Thursday, February 12, 2015

Insurance and co-payments and deductibles, oh my...

I love these lips!

First, the good news is that our pediatrician submitted for synagis (RSV vaccine-technically not vaccine, more antibodies to RSV) even though the hospital told us Brooks doesn't qualify because of new guidelines, but he got approved! They approved 2 doses for February and March. I think I mentioned before that RSV would be like a common cold in an adult or older child, like Brennan, but it could be deadly for Brooks. He could very well end up back on a ventilator or worse, not survive the virus. We are taking every measure to keep him away from it (among everything else), Brennan did not come close to him when he was sick before and even now he doesn't get in his face. We wash our hands really well, we don't take him in public. Renee is babysitting him for the first few months until he gets bigger so he doesn't have to be exposed to any kids, but it will still be nice for him to have the synagis, just in case. It doesn't necessarily keep him from getting RSV, but if he does get it, it should lessen the severity.

I knew it would be expensive because Brennan got synagis. At that time, 7 years ago, it was $1,500/dose and they are supposed to get it every month through RSV season (September-March). We got the letter in the mail about the approval so I texted our home health nurse this morning to see if she would come to our house to give it. Then a little bit later the specialty pharmacy happened to call with all of the info. So far, nothing has been billed to our insurance for the 6 days Brooks was in the hospital this year so we haven't paid any deductibles/out of pocket for this year. So we first had to meet our out of pocket and then the insurance is only paying 80% and we would be responsible for 20%. That brought us to a grand total of $1,700 for one dose-out of pocket. She said the drug company has a co-payment program so she checked to see if we qualify and we do! I didn't even know about this, but apparently alot of very expensive medications have these programs, it never hurts to ask. You can't get any aid from the state and we don't so that helped us. But basically, the drug company (for this particular medication) pays $2,000/season for the medication and all we have to pay is $30. Now after this dose there will only be $300 left for the next dose so I don't know what that dose will cost, but at least for now we are only paying $30. AND that $2,000 they are paying is paying for our out of pocket from the insurance, which is a bonus. Another bonus it that our nurse is going to come to the house to give the injection {boo for a shot:( } but we get a weight sooner than we thought we would. I'm not sure when she is coming yet, but I will update his weight as soon as I know! I'm guessing around 8lbs:)

I wanted to write about my insurance/claims experiences for this pregnancy/delivery/NICU stay in case this can help anyone. It seems like every year we fork out a ton of money for medical expenses...all being from me. I don't have an chronic conditions per say, but I have had 3 difficult pregnancies, a miscarriage requiring a D&C, appendectomy, hip replacement, IVF, I have a blood count disorder that required a bone marrow biopsy at one point. So any random, weird thing you can think of, it would probably happen to me. 

Medical care is soooo expensive. I work in healthcare and it is still outrageous for me and for not that great of coverage. I work part time so my benefits are more expensive to begin with. I was on Casey's insurance, but when I found out I was pregnant and still in the enrollment period for my job, I got my benefits because I work for the health care system I knew I would use throughout my pregnancy. If anyone has worked for a health care system, then you know you get better coverage if you use their facilities. So when I signed up, I thought all I would pay was $1,000 for pregnancy/delivery. Welp, that turned into $2,000 because while the out of pocket for the facility I was using was $1,000, the physician out of pocket maximum was $2,000 and I saw my physician ALOT. Probably close to 30 times during my pregnancy. So $1,000 turned into $2,000. Then I added Brooks to my policy because I knew he would be in the health care system I work for. So I thought we would be considered  a family plan and then would only have to pay an additional $1,000 for him (totaling $3,000 for family). Oh no, he was a separate individual so it was another $2,000. yay. 

So the bills start coming in and I paid for my doctor office bills throughout my pregnancy, but once I finally got the answer on the $1,000 vs $2,000 out of pocket I started adding every single EOB (explanation of benefits). The EOB comes from the insurance and tells you in detail what the insurance is paying, what the company that is billing is writing off (usually due to a contractual agreement) and what you owe. So I added up everything billed by my doctor, labs, facilities, etc. One bill was never submitted for $255. I also had to take an ambulance from one hospital to another before I delivered so I got an additional $400 bill for that after my insurance paid even though my EOB said I only owed $50. So I printed my EOB and highlighted where it showed the $50 co-payment and sent my $50. Well, I got a letter saying they aren't contracted with my insurance and that I owe the remaining balance. I didn't pick the ambulance company so I shouldn't be responsible! I called them and they said I could call the insurance to appeal it so I did. They told me I did not have to worry about paying that part and they would work something out with them. So I'm glad I didn't just pay the bill! I'm sure in the past I have paid something like that not paying attention! So another way I saved money is I noticed on one of the bills that it said we may qualify for a discount if we pay our bill in full so I inquired. Sure enough, we got $400 knocked off of Brooks $2,000 bill. The bill that didn't offer a discount, I set up a payment plan.

So, next we got another $1,100 bill for Brooks. We switched insurances to Casey's plan this year so we're all on one now and I thought the bill was for the 6 days this year that Brooks was in the hospital on our new insurance. Nope, they had billed our new insurance for one day in December (and since that was the only claim, our deductible/out of pocket kicked in, that's why it was so much). Our new insurance should have pushed it back, but they paid it so they didn't question that it should have been billed to my insurance from last year. I called on that one today and they are resubmitting the claim to my previous insurance so that should be covered. I still haven't gotten the bill from the 6 days he was in this year. My friend said her doctor office offered a discount on her bills for office visits, but mine didn't-worth checking into though!

Obviously, he is worth every penny in the whole world, but my point is pay attention to everything you are billed!

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