A NJ couple is beaten against the Horizon insurance refusal to have a baby and won

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After four miscarriages and refusal from New Jersey's Horizon Blue Cross Blue Shield to cover fertility treatments, Deanna and Jon Harkel prepared for more disappointment.

But when they read the letter from the doctor who reviewed their appeal for denial of insurance, they were comforted. The doctor agreed with them. The service should have been covered. The decision of Horizon was canceled.

"It has been so many years that bad news is being repeated all the time, I have been pretty shocked," Deanna Harkel said.

The Harkels are part of the growing number of New Jerseyers who appeal their insurance refusals to the state's Department of Banking and Insurance. And they find success. More than half of insurers' refusals in recent years that have been appealed have been quashed.

State officials said it was a sign that consumers were more aware of this option and were reacting more aggressively.

They argue over doctors and insurers about what constitutes medically necessary treatment. And this could intensify as new costly advances become available.

But as the Harkels show, the process is exhausting, forcing them to find the time to take off from work, to plead their case before the Horizon Insurance Commission and to fall asleep.

"The consumer can sometimes be put in the middle of that and forced to make phone calls, which adds extra stress to his health care experience, which is really useless," said Theresa Edelstein, Vice President of the New Jersey Hospital Association, a professional group.

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Call program

Consumers are increasingly fighting against the state's independent health care call program, an appeal process available to many New Jersey consumers since 1997, but which has rarely been used.

Horizon said Thursday in a statement that he was relying on medical and scientific research to "ensure that, no matter how complex the state or medical procedures, our coverage provides the care the more appropriate and safest, based on the best clinical evidence available. "

Insurers' decisions, however, are increasingly challenged.

From January to July 2018, 1,151 consumers appealed their insurance refusals, up 110% over the same period in 2017 and more than 200% from the same period in 2016, according to state data.

State officials indicated that it was only a tiny fraction of the total claims, since more than 3 million New Jersey are covered by plans overseen by the program.

But when consumers appeal, they prevail very often. Almost 54% of calls were canceled in the first six months of 2018; 60% were reversed during this period in 2017; 51% in 2016, the data show.

In comparison, about one-third of the 136 appeals filed in the first six months of 2008 were rejected, according to the state.

"The reason for the recent rise is probably due to the awareness of the provider and the consumer to the right to appeal," said a spokesman for the Department of Banks and Insurance.

S & # 39; install, the time had come

The Harkel were grateful for the state's appeal process.

But they said that they could have been spared if their application for coverage had been approved from the start.

As things stand, they suffered a fourth miscarriage, sleepless nights, countless blood tests and a visit to the Horizon Headquarters in Newark to do what was ultimately a plea. unsuccessful in front of the appeal committee of the insurer.

The Harkels, both 31, live in Hightstown. Deanna is director of donor relations for a private school. Jon works at the communications office of a New York college.

They met when they were students at New Jersey College in Ewing and got married five years ago. They started their careers, bought a house, and decided two years ago that it was time to start a family, even if they worked more to make ends meet.

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The Harkels had little problem getting pregnant, but when visiting a doctor, the nurse became strangely silent.

"We went for the first ultrasound, we expected everything to be done, you print the photo and everything else," said Jon Harkel. "The nurse had her poker face and Deanna said," Do you see something? "And she said," We'll have to wait for the doctor, "and we were as if everything was fine, that's a problem."

Pregnancy was not viable. Deanna is having a miscarriage. They are pregnant again. And Deanna again miscarried, prompting them to test the fetus for chromosomal abnormalities, the most common explanation for miscarriages.

The results showed abnormalities and the Harkel were referred to Dr. Debbra Keegan, reproductive endocrinologist at the Institute of Reproductive Medicine and Sciences of St. Barnabas.

Keegan suggested that they try again, noting that it was statistically unlikely to have a third miscarriage. They tried again. They still had a miscarriage.

It was then that Keegan recommended in vitro fertilization with a preimplantation genetic test to detect genetic abnormalities of an embryo before its transfer into the uterus.

The test, she said, would allow her to choose a healthier embryo and increase their chances of getting a viable pregnancy. But they encountered a roadblock. Horizon would not approve it.

Calls multiply

The frequency with which such requests for insurance are denied is unclear. But the rise in remedies is a surprise.

Insurers have advocated closer cooperation with health providers in recent years to try to provide more cost-effective care.

