[insurance] $4000 medical bill because giving birth is "not a medical necessity" ?!

[u/uhcsucks]

Hi PF,

Long time lurker, first time poster. Here's a question - whats the best way to argue with a crappy insurance company about something they chose not to cover?

My wife just gave birth to a healthy baby 6 weeks ago. During that time we were covered under an ACA Silver plan (I got laid off and had to scramble, I got a new job and now we're under that insurance). This is our 3rd child, and the first 2 were C-sections (both C-sections were unplanned, but the circumstances forced the doctor and my wife to make those decisions ). My wife was able to successfully have a normal delivery this time (VBAC). Now we got the bill from the doctors office and on it is $3,947 for the delivery and insurance is not covering any of that. The note says "PR50: These are non-covered services because this is not deemed a 'medical necessity' by the payer."

What did the insurance want my wife to do, hold the baby in?!

Any help would be much appreciated.

Edit: Here's the codes on the bill - 654.21, 650, V27.0, V22.22

Edit 2: Thank you very much for all of your advice, PF! My wife spoke to the billing person at the doctors office and even they agreed that it's not correct, and the billing person will look into it and get back to us soon. Thank you so much to all the helpful people.

[u/atm5426 → u/[deleted]]

I'm a coder and I barely understand sometimes. It's a confusing business, but bottom line, icd-9= old billing method icd-10= new required method. The codes are more specific, but it's kind of appalling someone got billed by old, incorrect codes.

[u/too_too2 → u/atm5426]

I was always under the impression that if it was coded wrong and therefore instance didn't pay, the hospital had to eat hat cost because it's their coder's mistake. And I also find it sorta crazy that they could still be using ICD-9 codes. My workplace made sure everyone was aware of this hangs and what it meant even for non coders like myself.

[u/toiletpaper_monster → u/too_too2]

If it's coded wrong you can usually resubmit with the corrected codes. Our policy is that if it's coded wrong and it's past the timely filing deadline, we eat the cost.