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Negotiating for Health Insurance Coverage

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My insurance co will only pay for a homebirth attended by a DR. And then, only if there are no prior complications.  They view my 2 prior c/s as complications and therefore wouldn't even pay for a DR to attend me at home.

Ask them (or someone in Ill. State Dept. of Insurance - the people who have oversight over ins. cos. in your state) where the law defines their coverage of care provider at home births.  Most likely, it only says that they cannot withhold reimbursement for a home birth (at least that is how it reads in NY).

*1* If this is the case, then ask them to point out to you which of their participating health care providers attend home births.  (The insurance company can only insist that it be an MD if there is an MD that attends home births - otherwise, they are creating an artificial barrier.)  Tell them you would be happy to have an OB/MD attend your home birth!  (Even if you aren't so sure.)  There may be laws (as in NY) that specifically forbid insurance companies from creating barriers to home birth.  Ask them to help you find a home birth MD.  You may find a chink in their armor.

*2* Do they reimburse CNMs at hospitals?  If the answer is yes, then you have just identified an unlawful restriction of trade, and I urge you to point that out to them.

*3* As for complications, a health insurance company is not allowed to define what your 'complications' are.  That is for your doctor to do.  When they do it they are practicing medicine without a license, and I urge you to point this out to them.  If there are OBs/MDs out there who are willing to attend home births, and you find one, it is up to that MD to determine whether your prior C/Ss are a 'complication'.  In the case of CNMs, they are generally constrained to practice within the scope of the written practice agreement that they negotiate with their backup physician.  If it says no VBAC homebirths, then that is that.  If there are no MDs or CNMs on there list that DO homebirths (forget about VBAC issues for now), then demand an out of plan referal to your midwife! (Remembering point #2)

So, let me (briefly) tell you what I did.  I was 30-32 weeks pregnant, when my midwives' collaborating physician suddenly announced NO HOME VBACs!  I took the whole day off work, went to the insurance company office, told them they needed to help me find a new OB/CNM team for a home birth, and I wasn't leaving until I had this issue worked out.  They didn't help me all that much:  they handed me their provider list and gave me a cubicle with a phone.  They did try to assert that a VBAC shouldn't be home birthing - I raised point #3 above.  They knew they had home birth providers on the list, but they couldn't say for sure how many.  They knew because some time back, they were required to reimburse for 'out of plan health care providers', and they took active steps to recruit health care providers after that in order to avoid that problem.  (See point #1)

We are hoping to convince the ins. co. of the relative "cheapness" of homebirth compared with the hospital and all it's "extras" because of my complications.  So far, the problem is, is that they view all the interventions and hospitalizations as "standard care" and think they would pay more money if I were to transport in an emergency.  Any chance you have any documentation showing that it wouldn't cost any more (or maybe even less) even if I did end up transporting?
While this is a TOTALLY valid point, I'm afraid that approach won't work until they have a few experiences under their belt.  I tried it.  These folks are so medical model oriented that they are incapable of seeing it from this perspective (if they could - you can be sure that Ins. Cos. would have changed the way Maternity Care is delivered in this country).

If it could work, though, this is what I would say:  A normal uncomplicated birth in the hospital costs about $7000.  A C/S with its attendent 4/5 day hospital stay is $10,000 (more than uncomplicated even if the MD gets paid the same regardless of outcome - because they need an operating room, anathesiologist, and several days stay for you and babe).  A home birth with midwife, you said was $3200.  Worst case scenario is a $13,000 transfer to hospital for C/S.  VBAC success rate is 70%, so there is a 30% chance they pay an additional $3200.  But there is something like a 50% chance that they will save $3800, and a 20% chance that they will break even with a home birth that turns into a hospital transport, but that does not end in C/S.  Tell them that in any event, you do not intend to put anybody at risk, and you'll sign whatever waivers they want!

If I were you, though, I would pay careful attention to what the law allows.  They WILL conform to the law, even if they don't like it.  (Unlike Drs, who might just break the law anyway with practices like not getting informed consent.)

The problem I have had when talking or corresponding with them is that while it is self insured - the Benefits dept doens't seem to have anything to do with this.  They have one company that administers the claims and another company that does the providers.
This is very common with self-funded insurance plans.  The company is proud beyond words that they could come up with a more cost effective (cheaper) way to do business.  They contract out the maintenance of that plan, and assume because they are paying someone to do it that it will be managed well.
She has called several times to get the paperwork to get on the list but they never send it.  I've even tried calling on her behalf once and was told it "wasn't my problem".  I finally got thru to somebody by email (the one that gave me the low down on the midwife coverage) and she said she called the right people and got the paperwork requested to be sent - but again she never got it.  I get the feeling it is the same thing for the midwives.

so how do you find the right people to talk to?

