The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
The AMA wants to make birth centers illegal, along with homebirths,
even though
Read more about the ACOG 2008 Press Release from The Big Push for Midwives and Childbirth Connections You can also educate yourself week-by-week in your pregnancy with theLamaze Weekly Pregnancy Newsletter for Parents |
WARNING!!! If you have Aetna health insurance, you may want to change at the next opportunity, when your employer has their annual "open enrollment". Aetna doesn't cover homebirth, citing a single study based in rural Australia which shows that high-risk births far away from a hospital are high risk. They further cite the policies of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, both business competitors to homebirth providers. Their policy statement ignores a mountain of evidence that homebirth is as safe as or safer than hospital birth for normal, healthy pregnancies.. If their policymakers have any integrity, this logic will soon lead to cessation of coverage for planned VBAC's . . . there's no dearth of studies and AAP and ACOG policies proclaiming the danger of VBAC's . . . and then they'll stop coverage for any woman who declines standard ACOG/AAP recommendations regarding routine ultrasound, routine induction, routine IV's, routine use of continuous electronic fetal monitoring, routine administration of antibiotics for all GBS positive women (up to 40% of birthing women), and prompt cesareans for any woman who fails to progress in a timely fashion during labor and pushing. They may also stop coverage for children who are not vaccinated according to the full schedule of vaccinations recommended by the AAP, even though many intelligent parents decline the newborn hepatitis B vaccine and practice selective vaccination according to their child's own needs.
If this is troubling to you, as it should be, let them know. You
can easily send
e-mail to Aetna's National Media Relations Contacts and simply tell
them that they should not be in the business of denying coverage for reasonable
healthcare choices, such as homebirth, waterbirth and VBAC. They
will especially want to know if you are choosing another healthcare provider
because of this unreasonable policy. You might also suggest that
they expand their research beyond ACOG and AAP recommendations. They
could start at: http:
Even though Aetna claims not to cover homebirth, they should still pay
the unbundled prenatal and postpartum care, which are not technically homebirth
services, even if provided in the home.
Fed Court - Whiney Aetna "Spanked" Again... Opinion by Consumer
Advocate Tim Bolen [3/9/06]
Aetna, being sued by Cavitat Medical Technologies on several counts,
has had a history, in this case, so far, of bad behavior you can read about
in my earlier articles - including the sending of thugs to my home in a
clear attempt to dissuade me from writing about them.
The Cavitat v. Aetna case is a "donneybrook" - a battle for supremacy.
It is the first outright challenge, by the public, of "the decision process"
Aetna insurance, and its affiliates, uses to determine exactly what health
care offerings they will pay, or not pay, for. Cavitat, in essence,
has accused Aetna, of using questionable standards, and dubious individuals
(the "quackbusters"), to evaluate health care offerings - and is being
very specific in those accusations. The case, if successful, will
force Aetna to use standards more in line with the reality of health care
- and Aetna is pulling out all of the stops to try and stop this attempt.
But Cavitat, last week, played a new card Aetna didn't expect.
They brought in well known California Litigator Carlos F. Negrete to take
over as lead trial attorney - and Aetna started to seriously "whimper"...
"
Resources
First Things First - Get the Right Numbers for Business!
It is best to do all this early on, so you have all your numbers in place
before filing insurance claims or signing up an electronic billing service.
If you sign on with a regular billing service, they'll usually handle the
third step for you, which is really nice.
The National Plan
and Provider Enumeration System (NPPES) to assigns unique identifier
for health care providers. Your National Provider Identifier (NPI)
is your standard unique identifier. As part of the registration process,
you'll be asked to classify yourself in the taxonomy
of providers. A taxonomy is just a set of hierarchical categories,
and it's important to make sure you're in the right group so insurance
companies will understand that you're a licensed healthcare provider providing
medically necessary services. For example, if you're in the same group
as veterinarians and funeral directors, you might not be in the right subgroup.
Here's a current listing
of the codes, plus more information about the Provider
Taxonomy Codes, including what
the levels mean.
I did some poking around to find the best category for NRP-certified assistants, and I found this one:
# Respiratory Therapist, Certified - Neonatal/Pediatrics - 2278P3900X
The U.S. Department of Labor, Bureau of Labor Statistics offers the following definitions for Respiratory Therapists:
"Respiratory therapists and respiratory therapy technicians—also known
as respiratory care practitioners—evaluate, treat, and care for patients
with breathing or other cardiopulmonary disorders. . . . Respiratory therapy
technicians follow specific, well-defined respiratory care procedures under
the direction of respiratory therapists and physicians. . . . In this Handbook
statement, the term respiratory therapists includes both respiratory therapists
and respiratory therapy technicians."
In any case, it does help to understand what it's all about. There are some good introductory books about insurance billing. I was very happy with Medical Billing Basics from Ingenix. This is an excellent overview of medical billing, and although the book doesn't have all the codes, it comes with a demo disk of Encoder Pro, which DOES have all the codes. (I found it at a discount at medetrac.com, or if you get coupons from MooreMedical, this is a good time to use them!) Encoder Pro has an excellent search facility, and this is how I familiarized myself with the diagnosis codes, which are tricky if you're looking for anything outside maternity/birth/newborn codes. (The demo expires after a few months, but you can just re-install it and continue to use it as a search resource. NOTE - I think they have the codes from 2004 in there - the only common diagnosis codes that changed were the Pap codes.).
Eventually, I purchased the AMA CPT Standard Edition, just to have the most complete definitions of the procedures. And just this year, I purchased the ACOG book, The Essential Guide to Coding in Ob/Gyn, to help fill in the gaps.
If you've got the budget for insurance billing resources, it makes sense to purchase the above overview, CPT and ACOG books. I've found the Encoder Pro and online diagnosis resources to be superior to the books, because you can search more quickly and more easily.
I also read through some good online resources:
American Academy of Family Physicians (AAFP) pages on Coding for Intrapartum Care and Other Obstetrical Services [My notes]
Official ICD-9-CM Offical Guidelines for Coding and Reporting [My notes] There are lots of online databases of diagnosis codes, because governmental agencies have a strong interest in accurate diagnosis coding.
