I just got a claim statement from Blue Shield, my insurance carrier. They are telling me that my emergency room visit back in September is not covered because
MY BLADDER WAS PROTRUDING OUT OF MY BODY! Are they telling me I should have known that wasn’t a big deal??
Sure, now I know it’s not too unusual for a woman post-partum to have some sort of pelvic prolapse. But an internal organ going external seems pretty worrisome to me, and it certainly was beyond my realm of experience. And, when I called my OB, they said to come in the next day OR go to the ER if it gets worse or if I otherwise I feel it’s necessary. Um…being able to see my bladder ought to be reason, right??
Fuck. Do I have any recourse in this? Is there any hope whatsoever of me convincing them that it seemed like a worthy reason? Or shall I just suck up the $415??
You should fight it. All decisions are made by individuals, and you have a different chance every time you ask someone new. It’s like the decisions of the Supreme Court. 5 to 4 may go against you, but if you appeal and a new judge it sitting that year it becomes 4 to 5 and you win.
I’ve been told that it’s SOP to deny coverage for everything possible at first. Call them up and say that you are calling to appeal a decision. Then be very specific - “Are you saying the fact that my bladder was hanging out of my vagina was not an emergency?”
I wouldn’t pay it quite yet.
Good luck. And sorry about the vajayjay problems.
Sometimes, the insurance monkeys are none too bright, or they’re stuck trying to figure out where the “line” is. They pulled this on me regarding anaphylactic shock last spring.
<mild rant>
I went in to the urgent care clinic, was put in critical 1 exam room (O2 sat? Whazzat? BP? Baaaah, who needs it!), treated, but the clinic was closing, so they transferred me to the ER down the street for observation. That’s only an Emergent transport… but the Urgent Care clinic couldn’t in all good conscience send me home when I was risking relapse and, well, death.
Now, you’d think that BCBS would be pleased that I sought treatment from Urgent Care rather than the ER originally! Cheaper for them!
But nooooo… they were willing to take the Urgent Care bill, but not the ER or the transport. Like I had any choice in the matter - the docs had to transfer me, it wasn’t like I could just walk myself to the ER with an IV in my hand (ow, motherfucker!), full of epinephrine and benedryl, wheezing like a tea-kettle.
</mild rant>
Fight it. You’ll win.
Oh God… Another time I am so happy I’m not a woman (sorry). I definately agree with everyone saying you should fight this. I have no idea how to fight this, but if my bladder leaked out of my penis, I would never wait for an appointment.
What does your insurance think you should have done - poked it back in yourself and applied copious amounts of duct tape? I think that will be one of my cardinal rules of medical care in the future, too - internal organs come out, I’m going to emergency. Period.
Since you say it’s Blue Shield, you definitely have recourse. Specifically, there’s an appeal process that is probably explained somewhere on your Explanation of Benefits form. You basically write a letter explaining why you think it should have been covered. Getting a letter from your OB saying it was an emergency would be an excellent thing to include as well. You should also contact the hospital billing department and tell them you’re appealing the insurance company decision. Then they’ll hold off on billing you directly for the ER charges until the appeal is complete.
Nitpick: technically, it was hanging out of her urethra, not her vagina.
Jesus Christ, if that happened to me, even if THAT wasn’t an emergency, I’d probably have to go to the ER anyways, after I cracked my skull on something, right after I fainted.
Definitely appeal. There should be a standard form or number to call on your bill that tells you how to appeal a denial. Then they will have you fill out a bazillion forms and send them in. It sounds like you got rubberstamped with a rejection and hopefully once a person actually takes 2 seconds to look at your claim they will see that it was an emergency.
I also want to say that now that I went back and read your first thread I have started doing Kegels and never plan to stop. I am going to buy a Kegelsizer like Amy has in Futurama. Oh lordy the kegels I will do. Yep.
(almost too afraid to ask, and maybe some of the links answer this but I am too scared to click on them, but in the case of the falling out uterus, how does it get past the cervix? I am already regretting asking this question but here I go clicking “post” and hoping for the best…)
The hospital billing department may even be able to help.
I’ve had a case where they’ve said “well, lets recode it” - they resubmit and it gets paid. Or maybe they called up and yelled at insurance for me. All I know is it got paid and I didn’t do a darn thing with my insurance company.
In insurance they tend to deny anything that sounds the least bit fishy to them or that wasn’t documented properly, etc. If you follow their procedure to appeal their denial and possibly have the hospital follow up it should be taken care of for you. I am in insurance (though it is auto insurance which is a little different) and I can’t tell you how many times we have had people file claims for $70,000 for a 2 mile and hour, slight rear end in a parking lot. Insurance companies are trying to protect themselves from fraud to prevent having to increase premiums. Unfortunately due to the way things work in the US with no standardized health care, insurance is really your only option and it often isn’t a very good option. Insurance is essentially gambling and we all know that the only rule in gambling is that the house always wins.