You hit the nail right on the head.  This is the key to successfully navegating this maze.  You need to find the person in the (your husband's?) company who has a stake in the success of this outsourcing relationship.  Usually that is the person who created the plan (if they are still with the company).  Perhaps you can go back to the person who said "it isn't your problem" and remind her that if you have to pay 30%, then it IS your problem, but that you would like to help her through this.  That if the company that administers the plan isn't cooperating, then the two of you together could escalate the issue to/through corporate management?! (As soon as they figure out that you are ready to escalate it to the next level, they panic and fall all over themselves to try to get things to work without 'escalating it', or they get pissed off that you would 'go over their head'.  You would have to be careful, and tactful, to make sure they understand that you are looking for a win-wi!
! n solution, not out to burn them.) >
> I don't mind trying some more - because I've already been corresponding them on coverage.  But, I just can't put up with the nonsense if they start that. And the hardest part I find is getting to the right person!>

I can only offer this:  Keep good records of every call, copies of every submission, letter, response, etc.  When you think you really can't take it any more, go to the head of benefits/head of the company with your packet, and lay it all out for them.  Make it their problem.  Show them how much you have put up with already.  That is your ace-in-the-hole move, so make sure you really don't have any other direction to turn.  Remember how many other women will benefit from the ground you break in that company, with that plan administrator...  It's all for the greater good!

Thank you very much for your time and response.  I have forwarded what you said to my dh and he is already ready to fight!  And I do really believe that it lays the ground work for other women.  Just from what I'd already done and talking to the midwife she was able to call a client the week of her due date to tell her that she can submit the claim and get 70% back. They had thought they would carry the 100% themselves!  What a nice thing to happen right before you are ready to go into labor!!! 

When you introduced this thread you said she leaves it to the consumer to collect the reimbursement.  Then you wrote that your insurance company will only re-imburse the health-care provider.

This prompted a couple of more thoughts: #1) It is almost certain that this midwife does not expecther that you will be successful at getting reimbursement for HER or for YOU.  That is making it your problem.  (That is to say, is unwilling to make it HER problem - you see what I mean?  She has probably tried to fight this fight, lost, and washes her hands of Ins. Co. reimbursemnt issue, does business with people who are prepared to leave the Ins. Co behind as well.)

#2) Returning to my experience, the Ins. Co. rule is that they only reimburse the health care provider, but there are exceptions!  In my case, out of plan referrals fall sometimes fall into that category.  Reimbursement for rental of an oxygen tank (on perscription) fell into that category too.  Supposing you've had careful conversations with your insurance company (per previous post) and they finally allow you to have this midwife attended home birth, I am sure this issue will work itself out.

#3) I just realized another 'aspect' of Ins. coverage that might be playing into this.  My Ins. Co. did not 'allow' a CNM to be the primary care provider for OB/GYN services.  In practice, this was a formality, because the OB wrote a 'referal' to the midwife with whom he has written practice agreements.  The 'only MD at home birth' rule may be an expression of this Ins. Cos. business practice.  Make sure you have a good understanding of this, so you can 'speak their language'.  If this is how they do business, then you may have to repeatedly phrase your request for a midwife as a 'referal'.

I am in the East -- Georgia to be exact.  Homebirth is covered here because we our company happens to have this really hip insurance administrator -- me!  When I took the position, I changed the policy, quite frankly, for myself.  But before I got the chance to use it, our accountant's wife got pregnant, and they had the first homebirth!

First of all, DOCUMENT EVERYTHIG!  Every phone call, every letter, including the name of the person at the insurance company and the time/date of correspondance/phone call etc.  TAKE NOTES DURING THE CONVERSATION!

Get a copy of the COMPLETE insurance documentation (ie what they cover, what they don't) inculding all covered practitioners.

Contact your state Insurance Office.  (In New Jersey, it was the office of Insurance, and is specifically there to deal with cases in which the insurance comapany is not doing what they are supposed to do)

Get a copy of your state regualtions regarding birth, midwives, birthing centers, homebirth etc.  In New Jersey there were two different places this was kept.  One was actual legislation about midwvies and what they can/cannot do.  The other place was the Board of Medical Examiners, who passed guidelines, which are not laws but rather recommendations about what is what in terms of midwives vs doctors and home vs hospital or birth center.

We were able to get the Bd. of Med Ex. guidelines by calling their office, then we were able to get the legislation on the internet.

WRITE A FORMAL APPEAL to the insurance company.  Also, write a formal COMPLAINT to theState insurance office.  Be specific and offer documentation for each reason you give.  Be concise, and not emotional. Cite solid medical sources (including journal articles which discuss the safety of home vs hospital and midwives vs MDs.

Keep copies of everything, and cc both on what is sent to the other (ie the insurance company should know you have filed a complaint, and the office of insurance should know that you have filed an appeal)

We will be doing the last step of this as soon as we are sure my husband's company isn't being bought and our insurance changing.  But we have all the documentation in place and ready to go.

Sometimes even an HMO will cover homebirth if you approach things in the right way.  First, read your health insurance policy; this is a contract that legally binds the insurance company!  They may have a clause that says that they may cover alternative treatments that are less expensive than standard treatments - this certainly includes homebirth!

This Web page is referenced from another page containing related information about Money and Paperwork, Parents Share Information About Homebirth, and For Parents - How to Get the Best Care


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