From time to time, the complete ICD-9 and CPT-4 code sets have appeared online, although the CPT-4 seems to come and go more quickly.
I have tried to write up a good introduction with Sample Billing Scenarios for a Homebirth Midwife.
And the rest of these web pages have lots of links into solid references as well as lots of midwife hearsay.
Midwifery Today has had some articles about insurance billing, written by Linda Lieberman, a midwife in Oregon:
Midwifery Today #74 (Summer 2005). In the Business of Midwifery column titled "The Federal Register", there is a lot of detailed info on some of the tools for setting fees.
Good luck!
There is a yahoo group - InsuranceBilling
- about insurance billing for homebirth - "Increasingly, homebirth services
are being covered by insurance, but most midwives know little or nothing
about how to appropriately bill for their services. Those who do bill usually
underbill. Proper insurance coding is tricky but can increase a family's
reimbursement and a midwife's income significantly. This group is designed
to gather together homebirth midwives who know nothing about proper insurance
billing with those who are experts in the hopes we can share ideas and
all learn to make our practices more productive. This group is currently
open to practicing midwives only and may open to students in the future."
What You Should
Know About Filing Your Health Benefits Claim - If you are an employee
or family member of an employee who receives health benefits from a health
plan provided through employment in the private sector, a Federal law,
the Employee Retirement Income Security Act (ERISA), protects you. Among
the protections, ERISA sets standards for administering these plans. Those
standards require plans to give you important information about the plan
and to have a fair process for handling benefit claims.
Resources & Bibliography:
Billing and Coding for Midwifery Services from the ACNM.
Billing
For Nurse Practitioner Services -- Update 2007: Guidelines for NPs,
Physicians, Employers, and Insurers CE from Medscape
This site offers a free 7-day trial - DocOfficeRx
is your #1 online resource for a full suite of coding tools including fast,
accurate and up-to-date access to CPT Codes, ICD9 codes, HCPCS, LCD Data
and CCI resources. But that's not all! DocOfficeRx is the only online coding
resource to offer full access to procedure, diagnosis and modifier coding
resources plus a full suite of practice management tools that will increase
reimbursements and decrease your costs associated with with the coding
process.
Glossary of Common Terms - some good definitions of insurance terms
Another good list of insurance terms
How
do I use the new Pap smear codes? from ACOG
Negotiated Settlements from
Larsen Billing Service
Supporting
Breastfeeding and Lactation - The Primary Care Pediatrician's Guide to
Getting Paid - this excellent document from the AAP about billing for
breastfeeding assistance does a nice job of discussing the issue of providing
care and billing for two separate patients, and how to bill for followup
visits.
I recommend "Shameless Marketing for Brazen Hussies" and "How to Start an Independent Practice:The Nurse Practitioner's Guide to Success" By Carolyn Zaumeyer
Some useful information meant for nurse practitioners:
http:
- an interactive(?) web site on building your own practice.....
and
Reimbursement Realities for Advanced Practice Nurses from The Collaborative
Rural Nurse Practitioner Project, funded by the Minnesota office of Rural
Health and Primary Care.
I found a fairly inexpensive SOAP notation text for docs that I will
recommend: SOAP for Obstetrics and Gynecology by Peter Uzelac, Blackwell
Publishing. Under $25.
Physicians Practice
- The Business Web Site for Physicians
Paying
Physicians for High-Quality Care
The recent call from the Institute of Medicine for government payers
to increase payments to health care providers who deliver high-quality
care is one of several signs that practicing doctors can expect some fundamental
changes in the way they are compensated.1,2 Health care insurers and purchasers
in the private sector have begun moving along a similarly ambitious path.
Many physicians are already familiar with quality incentives from their
experience with managed care; such incentives began as small payments for
higher ratings of patient satisfaction or for the use of preventive services
such as mammography.3 These incentives . . . [Full Text of this Article]
The Emergency Medical
Treatment and Active Labor Act (EMTALA) has specific regulations for
hospitals relative to women in active labor. The purpose of these
federal regulations is to ensure that patients with medical emergencies,
including women in labor, are not denied treatment based on any reason
other than those that reflect the hospital's capacity to examine, conduct
tests, and treat the emergency condition.
All women in true labor are considered to have an emergency medical
condition, and are therefore unstable. "Labor" is defined under EMTALA
as the process of "childbirth beginning with the latent or early phase
of labor and continuing through the delivery of the placenta."[1,5] The
presence of an emergency medical condition triggers all of the obligations
of EMTALA.
So if you end up transporting to a hospital that isn't a preferred hospital,
the care should still be covered as a preferred hospital because of the
emergency condition, i.e. active labor.
A Consumer Guide
to Handling Disputes with Your Private or Employer Health Plan - Kaiser
and Consumers Union have a great set of web pages about Consumer Rights
and Health Insurance.
Facility
Labor and Birth Charges, U.S. 2003, By Site and Method of Delivery
- note that these are facility charges, meaning they do not include the
services of the midwife, anesthesiologist, pediatrician, OB or family practice
doctor.
Prices, as quoted by Alabama Birth:
Home Birth $2300-$5000
from O'Mara, P. Having a Baby, Naturally, 2003. p. 322. Based on figures
published in 1999.
This summarizes
standard maternity costs
See also: HIPAA - Legal Aspects of
Midwifery / Health Insurance Portability and Accountability Act
From: Frequently
Asked Questions about Portability of Health Coverage and HIPAA
Under HIPAA, . . . preexisting condition exclusions cannot be applied
to pregnancy, regardless of whether the woman had previous health coverage.
Newborn's
and Mother's Health Protection Act Statutory Text
Newborns'
& Mothers' Protections (Newborns' Act)
The Newborns' and Mothers' Health Protection Act (Newborns' Act) includes
important protections for mothers and their newborn children with regard
to the length of the hospital stay following childbirth. The Newborns'
Act requires that group health plans that offer maternity coverage pay
for at least a 48-hour hospital stay following childbirth (96-hour stay
in the case of Cesarean section).
From: Frequently
Asked Questions about Newborns' and Mothers' Health Protection
Q: Under the Newborns' Act, when does the 48-hour (or 96-hour)
period start?
