Expectant parents have enough to worry about. The list of tasks is endless.
Between the doctors’ appointments, the shopping, the nesting, the psychological preparations, the arrangements for parental leave — there’s not a lot of spare room in the minds of parents-to-be.
Which is why one crucial concern might slip past their notice: insurance paperwork.
And that can be costly. Just ask Scott Craig and his wife, Samitha Hendrickson.
Last February in Tacoma, Washington, Samitha and Scott welcomed their son Haroun into the world. They were thrilled to start their family, but it wasn’t an easy delivery.
Samitha experienced serious complications. She needed an emergency C-section, and when Haroun was born, he couldn’t breathe on his own. He had to spend two days on a ventilator in the neonatal intensive care unit (NICU).
When Samitha and Scott were finally able to bring their Haroun home, they got the hospital bill. They were shocked to find that, while Samitha’s care was covered by their insurance, Haroun’s was not.
And the price for it came to $27,411.81.
This is a nightmare scenario for most parents. Who can afford a bill like that?
To this day, Samitha and Scott are still working with CoPatient to fight the charges.
They want to share what they’ve learned so that other couples don’t have to go through the same thing.
Lesson #1 - Even if you have insurance, don’t assume the baby will be covered
Scott and Samitha were both covered under an Anthem Blue Cross Blue Shield plan from Scott’s employer. They expected the coverage to extend to Haroun once he was born.
Just common sense, right?
Under many insurance plans, that’s exactly what would have happened. Scott and Samitha felt extra safe in Washington state, where a law called the Erin Act says that newborn babies are automatically enrolled under their mother’s insurance plan for the first 21 days of their life.
But Scott’s Anthem plan was different. It was an employer-sponsored plan. So that meant Haroun’s insurance coverage wasn’t bound by Washington state’s requirements.
Instead, Scott’s plan is governed by ERISA, law that regulates employer benefits. (ERISA was passed in 1974 — it hasn’t quite caught up with the times.)
Under ERISA, when employers pay the healthcare bills, they don’t necessarily have to provide newborn coverage. This gave Scott’s plan a loophole just wide enough to jump through — and saddled Scott and Samitha with an enormous bill.
Remember: Even if you get your insurance from your company, your plan will try to avoid any unnecessary expense. This means denying claims, if the law allows. Make sure you understand what the law says about your plan.
Talk to your HR representative at work, or, talk to your plan administrator, to make sure you know exactly what’s covered, and what isn’t.
Lesson #2 – Often, newborn coverage isn’t automatic!
ERISA struck again when Scott and Samitha tried to get coverage for Haroun after the delivery.
Remember, they thought Haroun was already covered, under Washington state law. But buried in the policies and procedures for Scott’s health plan was a requirement: to get coverage for Haroun, they were supposed to file his enrollment paperwork within 30 days of his birth.
By the time they discovered this requirement, and the hospital bills started rolling in, it was already too late. The 30-day window was up.
“Not one of our providers or billing agencies advised us that we needed to get Haroun enrolled as soon as possible,” Samitha said.
Even if they had gotten reminders, such concerns were probably the furthest thing from their mind after their traumatic episode in the hospital.
As Scott and Samitha learned, bureaucracies are unforgiving. The whole incident is a frightening reminder of how important it is to dot your “i”s and cross your “t”s.
It’s down to individual patients not to give their insurance any excuse to deny their coverage. This means they have to know the letter of the law — and their insurance provider’s policies.
Remember: Every insurance plan has their own process for newborn enrollment.
To make it even more confusing, requirements also vary between US states. (As in Washington, where enrollment is automatic for the first 21 days of a child’s life.)
Private health insurance typically gives couples 30 days to enroll their child. Obamacare marketplace plans give parents 60 days.
Employer-sponsored plans are all over the map. Each company has their own policies.
This is why, well before your due date, you should make sure you speak with your HR department or your plan administrator, and ask: ‘What do I need to do to get my child covered?’ Document the conversation, and do what they say. The diligence will pay off.
Lesson #3 - Shop carefully for providers
Scott and Samitha tried one more tactic to get coverage for Haroun: buying a new insurance plan on the Washington state insurance marketplace.
They were delighted to find that the plan would cover Haroun’s care, retroactively.
Or at least it would have. If the hospital had been in-network.
Their new insurance plan reported that they were going to deny Haroun’s claim, too. They said that Haroun’s hospital didn’t fall into their network of providers.
Network woes will be familiar to a lot of healthcare customers. In Scott and Samitha’s case, there’s not much they can do about it — the care was already delivered.
But for expectant parents it’s not too late. They can shop around for a hospital that both provides the care they need and that falls under their insurance plan.
Remember: Out-of-network care is outrageously expensive, and it’s not always clear who’s in your network, and who’s not.
So, contact your health provider to get a list of eligible hospitals. Then, contact your hospital of choice and confirm that your baby’s care will be covered.
Lesson #4 - The system is confusing. Get someone in your corner.
Behind all this, it’s important to remember that Scott and Samitha want to pay for Haroun’s care.
“They took good care of our baby,” Scott said. “And I want to pay for that. But all I want is to pay a price that’s fair.”
Few would call $27,000 a fair thing to ask of young parents. So after all their insurance gymnastics, they tried to challenge the bill itself.
They tried negotiating with the hospital. No luck. The hospital insisted that Haroun’s care was a “flat, non-negotiable rate.”
They tried appealing to the insurance company. Same thing. It wasn’t budging.
In both cases, Scott was bewildered by the bureaucratic hang-ups.
“The story kept changing when I talked to the insurance people,” he said. “Every phone call was to a new person, who needed a new set of forms. And talking to the hospital, just getting our records out of there, was just as hard. If not harder.”
This is distressingly common. The machinery of healthcare documentation is complicated, and it moves slow. It can be impossible to navigate for people on the outside.
That’s why Scott and Samitha turned to CoPatient.
CoPatient’s expert advocate, Mindy Buss, has taken on their case, and taken their side in the fight — so they can focus on taking care of their new baby.
Mindy has been tirelessly organizing, advocating, and documenting the back-and-forth between insurance company and healthcare provider. With luck, she’ll succeed in securing a settlement, or winning an appeal.
Remember: If you don’t understand your bills — or if you don’t agree with them — don’t pay them!
Contact a billing advocate like CoPatient first. They can help you understand your bill and show you opportunities to save. You may be able to reduce your out-of-pocket expense, in some cases to just a fraction of what you would have paid.
You’re right to fight unfair medical bills. But you don’t have to fight them alone. If you’re facing a sky-high bill, reach out to CoPatient today.
See press coverage of this story on healthline.com.