Can I somehow convince my HMO that I want to have my baby in a hospital *I* choose?

Factual Questions
1

I had my son at a local community hospital back in 2006, and it was a wonderful experience. Also, checking multiple hospital-grading websites (Consumer Reports recently featured hospitals and listed websites to use for checking hospital ratings and statistics), it turns out it’s the highest rated hospital in my area. Problem is, my insurance carrier dropped it from their plan in 2008.

I went from having three choices of hospitals to deliver in three years ago to now just one. This one that remains has the worst rating on all of these independent sites. FWIW, I’ve been there for back surgery and had a very positive experience, and I checked out their maternity ward when they did their open house while preggo with #1, and I had no complaints*. (Anecdotally, a friend who gave birth there hated her experience.) It seemed okay to me, but honestly, all things being equal (and apparently by ratings, they aren’t), I’d rather go to the community hospital.

The community hospital is served by my OB’s medical office, so it wouldn’t be a problem with them.

Do I have any recourse, or am I just stuck with the only choice my insurance has given me?

*Hubby has major complaints about how I was admitted for the back surgery. During pre-admission they said they would have a gurney for me when I arrived, as I couldn’t walk or sit, but then when I actually arrived they wouldn’t get one for me until I collapsed in pain and broke down sobbing…but once I was in, it was smooth and overall a very positive experience.

2

If the hospital is not contracted by the HMO then your answer is 99.99999999% no. Insurers can always make exceptions to their policies. But they don’t have to.

3

Write the insurance carrier a request for a variance to use that hospital.

And oddly enough, the hospital may have severed relations with the insurance company over payment issues, not the insurance company 'firing; the hospital…

4

Well, you can always pay the bill out of your pocket instead of having your insurance pay it. But if want insurance to cover it, you have to work within their rules.

5

If you were already pregnant when they made the change (seems just barely possible if they dropped at the end of 2008) there is a slight chance you may be grandfathered. This is done for pregnancies sometimes when providers are dropped from HMOs. The thinking is the benefits of continuity of care outweigh the billing differences.

Other than that, you can ask but it is unlikely.

6

It’s a crappy system, but it’s a system nonetheless. For most of them, it’s a “my way or the highway” kind of system.

7

If the hospital does emergency deliveries you could always wait till your contractions are just a few min apart and “not make it” to the preselected hospital. Many such insurance plans are required to cover such things under emergency circumstances. If you come in as an imminent delivery they will have to take you. Of course your doc will not be there, they will not have any preadmission info, and you will not have any fetal monitoring etc making it possible your baby can be in distress and need to be sectioned immediately but you would not know it.

8

Most insurance plans have exceptions for ‘emergency’ situations (usually required by state law).

So if you happened to be on the side of town nearest the community hospital (or even visiting a patient there) when you suddenly went into labor … well, that might make a good case for an exception.

You might have to call your insurance company from the labor room, but it might be rather hard for them to at that point to say that you have to be moved to the other hospital. Just the cost of an ambulance ride might make it too expensive for them. (And if they did demand you be moved while in labor, I’d complain to your state’s Commissioner of Insurance. And the newspapers.)

9

This probably doesn’t relate to your specific situation, but people who are reading it might find it helpful - I’m not pregnant, but after I saw a documentary lately I looked into the available local options, you know, just to find out. And the local birth center points out that a birth there that you totally pay for yourself is often, even usually, cheaper than your copay and deductable for a hospital birth.

10

Hmm, that would work OK unless the ER sends you to labor & delivery directly. Then it’s an out of network hospital admit, not an inexpensive proposition for an HMO. I guess you have to cross your fingers and hope the ER does the admission and not L&D.

11

Couple of questions: Does your OB-GYN have privileges at the hospital you want? The insurance company might be willing to be flexible if the request comes from your M.D.

Does your insurance coverage come from a source that permits an annual open enrollment period? I have no way of knowing if it might be so, but I have the sense that the prospect of losing your premiums to a competitor might be a motivator for your insurer to find flexibility.

When are you due? And is your son excited about becoming a big brother? :slight_smile:

JFTR, health insurance carriers in California are regulated by the Department of Corporations, not the Insurance Commissioner.

12

To those who’ve suggested “going into labor” too close to the community hospital and too far from the in-network one… I seem to recall that Ruffian is considing a scheduled C-section due to back issues etc. so that wouldn’t work. Similarly paying out of pocket at the desired location might be prohibitive due to surgery.

And from things others have said in other threads, some insurers don’t care about it being an emergency (bastards).

Does your insurance have an out-of-network option where you take on a larger hit but they pay something? If so, that might be an option if you can afford it.

Can your OB make a case that because of your back issues and how they were handled (or not) at the in-network hospital, you need an exception? This might be a lengthy process and I don’t recall how far you are along.