If you deliver in the hospital, the 48-hour period (or 96-hour period)
starts at the time of delivery. So, for example, if a woman goes
into labor and is admitted to the hospital at 10 p.m. on June 11, but gives
birth by vaginal delivery at 6 a.m. on June 12, the 48-hour period begins
at 6 a.m. on June 12.
However, if you deliver outside the hospital and you are later admitted
to the hospital in connection with childbirth (as determined by the attending
provider), the period begins at the time of the admission. So, for
example, if a woman gives birth at home by vaginal delivery, but begins
bleeding excessively in connection with childbirth and is admitted to the
hospital, the 48-hour period starts at the time of admission.
I want to share my point of view and hope it's not too controversial.
I think many of us are VASTLY under-charging. Probably especially
those of us serving special communities with a lot of homebirthers (thus
a lot of competition), etc. I wish a given community of midwives
really could agree to a standardized price for a standardized service and
not worry about anti-trust violations (everyone else is doing it for heck's
sake). Extras should be extras - a birth assistant, a birth center,
extra home visits, etc, should cost more.
I say this gently... I think the idea of a "free birth" for purposes
of 'vocation' or mission work sounds nice, but in actuality does not serve
anybody. This is our livelihood. This work, the education,
the preparation, the supplies, the hours, the stress, the risk, most of
all - the personal investment, the time, the energy, the sacrifices we
make, and the love we give - it deserves compensation. For truly
impoverished families, I am comfortable with a very low fee. But
charging even just $50 or requiring real trade (in work or goods or whatever)
gives midwifery services value. It makes a point that I think is
very important for our clients to understand.
I live in an area where a lot of homebirthers have the bargain hunting,
yard sale mentality. People will come to me as say " Well I have interviewed
x and y midwife, and they only charge $1000 or $1100,or even a couple hundred
less then me. Will you give us the same price" . I politely say.
" I charge what I charge because I schedule my prenatal visits to be 1
hour long, I do CEDS testing at every visit, I include Prenatal Parenting
TM and Childbirth classes, all your supplies, and the birth tub as
part of my service. My service is worth a lot more then what I am asking,
you are actually getting a really good deal." Most of them say oh,
I see. Some of them never come back, but a lot do, even though they
may be paying me more. I have to tell you. I think when you charge
what you are worth, or at least not give your services away, your clients
respect your advice more, and you will not get as burnt out as fast.
I do not do free births. If someone really wants my services, and really
can not afford to pay me, they can do work for me. Most are more then happy
to do it. It make what you are giving them worth something to them
The clients that have the most problems with the fee, give me the worse
problems, don't take me seriously, and take the most amount of my time.
If someone from the beginning has a problem with my fee, I let them
go to the cheaper midwife. I never apologize for my price. You would think
I would have less business. The exact opposite is true. Since I have
raised my fees, and made no apologizes, my business has gone up dramatically
! I already have 3 times the number of births already signed up this
year!
The other thing I never do. Give discounts to last minute-ers
who have had no prenatal care. The only discounts I give are if another
care provider has provided prenatal care, and they can prove they are square
on their bill with their previous provider, then I will give a $50 discount
for each prenatal visit with a Maximum discount of $500.00. So my
fee is never lower then $1200.00. They must show me that they paid the
other provider so that I avoid the scenario of someone seeing someone
else, and then switching at the last minute leaving the other provider
unpaid, just to get a discount!
Birth Business - A workstation
of simple and practical techniques, information, links and resources for
the self-employed Birth Professional
Getting
Paid - Why Every Practice Needs a Payment Policy [Medscape registration
is free]
Should You Charge
Your Patients for "Free" Services? [Medscape registration is
free]
Ingenix will custom-make a Customized Fee Analyzer for you for about
$250.00. It is specific for your speciality and area. Expensive,
but well worth it every few years. Maybe a few midwives in the same
area could share one. Phone - 1-800-464-3649, but be
prepared for lots of sales calls. You must be firm with them.
Just tell them to send mail, absolutely no phone calls, or they'll call
every week. This is also a good place to get CPT, HCPCS, and ICD-9
code books, usually about $50 each, but sometimes they have a special going,
especially if you get more than one.
A
discussion of price fixing among medical professionals: "An agreement
among competing professionals on a minimum fee schedule, for example, is
a violation of the antitrust laws."
Midwife's Financial Agreement / Informed Consent
Home Birth Financial Agreement
Homebirth Disclaimer by Joan Mershon CP
In my homebirth practice, I charge primes $300 more and require a labor
doula. I think I should charge more!!! Of course, the requirement
for a prof doula is negotiable if she has excellent, experienced support
planned. Just as long as they understand that I am not going to be there
for 2 days rubbing her back.
FEES I observed a friend who is a naturopath in an initial visit once,
who straight forward told the clients his fee was $900 (at the time, mine
was $500--this was 1982, I believe) and he expected full payment by the
eighth month. His clarity was reflected in their immediate response, a
frank and open discussion about payment schedules, and he almost always
got paid.
We have the same approach with our clients. We also almost always get
paid. Infact, when we don't get paid, its usually because it has been agreed
to do the birth anyway.. out of a sincere need. Our fee must be paid in
full one month before the baby is due. Of course that fee is sometimes
adjusted to the needs of the individual.
However, the initial discussion of fees (including what's NOT covered
as well as what is) must be done by the midwife. I hate this conversation
but not as much as I hate getting stiffed! Here's my approach: Set a fee
you can be proud of, that reflects your effort and the going rate where
you live. (begin by estimating the avg time spent at a birth and giving
ap & pp care, plus all your supplies, phone calls, pager costs, mileage
at $.28/mile, etc.). The only one you have to justify your final charge
for services with is yourself. When you can look in the mirror and say
your fee without any apology, you're ready for the next steps:
This discussion about doula fees had many fine insights:
I live and usually work in San francisco. I do not know how fees here
compare but many doulas here do births for free in the beginning. (I personally
oppose doing births for free just because you are inexperienced. I think
even a new doula has a lot to offer and people value what they pay for.)
An experienced doula in SF charges between $1200 and $2000 for birth doula
services. For perspective, a one bedroom apartment in my neighborhood rents
for approx $2500 per month and parking is an additional $300 per month.
So no one is getting rich here either!
