Well, that was interesting. I just got back from my meeting with the Blue Shield grievance panel in LA. for my
2nd level appeal. The incredibly rude grumpy receptionist called up to tell our panel that we were there then she made
us nametags. We were early and had to wait in the giant lobby with no chairs or stools. Remember, I am now 5 months pregnant
and I have sciatica. I was about to sit on a giant potted plants pot rim when my case manager Lisa came down and got us.
In the elevator she told me that she had done some research and had come up with an IPA in my area that did employ midwives.
I was stunned and told her thanks, she had succeeded where others had failed. but the problem was those midwives only did
I had been told that there would be 5 people on the panel and that they would give me about 15 minutes
and then each would have a vote in the decision making process (not in my presence, of course). My husband and
I showed up to find at least 8 people around a table and 2 more on SPEAKERPHONE! One was Dr. Fass, the doctor that had
denied my first appeal. (I had been told I would get all new people unconnected with my case in
the interest of fairness. I may have to investigate this further.) A few were nurses, a few were appeals and
grievances dept. people. and I have NO idea who the people on the phone were. A minute taker was taking
everything down in shorthand.
Luckily, I had prepared a statement which I basically read to everyone present. I stopped to read the
pertinent sections from their own Evidence of coverage booklet. (page 4) The doctor seized on the fact that I had said
that midwifes are the specialists in normal births. He felt that the term specialist was only to be applied to a doctor with
advanced training in a specialty, like cardiology. I agreed with him that I had been using the term in a different fashion.
more of a lay person definition rather than a medical one. I expanded on this fact because I knew, they all did too, that
the section I had read from was from the specialists section of the EOC book. I told them in that paragraph it simply states
A plan provider not a plan specialist.
One appeals and grievances person, (my husband called her Jaws ;) was the one that basically ran the
meeting, took time to ask me if I knew I could switch to the PPO. I said yes at extra expense to me I should have
gone on longer on this point though. I would have to switch my whole family not just myself. My husband is
diabetic, there would be only extra expense for us. And then there would be the risk of 20% of a hospital bill in
case a transfer to the hospital in labor did become necessary. After all, if the benefit is covered as she said in the
previous breath. Why would I want to switch? I really wanted to scream out DUH!!! (but I didn't)
I had 5 copies of my statement which I handed out to them ( I had planned for 5).
I had hit the highlights of the great quality of care in my statement but I also had a notebook of well done medical
studies on the safety of home and birth centerbirth and midwives in general. I offered to show them to them but they said
"We know it's just as safe. that's not the issue." I said if they were willing to stipulate to the safety and
quality of care of CNM's then I was done.
I took the opportunity to tell them that in my research with midwives I had learned that Blue Shield was one of the few
HMO's that didn't cover this and that I felt they were really behind the times on this issue. 'Jaws' piped up again and
said that they were covered they just had to be in the IPA. She gave me the handout that Lisa had told me about in the elevator.
I said Thanks, I know of them but they only deliver in hospital. That is the problem. I did say that It took Blue Shield
months to come up with this simple information? I should have been able to get this from the member services # The speakerphone
lady said that they are in the process of getting that info on the system for their member specialists at the 800 #.
One nurse asked me if what I meant was an alternative birth center I said yes and to clarify I specified an alternative
birth center not in a hospital. (as is the common marketing ploy used by hospitals currently) She nodded and seemed to understand
Jaws did say that they were contracted with 200 IPA's and they didn't know which ones had CNM's .
Like that's some sort of excuse. I told her yes 200, and you found 1 with them. I told them I did know of
midwives that were applying and were being kept out of the IPA's on purpose. And that it wasn't right based on
the quality of care research, superior outcomes, and cheaper costs.
When we were being led out by Lisa she said & Good point from page 4 and she said she would know,
and call us in a few days.
I really don't know how it went. I wasn't optimistic with the way Jaws kept hammering at me with her circular logic.
She said they did have my previous letters and that they all had read them ( is she lying ?) If that is true everything
I forgot to mention on the spot was in those letters so I shouldn't feel bad. I don't know if Lisa was just trying to pacify
us or if that was a tip off that I would win. We'll see.
Oh and the flyer they gave me that had 3 cnm's listed on it in talbert medical group had them listed under "specialty
care" so I wrote another email for Lisa to forward to Dr. Fass. So apparently Blue Shield Considers CNM;s Specialty
care providers as well.