating amount of money to my husband and I when you consider that we already paid $8,000 out-of-pocket to cover my pre-natal care and Lily’s birth.  We followed all of the recommendations of our insurance broker and we paid out-of-pocket,up front, in full and early for all of my maternity care and delivery.  Now due to a narrow definition that seems to be solely motivated by money, our family finds ourself in a situation that we believe no parent and no patient should find themselves in.

I have now spent countless hours on the appeal process only to be denied at every level.  While my husband and I cannot afford an attorney to fight on our behalf we have instead chosen to share our story with the public.  We know that we are not alone in this situation.  We know that other patients have found themselves with overwhelming hospital bills and the daunting task of fighting their insurance companies over technicalities.  Our hope in sharing our story is that we can create a collective voice and let large insurance companies like Blue Cross Blue Shield and our elected officials know it’s time for health insurance to change.