However, i just wanted to share something that has worked for me. I
have been a full time doula for a few years and what ultimately worked
for me was to say something like this... when a prospective client asked
what my fees were i would tell them and wait to see what their response
was. If the fee seemed to surprise them or they said they could not afford
it i would tell them that I believe that every women deserves a doula if
she wants one and I would not want money to be the reason that a woman
does not get the support she wants. I would then encourage them to interview
several other doulas, (not necessarily no fee/low fee - i think chemistry
is the most important piece) and stress that if after meeting a few other
doulas they feel i am the right doula for them i will creatively work something
out with them to make it work for us both. I also let them know that I
can afford to take one reduced fee/trade client per month and if they can
afford to pay it is important that they do so that those in true need can
take advantage of the reduced rate. i also state that i firmly believe
that doulas are worth far more than what we charge.
If they come back and want me to be their doula we work it out together.
I start by asking what they would like to do. I have been surprised by
the number of folks that want to pay just $100 less than what i was asking.
I have also worked out creative payment plans where folks take a year to
pay me, add me to their baby shower registry, pay me in complete trade,
(I have gotten fancy haircuts and color for a year, frequent flyer miles,
gelato, meals at restaurants etc.). While trade wont pay the rent, I have
never felt like i got a bad deal. I have even gotten my final payment on
a baby's first birthday and never had anyone skip out on a payment.
I have found that some people are just bargain hunters and will try
to get a deal whenever they can. They are usually very willing to pay full
price when I explain myself to them. In fact, several folks who originally
asked for a discount actually offered to pay a little more to fund more
of my pro bono/reduced rate work! I have never asked clients to prove their
need to me, I just take their word for it.
PayPal charges a 3% surcharge
for credit charges.
CareCredit - patient/client
financing
Medicare
Participating Provider Program Enrollment Package and Fee Schedules
[from CIGNA] - These fee schedules will give you a good relative sense
of costs associated with different services. As a rough guide, the
Tennesse guide for 2001 non-par FS is roughly equivalent to the benchmark
fees from 1998.
A benchmark fee table is a table of fees that shows the relative values
of different procedures; you'll need to figure out your Geographical
Multiplier to know what are considered Reasonable and Customary Fees
in your area.
The 2005 conversion factor for 2005 is $37.90. The conversion factor
for 2004 was $37.34.
Medicare Physician
Fee Schedule Look-Up
Benchmark
Fees and codes for different procedures - type in maternity
or newborn [currently not available?]
North
Dakota Medicaid Fee Schedule as of 7/1/04
CPT
codes and Fee Schedule for Arizona Health Care - Maternity Care And
Delivery
Check out ACOG's
2005 Benchmark Fees w/explanation of geographical multiplier
Geographic Multiplier -- A factor used to make geographic adjustments
to
the Medicare Fee Schedule or any other fee schedule. The term "geographic
factor" is also used.
Midwives and clients alike need to understand that comparing the cost
of midwifery services in Alabama, New York City and San Francisco makes
no sense unless you include a "geographic multiplier" to adjust for the
relative cost of living. Obviously, every midwife is going to offer
a different level of quality and services, but identical services in the
San Francisco area might cost twice the services in a rural area.
Here are some resources to help you understand this better:
THE SALARY CALCULATOR
- compare salaries necessary in different cities to maintain the same standard
of living. The reason your midwife in the Silicon Valley area charges
more than your net-friend's midwife in St. Paul, Minnesota is that the
cost of living is almost double in Silicon Valley.
Methodology
Used To Calculate The Median Price Of Dental Services In 300 US cities,
which includes a relative
cost calculator
ReloSmart
- This page gives comprehensive comparisons of many aspects of relocating,
including differences in salary necessary to maintain the same standard
of living.
National Physician
Fee Schedule Relative Value File contains the geographic practice cost
indices (GPCIs)
In 2005, Independent homebirth midwives in the UK were charging about
$2500-$3000 for comprehensive maternity/newborn care; this translates into
$4400-$5300 US $$, and I think this was in suburban areas. While
on the subject, here's the care offered by an
independent hospital-based OB in the UK - $3200 for repeat clients
to $4000 for first babies. Interestingly, he charges only $1000 for
a single consultation and cesarean surgery. This is the first time
I've seen such a high value placed on a vaginal birth!!!
My question is- how do you get 100% payment from 100% of the clients?
Everyone I know has a list of clients who never finished paying. I have
about $5,000 dollars of unpaid fees out there somewhere. What is your secret???
It's pretty simple. I expect it. At the consult, I discuss finances
at the end of the visit. I explain that their commitment to pay me equals
my commitment to show up. I state that I really don't like talking about
money in relation to midwifery, that I must be paid to afford to keep being
a good midwife. I have a financial agreement. I allow them to decide their
own financial plan within two parameters...a $500 deposit at the first
prenatal, total fee paid by 36 weeks regardless of time of registration.
They can choose however they want to pay the rest in between, but it must
be decided, written down, signed, returned to me by the next prenatal visit,
and the contract must be adhered to. I explain that I never want to be
put in the position to ask for payment and that I never want money to interfere
in our relationship-building, which I consider very important. I've never
had to ask for a payment. They come with the checks in hand...a couple
of times, families have forgotten their checkbooks, and both these times,
the check was in the mail that week to me. The consultation is usually
the first and last time we discuss fees.
I do OCCASIONALLY (few times a year) reduce my fee. I never tell that
to someone. If they complain, I respond that they need to decide how much
a priority it is for them to have this birth this way. I suggest ways to
find the money. I leave them to take the responsibility to say something
like, "I really want a homebirth, and I really want you to attend me, but
I just cannot find a way to afford this. Please, let's work something out."
If they do, I may negotiate a lesser fee, but I insist it is paid in full
before the birth--I accept no agreements to pay after the birth. I would
prefer to reduce my fee by $500 and know I have it in hand before the birth
than to agree to accept the full fee but in payments after the birth.
I find that, for the most part, I have really respectful and responsible
clients. I think this plan weeds out the more problem people; however,
the vast majority of families that interview with me choose my practice.