13

Sigh… shoulda re-read the OP. Judging by your comments about the back surgery, that option (“can’t handle her unique requirements”) might not fly.

Some devil’s advocate comments: Since you’d have the same OB-GYN (or at least the same practice) that might override some of the negatives about the HMO-approved hospital.

Plus: My first child was born in the biggest maternity hospital in the area. Supposedly the best. My experience was a nightmare of bad care, poor communication, pain and terror. I have one friend whose baby nearly died because of the “care” at that hospital, and another who nearly died herself because they ignored something.

So, ratings aren’t everything.

Needless to say, my second child was born at the other hospital (the one the first was supposed to be born at). To this day I regret that I didn’t show up at hospital 2 and claim I’d had no prenatal care; I truly believe the care would have been better. Oh, and I regret I only hit the OB once, and I regret I didn’t hit the anesthesiologist at all.

14

I’d be really surprised if this were the case with an HMO. The HMOs I’m familiar with market very low costs for the pregnancy/ childbirth process. The HMO model is all about preventive care and planning ahead and working with a network, and sometimes results in “free” or $25 babies. Now, it might be the case with some kinds of high-deductible or 80/20 plans.

Aside from the fact that this may be a planned C-section, the HMO is likely to resist the “emergency” birth at the other hospital, unless it is truly a crisis labor, struck down with emergency abnormal bleeding or something. They often have wording in the policy making it clear they won’t pay if you travel within the last couple of months of pregnancy, to make sure you are able to get to the network hospital when the time comes. Experiencing normal labor on the other side of town probably isn’t going to be considered an emergency.

15

Thanks for the input, folks. The “Ooops, lookit this, I’m in labor!” technique won’t fly, for two reasons: 1) I’m pretty certain I should have a scheduled C-section, and 2) the community hospital and the HMO-approved hospital are essentially equidistant from my home. I can just as easily go to one as the other.

Harriet the Spy, you are correct–by staying within the network, we will not pay a dime; that was the case with our son. I don’t even have a copay for my routine OB appointments (any and every other appointment does require a copay).

Well, phoo. FWIW, I don’t particularly mind this hospital (except the eyebrow-raising ratings); it was my close second choice back when I had a choice of three hospitals for delivery.

kaylasdad, I’m due January 2, and my son is ecstatic about being a big brother. He talks about the baby all the time–heh, when we dropped him off at his preschool this morning, the teacher told us, “He talks about the baby allllll the time!” And now we know it’s another little boy, so he’s excited about having a baby brother. He now insists on kissing my belly and hugging it goodnight at bedtime, saying, “Goodnight broder!”

Mama Zappa, I do have a doctor within the same medical group, but that’s no guarantee of experience, either. I went into labor with my son when my regular OB was on vacation, and then my labor progressed so quickly (after a long early labor–once my water broke, it went from going 20mph to “Get your catcher’s mitt!”) the OB on call couldn’t get to the hospital in time. The nurses reluctantly delivered him (after trying to get me to hold him in–yeah RIGHT), and when the OB showed up, he was pissy, presumably that I didn’t wait for him. He barked at the nurses and gave me hardly a glance (well, in the eyes). Hubby did NOT like him at ALL, and I wasn’t thrilled with him, either. Made us glad the nurses delivered.

I might give my HMO and/or the hospital a call jussssssssssst in case, but I’m not holding my breath. While the only option doesn’t appear to be awful, having more than one would’ve been nice.

16

No advice on the HMO front, but if you need to schedule a C-section anyway, try to have it done in December. You get a nice tax break that way.

17

Wow, I’ve never had a “free baby” or even a $25 baby. My insurance always had a copay of at least $500 for an inpatient hospital stay, which is what delivering a baby is considered.

18

muldoonthief, this baby will come in December whether I go for the (likely) C-section or not. My son was 3 weeks early and 7lbs 11oz, and my sisters all delivered their kiddos by 38 weeks (37 is the average). If the doc tries to wait longer than 37, he risks the kiddo coming on his own, and in a hurry. Many (including my doc) have told me a second baby will come earlier, and come faster–if that’s true, I may end up one of those ladies on the news whose 3yro son calls 911 because Mommy just had a baby on the kitchen floor.

I’m guessing second week in December for this little man.

19

There exist plans that don’t have copays for inpatient hospital in general, on the premise that if you need to go inpatient, you probably didn’t have much choice, and plans that set specific terms for delivering babies, as a marketing move + incentive to good prenatal care and delivery planning. Now, those same HMOs may be the ones who get moms in and out so fast it barely *qualifies *as an inpatient stay …

Or did you get one of those fancy, gold-plated babies :)?

20

Gee, it’s almost like they have a “birth panel”.

Does Sarah Palin know about this?