After winning a months-long insurance battle after their first child was born, Stephen and Eileen Lombardi thought they knew how to prepare for their second child. They used the same hospital as before, Inova Fair Oaks, and the same insurer, Blue Cross Blue Shield. When daughter Emily was born in April, the parents expected the same result -- full coverage -- and maybe even an easier trip through the paperwork maze.
Two years ago, the Lombardis were surprised to receive bills for about $700 from Fairfax Neonatal Associates, a specialty group that helps staff the hospital. While Fair Oaks belonged to the Blue Cross network, this group did not. Trigon, the administrator of the Lombardis' Blue Cross plan for federal workers, eventually agreed to pay the bills for that birth "on an exception basis."
In a letter reversing its denial of coverage, the company even "apologize[d] . . . for any inconvenience."
That was so 2002.
In April, when Eileen Lombardi gave birth again, a neonatologist from the specialty group "was present in the room," she said -- a precaution that generated a charge of $474. Just as before, Fairfax Neonatal was not participating in the Blue Cross network, so the family got a bill for $474.
No problem, right? Same situation, same specialists, even the same mom.
Well, something had changed. The insurer -- Anthem, which acquired Trigon about two years ago -- is refusing to cover the bill.
"While we did make an exception in 2002," Anthem said in its denial letters, "you were advised that this was an exception." As another letter put it, "this was not a guarantee of future benefits."
Why not make an exception again?
"For well over a year," said Jane Pratt, an Anthem spokeswoman, the insurer has sent letters to members who are planning to deliver babies at Fair Oaks, warning them that the neonatologists there were not in the Anthem network and that "therefore, if your newborn requires the services of these specialists . . . your out-of-pocket expenses could be higher than if these physicians participated." (Officials at Fairfax Neonatal did not respond to calls seeking comment.)
"They had information given to them," Pratt said. "We did everything could to alert them."
"I know that we didn't get that letter," said Lombardi. "We'll see what happens" when the Office of Personnel Management considers their appeal.
Should the family need a neonatologist a third time, the insurance process may finally go smoothly: Pratt said Fairfax Neonatal now has a contract with Anthem. It took effect four days after Emily Lombardi was born.
-- Tom Graham
The System welcomes comments from patients, providers, insurers and others about the delivery of health care. While we cannot advocate on behalf of individuals, we are looking for examples of problems and solutions that may direct our reporting. Contact us by U.S. Mail at the address that appears below or by e-mail at firstname.lastname@example.org. Do not send original documents.