I suppose all that will change now that our cease and desist orders are
officially in hand in IL. [sigh] Any openings for a good, experienced midwife
somewhere legal where the winters and summers aren't brutal and where clients
pay their midwives?
My contract reads that payment is to be made in full by the 36th week
of pregnancy or 4 weeks prior to delivery. If not done so, contract is
null and void and there is no obligation for the midwife to attend said
birth and I have the parents read and sign. I tell them I hate to discuss
money and it is their responsibility to pay me and that after the baby
is born, the baby will have needs like diapers, immunizations, check ups,
etc. and that it is very unlikely that I will get the balance owed me after
the baby is born because of the babies needs are greater. Verbally I am
a little more giving. If they ask for help or an extension I will generally
give it. Usually the only ones I have a problem from are "friends".
I hear about how much everyone is not getting paid; well I'm curious,
how much are your charging for your services???
It's interesting to note that in life, in general, people often value
what they pay more for....maybe this would be a good tactic.
I always have clients pay in full by 36 weeks. My philosophy is that
my relationship is with my clients; their relationship is with the insurance
company. I explain that my priority is to keep my practice intimate and
have time for open ended appointments. With a smaller practice, I
can't have a reasonable cash flow if I do not get paid by the insurance
co until after the birth, 8+ months. I also explain that I am like
a savings account for them, as they will get a lump sum from the insurance
company that can be used for the baby's special account or such.
I totally let them set their payment schedule and barter as possible.
In my college town, I have about 30% self pay, low income but resourceful
people, and this prepay plan has not been a problem.
I get all fees upfront, and if they have insurance, I will bill for
them, despite being an amateur at it. That takes me hours, but I often
end up with additional money I would not have gotten if they didn't have
insurance, and the client gets the reimbursement which keeps them happy
about homebirth, so I keep doing it. I knew a midwife once who told
her clients that if she gave discounts, or if they didn't pay her, or if
she extended their ability to pay beyond the birth, that was equal to HER,
the midwife, PAYING to support that family, because it meant food off her
table, bills of her own that SHE couldn't pay, and that she could only
afford to support one family: her own. She said when she posed it
that way, she had no more problems with payment from people. I've
never had to use that tack, but once when I had someone deliberating about
their ability to afford a homebirth, she told me: "Oh, but to pay for it,
we'd have to take out a new credit card, and we just don't like to have
debt." My response was very gently put, "OH, I so understand! When
I don't get paid enough, I have to take out a new credit card to pay for
my living expenses, too, and I just don't like to have debt, either!"
That really hit home with her and personalized me in a light for her that
she could understand (because it was exactly what she would have to do
herself to afford something she didn't have cash for), that I was also
a regular person just trying to make it in the world, that I had bills,
a mortgage to pay, food to buy, a child to support. She took out
a 0% interest credit card (so readily available these days if their credit
isn't bad) and paid me in full.
Sometimes my clients act as if they think I'm unskilled labor that just
shows up to tidy up some of the blood and help the mom into the shower.
I've found it helps if I include something in my paperwork about "the going
rate" for healthcare fees and how they got to be so high. I emphasize
the years of training and internship during which I wasn't earning any
money (and for which I'm personally still paying off the loans!).
I try to make sure they understand also that I spend a lot of time on their
"case" even outside our appointments and the birth - time spent reviewing
labs, writing notes, consulting with other care providers as necessary,
researching special circumstances. Not to mention general work required
to keep a practice going: supplies ordering and re-stocking; paperwork
revision, copying and organization. Professional obligations required
to stay current with the field and your license - reading journals (whether
paper or online) and attending conferences and getting CEUs. And,
of course, everyone's favorite - insurance paperwork!
See also: For Parents - How
to Get the Best Care/Money and Insurance Issues
How To Get Insurance Reimbursement for Homebirth
I emphatically recommend that no one (client/patient and/or provider)
EVER call an insurance company and ask if they 'pay for homebirth' since
there is no such CPT procedure code; and place of service associated with
any code is an entirely separate issue.
Claims
Resolution Services for Healthcare Providers - too busy to follow up
on denied claims? Hire these people!
The ACNM's pages on Midwifery
& Midwife Practice have a great Sample Letter - Payment for Midwifery
Services for clients to submit to their insurance plan to get in-network
coverage rates.
100% Coverage: My Struggle Having a Homebirth
Paid for by the Insurance Company by By Karen E. Wallace, a homebirth
mom's story.
Medela's
discussion of getting insurance payment for lactation consulting applies
well to all interactions with insurance companies.
Alternatives for Overturning
Insurance Denials
Insurance Coverage for Homebirth
Homebirth Exclusion is Unlikely
How
to Fight Back - mostly about getting HMO's to cover alternative treatments
(such as homebirth), but this has good tips for dealing with insurance
plans in general.
Helpful
Hints for Dealing with Your Health Insurance Company
Insurance
Company Report Cards - reports on how well various insurance companies
reimburse providers.
"A fundamental goal of any health insurance company is to avoid paying
claims." Words of wisdom from a Patient
Advocate page.
Glossary of Industry
and Product Terms Used At Blue Cross and Blue Shield of Oregon
Negotiating for Health Insurance Coverage
In some cases, larger companies may "self insure" meaning that the company
itself is actually paying your medical expenses, even though it may be
administered by a health insurance company. If this is the case,
the people in the Human Resources Dept. should be ecstatic when you come
to tell them you're having a baby and would like to save them many thousands
of dollars by having a homebirth.
In any case, if you are not happy with the coverage your insurance company
is providing, let your employer know that this "benefit" that they're paying
lots of money for hasn't been as much of a benefit as they might think.
Ideally, your employer could specifically ask about homebirth when re-negotiating
next year's contract or in selecting another health insurance company.
It's a great idea to write to your insurance company about homebirth,
whether they pay readily or like Scrooge.
Also, it really helps to communicate your happiness and unhappiness
to the people who pay your health insurance premiums, usually your employer.
Talk with the people in Human Resources and tell them how important
it is to you that homebirth be covered by health insurance. It's
great if you've got some supporting materials regarding relative costs,
etc. But the most important thing is letting them know it's on your mind.
Especially in areas where companies are begging for labor, employees
bargain for all sorts of special deals on their employment, including vacation
packages, conference privileges, etc. Why not also bargain for homebirth
coverage.
