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By Karen E. Wallace
The most stressful part of my recent pregnancy was dealing with my insurance company. My husband, Jeff, wanted the insurance company to cover the cost of the prenatal care and birth. My priority was having a homebirth with caring, competent, normal birth oriented midwives of my choosing. After many time-consuming letters and telephone calls, our health insurance company finally reimbursed us 100% for our homebirth midwives. Our perseverance paid off, but was emotionally very difficult.
We now know the six-step process in getting the insurance company to pay for a procedure. I would suggest trying this for reimbursement for homebirth, a doula, and for childbirth education classes. Our insurance company booklet, the representatives on the telephone, and the letters that came to us always covered the procedures of the appeal process.
1. Call the representative on the telephone, who will say “no.”
2. Ask to speak to a supervisor, who will say “no.”
3. Appeal in writing. This is the first formal level of appeal.
4. Appeal again in writing. This is the final appeal to the insurance company. They will respond with their final decision.
5. Get the benefits department of the employer who is paying for the insurance involved.
6. Contact the state division of insurance enforcement.
What is essential in this whole process is the paper trail. On April 18, 2002, I sent a letter appealing the denial of pre-certification for coverage of homebirth midwifery services by a CNM. I selected an out of network CNM/CPM because the insurance company had no in-network midwives who attended homebirths.
The bottom line is to be persistent. Appeal and grieve at all levels
and document all conversations and keep copies of all correspondence. Although
homebirth midwifery care is worth the money to pay for it out of pocket,
take the effort to try to force the insurance company to pay for it. All
insurance companies should pay for all homebirths at 100% because in the
end, it saves them many thousands of dollars.
In February I went for my pap smear and while I was there had my initial pregnancy blood work done since I was pregnant. When I received a letter from the insurance company that said they would not cover the prenatal aspects of my appointment, I realized that working with this company could be very difficult.
I managed to get the initial prenatal costs paid, and then began the challenging task of getting a homebirth midwife pre-approved. We learned two major lessons from this exercise: 1) Insurance company employees believe that all midwives attend births at home, and 2) How to navigate through the appeal/grievance process.
I decided that before getting any more prenatal care, I would get my homebirth midwife pre-approved by our health insurance company. The first representative with whom I spoke asked me, “Do you actually need to have your baby delivered at home?” He told me that my plan allowed me to have a house call by a physician. He said I could have “any in-network surgeon deliver the baby at home as covered by the home visit benefit.” He did not understand that I did not want a surgeon, but a competent attendant in “normal” birth.
My request was for pre-certification from the insurance company stating that it would pay for a homebirth midwife to provide my prenatal, delivery, and post-partum care 100%.
The fee was $4000. An insurance company representative told me that the usual and customary fee that the insurance company paid the obstetrician and hospital was $6000 which did not cover the anesthesiologist and newborn care.
The insurance company initially denied my appeal in a letter dated April 22 because of their “provider available” clause. They listed the names and telephone numbers of three CNMs. After trying to make contact, we discovered that two of the midwives did not attend home births, and the third phone number had been disconnected. Immediately, I appealed again in writing, saying that the insurance company did not have participating midwives that attended homebirth. I again requested pre-certification of out of network coverage by the practice I had chosen.
On May 6 I sent the insurance company a grievance letter which appealed
the denial of pre-certification of homebirth midwifery services. I requested
antenatal, birth, and postnatal care by an out of network CNM/CPM MSN of
my choosing since no participating midwives or physicians attended births
at home. I discussed the safety, statistics, cost, and made special request
for an out-of-network provider since I had no freedom in my
A letter dated May 23 stated that the grievance review board had completed its review of the grievance and, “... After thoroughly considering all of the information available to it, the Board has determined that although Oxford does have certified midwives in your area, we are unable to provide you with a participating midwife who performs home birthing services. As you do not have coverage for out of network providers under your current plan, reference number XX will be updated to allow antepartum, postpartum and home birthing services with [my midwife] on an in plan basis.”
On September 26 my son, Seth Phillip Dean, was born at home attended by my midwife and her partner. My midwife sent the $4000 bill to the insurance company with all the correct codes and pre-certification information. We received a partial payment the next month. We knew that our work was not yet done.
After cashing the check, I called the insurance company. The representative said that the bill was processed correctly. “Midwives are only reimbursed at 65% because they are not OB/GYNs and the reimbursement was based on the geographic location (zip code) of the provider not the residence where the care was given.” Catherine Taylor’s Having a Baby Today says that Medicaid reimburses midwives 65%, which makes me think that is where my health insurance company came up with that percentage.
On November 7 I sent the health insurance company a letter in an attempt to appeal the amount of the coverage. After several attempts to get this settled, the insurance company said I would never get more than 65% paid. They said my only other recourse was to contact our state Division of Insurance Enforcement.
I referred back to a brochure from my husband’s employer who paid for our insurance. The brochure said that after trying and failing to resolve an issue on your own, call the Benefits Express and ask a representative for assistance.
My husband called his Participant Advocacy Service. After explaining the situation the ombudsman said that, without a doubt, our homebirth should be covered 100%.
On February 5, 2003, approximately one year after my first prenatal appointment, we received a check from the insurance company for the balance due for all services. After a lot of hard work, frustration and uphill battles, we finally got the insurance company to do what they said they would do in the beginning.. cover the services of a home birth midwife. *
[from Citizens For Midwifery
News, Spring/Summer 2004]
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