But the data shows that fighting between insurers and providers continues. Most of the calls stem from disagreements over prescription drugs and hospital admissions.

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But most specialties have increased. Internal medicine has gone from 48 cases in the first six months of 2017 to 298 cases for the same time in 2018. Infectious diseases have gone from 41 to 104 cases. Gastroenterology has gone from 132 to 165 cases.

OB / GYN, neonatology remained stable at age 23.

Which give? Theories abound:

  • More and more New Jersey have purchased insurance under the Affordable Care Act (Obamacare).
  • Insurers, faced with rising prescription drug prices, are struggling to convince consumers to turn to less expensive generic drugs.
  • The State Banking and Insurance Department raised public awareness in March by reminding consumers and suppliers of their rights of appeal.
  • Doctors and hospitals are increasingly inclined to fight initial refusals, knowing that if they win, this could deter insurers in the future.

"This is a huge waste of resources for the system," said Larry Downs, executive director of the New Jersey Medical Society, representing physicians, about the need for approval from the insurer before providing any information. care. "It's all about cost and care."

The fine print

The Harkels were soon caught in a medical conflict.

In vitro fertilization costs about $ 15,000; genetic tests cost thousands more. And there was a chance that the procedure would not be successful and they should try again.

They were not worried. They were covered by Horizon thanks to Deanna's work. They contribute $ 5,203 a year to their premium. The policy includes a $ 50 share for specialists, but no franchise for network providers.

What's more, New Jersey insurers who are mandated cover the infertility treatment of women who can not get pregnant or who do not carry a pregnancy before live birth.

But the Harkels discovered that the law was respected and their policy was not put aside.

Before covering IVF, Horizon had asked the Harkels to try cheaper measures, such as intrauterine insemination, which involves placing sperm inside the uterus.

Deanna got pregnant for the fourth time. For the fourth time, she had a miscarriage. When they asked Horizon to allow IVF and genetic testing, they were again refused, which prompted them to appeal the decision.

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The Harkels and Keegan went to Horizon's headquarters in Newark just before Thanksgiving. They sat in a conference room and, before a committee of what they said were about 10, they pleaded their case.

L & # 39; essential? They had experienced a physical and emotional roller coaster and were simply trying to buy insurance for a medically necessary procedure.

A Horizon employee called the next day, said Harkels, telling them that the committee was sticking to the company's initial decision.

"I've been sad for two years," said Deanna Harkel after the denial. "And now I'm just angry, I'm sorry they're asking me to continue doing miscarriages when they have science and technology to (use) IVF, science is there, science is there. The answer is there, and we pay for it in our policy. "

The value of genetic tests

Horizon was not in agreement. Its committee said that preimplantation genetic testing for Harkels was considered testing, making it a service that goes beyond the state's fertility mandate.

While Keegan cited studies showing that the test reduced the rate of miscarriage in IVF patients, Horizon was referring to a 2018 study by the American Society of Reproductive Medicine that concluded that the value of genetic testing on all IVF patients had yet to be determined.

Horizon in a statement said that he relied on the recommendations of medical and scientific organizations.

"In Ms. Harkel's case, the current standards established by the research and recommended by these expert organizations did not support the treatment requested by Ms. Harkel, a decision upheld by an independent expert certified by the board at the time of the appeal ( internal of the company) process, "he said.

The Harkels again appealed their case, this time with the state. And they were anxiously awaiting the decision, knowing that if they lost, they would have to wait a year before asking their insurer to allow IVF and genetic testing.

The decision arrived just before Christmas. The external doctor who examined the case said that preimplantation genetic testing was considered medically necessary given the history of the couple's miscarriage. He recommended that the denial of coverage be canceled.

"As we defend our policies and the science on which they are based, this issue is settled and our goal is to continue to support the Harkels in their efforts to grow their families," Horizon said in a statement.

The Harkels were free to proceed. They plan to start IVF from one day to the next.

"We are on the way we should have been a long time ago," Jon Harkel said after the decision. "It's hard to be too excited, there was a moment when I was really grateful that they did what was right, but I felt weird to appreciate that someone did what they were supposed to do. "

"I think we'd like to start the process," Deanna Harkel said. "It's a long process, it's just beginning, we would like to start as soon as possible, and we hope to receive some good news in 2019."

Michael L. Diamond; @mdiamondapp; 732-643-4038; mdiamond@gannettnj.com