Every time open enrollment comes up, ask which plans cover homebirth.
It's great to say thanks! to the insurance companies and employers who
cover homebirth sensibly, but remember, it's the squeaky wheel that gets
the oil, so get out there and do some squeaking!
Also, if your insurance company drags their feet, you can take them
to Small Claims Court. I've heard more than one person say that their
insurance company sent them reimbursement almost immediately after getting
the notice about filing in Small Claims Court.
Remember, you are the consumers. You'd expect that insurance companies
would be gung-ho about homebirth because of its cost effectiveness, but
many insurance companies are owned by doctors, and they don't like money
to leave their system. So they're not going to do it because they're
good hearted. They're going to do it because they're losing customers
to other insurance companies that cover homebirth more readily.
We have challenged insurance companies that would not pay for homebirth
and won several times. Get lots of info together and go before their board
presenting them with the info on statistics and cost analysis. It works.
Filing a complaint with the insurance commissioner is the most powerful
weapon you have. contact them by phone first. i know
of many companies that will reverse a decision simply when you mention
the insurance commissioner. they do not want to deal with the scads
of paperwork, etc. that this type of complaint generates. ESPECIALLY
if the insurance company (is it fully insured or a self funded program?)
has withheld vital information like that. i am not positive, but
i think that would fall under the category of bad faith.
to reduce it to barest bones:
Don't automatically assume that just because the midwife is not listed
on your insurance that they will not cover it. Midwives weren't listed
on my insurance or my friends and they are covered....they just didn't
"advertise" it.
My midwife charged $2400 for all prenatal (except lab work), the delivery,
and the post-natal up to and including the 6-week check-up for me and the
baby, all breastfeeding advice, etc. When I added up all the prenatal visits,
the labor/delivery charge for hospital, the post-partum, the pediatrician,
etc. for the conventional route, it came to well over $9871.00 if I did
NOT have a c-section. That was cost to the insurance company, not including
my $1000 deductible, $20/visit co-pay and my 20% co-pay for the hospital.
I challenged my insurance company to a "cost-comparison" and threatened
to appear in person at one of their board meetings to discuss how interested
the stockholders and newspapers would be to find out they would rather
spend 4 times as much for a practice I didn't want if they refused to cover
the midwife at the same 80% as the hospital. They agreed that I was correct
and paid my midwife 80% of the total $2400 global charge.
Actually, if I hadn't had to transport (eventual emergency c-section),
they would have paid all but $20 of her fee as it was a one-time charge
for the delivery, which would have been at my home and therefore fell under
the classification of "home health care", like elderly or injured patients
who have a day nurse come in. Apparently, if she billed it all as a visit
on the day of birth, it would count as one visit with a $20 co-pay.
I've been trying to get Blue Shield PPO to pay the preferred rate after
paying the preferred rate for my son. The "grievance counselor" or
what ever her term was was rather biased against homebirth and they wouldn't
pay the benefits saying I could have received the same care in the hospital
with an OB. I took my appeal to the department of managed healthcare
along with a 2 page letter explaining what happened and how homebirth is
different from hospital birth. A few days ago I received a
concession letter as well as a check for not only the $800 I was asking
for but also 1000 beyond that. They paid the preferred rate based
on the billed amount rather than the "usual and customary" Of course
they wrote a letter saying that this was a one time exception etc.
I will fight again the next time I have a baby though. So, in the
case of PPOs, it pays for your clients to fight too.
I'm in California & our insurance company (Blue Cross Prudent Buyer)
covers homebirth the same as a hospital birth
I had Blue Shield with my last pregnancy. During my pregnancy they told
me they would only pay what they normally pay an OB. After the baby was
born I sent them a letter stating that since I saved them a 10,000 hospital
bill that I believed I should be reimbursed the rest of the fee. They agreed,
and sent me a check for the balance.
I had the HMO, but it was the federal version. It was called Blue Shield
Access Plus. I had to file an appeal twice. First I had to file an
appeal for an out of network provider, and then I went back and asked for
the money for the balance. My baby was almost 3 years old by the time they
paid up, so they weren't exactly accommodating. It took a year just to
get the first half. I'm not sure what it was that made them pay. I just
pointed out the money they saved and that I should hardly be penalized
for saving them a bunch of money.
Another bonus (in addition to government funding) of legislation is
that midwives have hospital admitting privileges. That means if a woman
chooses a hospital birth or a non-emergency transfer from home to hospital
is necessary, the midwife remains the primary care-giver (no nursing or
medical staff is involved) unless a problem comes up that requires a consultation
with an obstetrician.
There are still hospitals/physicians etc. that are reluctant to accept
midwives, but at least the legal framework is there for midwives to practice.
I'm looking forward to getting out there and doing it!
How do others handle insurance payment? I am currently back to client
paying up front with me providing reimbursement paperwork because I got
totally sick of the hassle and "lost" claims submissions by almost all
the companies. May try again once I get computer shareware for submitting,
have heard claims get pd within 2 wks (8-10wks pp has been my avg.)
We also ask the client to pay on a regular schedule throughout the pregnancy,
with final payment due at 36 weeks. None of the insurance companies will
accept a claim before the birth, so it's not even filed until after the
birth. The insurance company reimburses the client. Sometimes it happens
within a couple of months. One Champus reimbursement took 11 months.
We tell the client in the beginning that we cannot guarantee that insurance
will reimburse our fee. LDEMs are not even acknowledged by insurance companies.
However, if they list reimbursement for CNMs then they usually reimburse
LDEMs. Still, the client has to want a home birth whether or not insurance
pays for it. Most folks with insurance can afford our fee even if it's
not reimbursed, and it also gives them more options for back-up arrangements
if they have insurance.
Thank you for some new codes. How do you go about coming up with fees
for each? Do you check with each company beforehand to see what is customary
in your area? The "customary" fee seems to differ so much between companies:
$2250-3500 before deductibles, etc. is normal here.
I've been doing a flat fee, then listing all the codes I had under,
but obviously have ripped myself off with this approach.
The whole insurance thing never ceases to humble me. In terms of coming
up with fees, figure out what you want as a flat fee for your services
and then set the fee. The insurers, medicaid included, will reimburse you
or whatever they allow, whichever is lowest.
