A medical-insurance victory.

Health and medicine explained.
Jan. 24 2006 7:15 AM

Congratulations, You've Been Upgraded

What I learned from my medical-insurance victory.

Illustration by Robert Neubecker.
Click image to expand.

Last August, I wrote for Slate about my health-insurance troubles. Six months after seeing a psychiatrist once for postpartum depression, I looked for a new health insurer because I was self-employed and my husband had left his job to start his own business. Initially rejected by Anthem Blue Cross and Blue Shield of Virginia, I was eventually accepted at Level 4, the insurer's worst rating, for a monthly premium of $730.

A week after my Slate piece ran, Lora Lee Hart, director of Anthem's underwriting operations, called to say that she would personally review my case. (Anthem advertises on Slate.) Though grateful for her help, I figured her call wasn't likely to yield much, since my previous two appeals to Anthem had produced only form-letter rejections, and I had no new arguments to make.

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To my surprise, however, Hart retroactively upgraded my rating, citing two errors in the handling of my application. The first she attributed to the psychiatrist I saw, who wrote on my health form International Classification of Diseases code 296.20—a number that corresponds to Major Depressive Disorder according to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. Anthem's underwriters committed the second mistake, she said, by treating my diagnosis as definitive, when a single appointment with no follow-up should have been regarded as a "working diagnosis." Hart said that as a result of the psychiatric appointment, my insurance rating should have been Level 2, not Level 4. And I should have been restored to Level 1 after a year with no further treatment for depression. In December, I received a refund check from Anthem of more than $2,500 for 12 months of overpaying. And my premium is now $189 a month.

The lesson of all of this? When you see a doctor or take a prescription medication, you may be minding your health; you may also be doing yourself out of affordable health coverage should you have to change insurers later. Then again, maybe you won't. It apparently depends on when you seek treatment, what numeric codes are scribbled down on health forms, how individual underwriters interpret diagnoses, and maybe even whether or not you write about your experience in a magazine. Anthem and other insurance companies don't fully disclose the underwriting guidelines behind their decisions to reject, accept, and rate people for coverage. Hart wasn't available for comment when I contacted her about this article. An Anthem spokesperson said, "We regret any inconvenience caused by the handling of this specific situation and we are happy and hopeful it has been resolved to the member's satisfaction."

Pregnant and postpartum women everywhere, here's some admittedly anecdotal advice about taking care of yourself if you're feeling lost or hopeless. It's based on my experience and those of others I've heard from since I had PPD:

1. Get help. But first read 2-6.

2. Don't delay. Tell your OB/GYN promptly if you feel depressed. For six to eight weeks after delivery, appointments related to treating PPD are typically included in the "universal fee" your obstetrician charges for prenatal care, delivery, and postpartum follow-up. If a patient's symptoms are not severe, a PPD diagnosis made within this time period is considered a medical postpartum complication. That means it's given the code 648.44, and usually no separate claim is made to an insurer. An OB/GYN can prescribe antidepressant medication and continue treatment for up to a year. But if patients approach them more than six to eight weeks after delivery, OB/GYNs generally refer them to primary care physicians or mental health professionals. These doctors and counselors typically file behavioral health claims to insurers for PPD diagnosis and treatment. And they use DSM-IV codes like 296.20, the one that started my troubles. Behavioral health claims seem to be alarm bells for insurers and can destroy access to affordable health coverage for years.

3. Psychiatrists bad. Counselors less bad. At least this appears to be what health insurers think. If talking things out is a better choice for you than medication, ask your OB/GYN to refer you to a psychiatrist or counselor who specializes in PPD. In an ideal world, he or she would be in the same practice as your doctor. But the odds are that even if you obey the six-to-eight-week rule, for talk therapy you'll be referred outside the office and end up with a behavioral health claim. Keep in mind that counselors and social workers seem to be less threatening to insurance companies than psychiatrists do. At the same time, only a psychiatrist can prescribe medication should you need it as part of your treatment.

4. Know the code. At the end of your appointment with your therapist, look at the number on the form she hands you. Depending on your symptoms and her coding habits, you could be deemed anything from 296.20, Major Depressive Disorder (very scary to insurers!), to 309.24, Adjustment Disorder with Anxiety (not as scary). Don't leave the office until you understand what diagnosis your number corresponds to—not to challenge the judgment of the person treating you but so you can decide how best to proceed.

5. Document everything. Keep all forms related to your appointments and prescriptions. Take detailed notes when you call health-care providers and insurers, who will probably be recording you. Insist that important information be backed up in writing. Get a fatty file from an office supply store to organize your medical paperwork; there will be a lot of it. Even with Hart herself overseeing my account, Anthem still misidentified my health plan, overbilled my family, and canceled my maternity coverage for my current pregnancy. Only my compulsive documentation saved me from this incompetence.

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