You might call various and sundry offices in your area to see what they
are charging (or have a friend do it) to get an idea of what the common
charge is for services. This info is not always easy to get. I did this
once for my old employer to find out where we were falling in the spectrum,
explaining that I needed to have whatever it was (an office visit, physical,
pap, etc.) and would need to pay for myself as I had no insurance. It was
still hard to get a quote -- most of the offices tried to steer me toward
the Basic Health Program in WA (here for people who are uninsured) rather
than tell me their prices! But I did succeed in collecting data.
Unfortunately, due to anti-trust laws, we are not all supposed to go
around comparing our charges or sharing that info -- this is due to concerns
about price fixing. This is another reason why you can't just call various
practices outright and ask what they charge practitioner to practitioner.
Another way of setting your charges is to look at what it costs you
to provide the particular service. Having been through this, I think that
it may be the wisest course. None of us want to cheat ourselves, but ultimately,
how we do business and what we charge has to be based in part on what it
is costing us to provide the service.
And some insurers will send you a list of what they reimburse on common
codes you use if you send them your list with what you charge for each
category.
I just wanted to tell you all that, at least in CA, it is illegal to
charge more to people with insurance than those without. This is where
a sliding scale comes in handy.
I also wanted to say that the first practice I trained in went out of
business because they were billing insurance and having to wait and fight
for every bill. They were, in effect, loaning their money to the insurance
company. I now have the people pay on a regular basis and then have their
insurance reimburse them. The companies reimburse the parents MUCH faster
than they do the providers.
There is a company that will pay before the birth IF you give a 10%
discount on the bill; they cover the "usual and customary" for my area,
leaving a decent reimbursement once deductibles etc. are paid. I like to
tell clients about their coverage because they are reasonable for families
and will send out info if requested. Good Samaritan, (317) 894-2000. This
is one of the companies with a flat monthly fee, a newsletter and prayer
list for members, etc. I do know they are easy to work with.
There is supposedly computer shareware available for billing insurance
that produces faster results on collections: 2wks avg I have been told.
The mw's husband who said he'd do an in-service on collections got busy
and forgot, I have several calls into him and will continue to bug. This
guy has a private therapy practice and approached me with the info.
I have had success with a variety of companies in collecting fees IF
time isn't considered as part of the equation. I do use my SS#, codes and
list OV/HV etc. I have also begun to give all clients with insurance our
state insurance board booklet with rules/regs governing insurance payment.
The board says they want to hear from clients, not the provider, on their
complaint form when a problem arises. Reading the rules was enlightening:
most of the companies I have dealt with do not follow the rules re: notification
of receiving the bill or the time frames required to pay the bill. It amazes
me how often they "lose" certified mail.
There is a policy that covers mw care and pays before the delivery if
you provide a 10% discount on the total fee: Good Samaritan. This company
has been pleasant to work with. It has been worth it for me to do this
rather than wait the 3 mo avg after care-f/u.
Can someone explain how they get around "usual and reasonable" where
we are compared to OB pricing?
I am currently in a phase of expecting payment at 36wks with bill and
supporting paperwork (documentation, IRS W-9) provided to the client. Having
9 outstanding insurance bills all at once 2m ago did me in emotionally---I
hate the endless f/u hrs spent on insurance. However, learning to better
navigate the insurance maze might change my mind.
As a licensed midwife in Arizona I think about 50% of insurance
companies pay for licensed midwives for homebirths. Prudential, Aetna,
Blue Cross Blue Shield and many more. Not the State health care though.
In my practice I do mostly hospital births but also attend home births.
In Washington state most insurance companies cover homebirth. Medicaid
does not, but the rumor is that they will start in January 1999 (of course
there have been semi-annual rumors for two years). One of my clients
on a managed care program through state medicaid has received approval
for a homebirth from the HMO already, and I understand that another HMO
on the west side of the state also pays for homebirths for the medicaid
clients. Due to a state law sponsored by our WONDERFUL insurance
commissioner Deborah Senn, if the insurance company covers births they
must cover all categories of providers who do births - meaning LMs and
CNMs and MDs.
Jan., 2008: Both
the House and the Senate in New Hampshire have passed bills that mandate
insurance companies to cover home births! The two bills
were slightly different, so not quite ready for the Governor’s signature,
but the bills passed by big margins. This is a terrific development for
home birth and perhaps and example that will be useful for other states.
Here is a
decision from the NYS Insurance Department :
2) Such coverage is available through the Healthy New York program.
3) The practice of midwifery is regulated by the Education and Health
Departments.
Florida
law requires that maternity care coverage include the services of certified
nurse-midwives and midwives licensed pursuant to Chapter 467 and the services
of birth centers licensed under ss. 383.30-383.335.-- emphasis supplied
[See Florida Statutes, s.626.6406; s.627.6574; and s. 641.31(18)].In requiring
such coverage, Section 467.002, F.S. specifically recognizes the need for
a person to have the freedom to choose the manner, cost and setting for
giving birth. The law requires that maternity coverage include midwifery
services and provides that an insured or enrollee be given the option of
choosing the setting for receiving such services. Therefore, no HMO contract
or insurance policy may directly or indirectly deny reimbursement for midwifery
services rendered in a home birth setting.
A
Florida web page that lists all their mandated coverage clauses:
"A policy or HMO contract that provides coverage for maternity care
must cover the services of certified nurse midwives and midwives licensed
under Chapter 467, and birth centers licensed under SS. 383.30-383.335."
bc/bs HMO will pay me, they are mandated by law to pay for alternatives
to their providers. Montana has laws that state the any co. selling
insurance here must pay licensed providers except the blues.
Improving Access
to Nurse-Midwifery Care Act (S. 911 and H.R. 872) is federal legislation
to increase the reimbursement rate that midwives receive from Medicare
to 100% from the usual 65% of what a physician receives for the same services.
There are some insurance companies that have a specific homebirth exclusion.
In 2007, the insurance company that comes most readily to mind is Aetna.
(I will say that even though Aetna claims not to cover homebirth,
they actually have covered my homebirth claims well, all the same.)
In any case, even if they "don't cover homebirth", this doesn't mean
that they won't cover any of the services provided by a homebirth midwife
in the extensive, comprehensive cycle of care. After all, the homebirth
"procedure" described by 59409 is just one hour out of the 20-60 hours
that I spend with my homebirth clients, and it represents just $3000 out
of the $10,000 - $20,000 fee for the equivalent care provided in the hospital-based
care model.
Even if you don't get paid for the 59409 claim item, you can still file
separate claims for all the prenatal care and for all the maternal postpartum
care and for all the newborn care. Maternal postpartum care includes
both the followup visits that occur in the days following the birth and
the recovery/observation care in the immediate postpartum, which is typically
3-6 hours in my practice.
Care in the immediate postpartum (i.e. immediately after the baby is
out) can even legitimately be billed as a separate episode of care.
If you want to be absolutely by the book about this, you can have your
assistant keep an eye on things while you step outside the house and off
the family's property. This effectively creates a new episode of
care when you go back into the house. You can be clear that the care
in the immediate postpartum is a separate episode of care from the birth
itself by using modifier 25:
25, "Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician on the Same Day of the Procedure or Other
Service,"
And don't forget that you can bill separately for all the newborn care,
too!
And in California, all care provided within 48 hours after the birth
is mandated to be covered under the "No Drivethrough Deliveries" law:
http:
I have some wonderful news on how to get HMO’s and PPO’s to pay for
midwifery charges. Recently, I billed a HMO $6,995.00 for a long
delivery. The HMO denied charges stating that the provider was not
included “in-network.” So I called the insured (dad) and ask him
if he knew his benefits manager personally. He did and gave me her
number. I called the benefits manager in Human Resources and she
was extremely nice and adored the pictures of the new baby. When
I informed her that the insurance company was denying charges, she said,
“let me make a call then call them back in about 2 hours.
When I called back they told me that a note “now” appeared with the
claim(s) and that now they are being processed at 100% billable charges
and that I should be receiving the check before Christmas. Merry
Christmas, Ms. Midwife!
So, if you have clients that have “self-funded,” plans (insurance plans
where the employer pays for medical out of pocket), ALWAYS get the benefits
manager involved. Bring up the Mother’s and Newborn’s Protection
Act 1996, and Florida’s clarification 627.6574 and the warning bulletin.
Of course, it is up to the good will of the Benefits Manager, so have the
insured call or you call and give them a brief explanation of why the home
birth treatment plan is desired and the blessings to the family (employee)
One of my midwife friends had a client go to her insurance board (arbitration?),
and she got coverage for her homebirth by telling them she wanted someone
who would honor her desires for a home birth. So they paid.
In 2003? there was a Supreme Court ruling that required HMO's to enter
into contracts with all kinds of providers. If you have more information
about this, please e-mail
me. Thank you.
To get payment from an HMO, I would have the mother call her insurance
carrier and request an "in-network midwife." They will
Sometimes you can get around the HMO limitations by obtaining a 'referral'
or 'transition of care' letter but it requires an inordinate amount of
work on the front end and very few docs will cooperate. I have probably
been paid but somewhere in the neighborhood of 60-70%? I would have to
go over my records to know for sure since individual plans have variants.
8/18/06 - The
final rule changes existing regulations to revise the definition of
'labor' in §489.24(b) to state that: "a woman experiencing contractions
is in true labor unless a physician, certified nurse-midwife, or other
qualified medical person acting within his or her scope of practice as
defined in hospital medical staff bylaws and State law, certifies that,
after a reasonable time of observation, the woman is in false labor."
Background information
As of June 14, 2006
See also: Discharge Time or Duration
of In-Home Monitoring for International Protocols
Most midwives are so committed to their work and their clients that
they would never leave the birth home before the mother and baby are stable.
But many insurance companies simply cannot understand why midwives bill
for more than "routine obstetrical care", which assumes the doctor leaves
the birth once the placenta is out and the suturing is done. This
section discusses the specific reasons why homebirth midwives stay longer
at a birth than a doctor practicing in the hospital.
In Kansas City the free standing birth center regulations are 6-24 hours
PP. They need to be nursing okay, voided, eaten and showered as desired.
The state made the rules on time frame not the midwives.
In our southern California birth center, we see go home around 4 hours
PP. They have to have good vitals, have showered, urinated, eaten
a meal and have nursed. I also then come to their home at about 24
hours PP.
See also: Preventing Postpartum Depression
After the
Afterbirth: A Critical Review of Postpartum Health Relative to Method of
Delivery by Noelle Borders, CNM, MSN
"Clinicians must initiate the discussion about postpartum health antenatally
and encourage women to enlist needed support early in the postpartum period.
Flexibility in the schedule of postpartum care is essential."
Does
continuity of care by well-trained breastfeeding counselors improve a mother's
perception of support?
" . . . the mothers were more satisfied with emotional and informative
support during the first 9 months postpartum. The results lend support
to family classes incorporating continuity of care."
A
Mother's Feelings for Her Infant Are Strengthened by Excellent Breastfeeding
Counseling and Continuity of Care
CONCLUSION. . . . guaranteed continuity of care strengthened the maternal
relationship with the infant and the feelings for the infant.
The Postpartum
Visit: Is Six Weeks Too Late?
"Although quality evidence may not exist that the six-week postpartum
visit is beneficial, evidence does suggest that some women may benefit
from an earlier visit. While "better late than never" may be true in some
situations, physicians need to recognize that the traditional timing of
the postpartum visit may limit their ability to help some women. Further
research is needed on the timing and content of the hallowed postpartum
visit."
2006/036 New NICE
guidelines on postnatal care will give babies best start in life
It recommends personalised care for mothers—in which an individual care
plan would be drawn up soon after birth—and a move away from the more common
"tick box" approach.
From: Health
Benefit Mandates:
"There is a sizable literature that focuses on early discharge and various
measures of birth outcomes. Three systematic literature reviews have been
conducted (Britton, Britton and Beebe 1994; Braveman et al. 1995; and Grullon
and Grimes 1997). The 1994 review covered literature going back as far
as 1943, concluding that “almost all published studies suffer from substantial
methodological limitations” including the problem of having insufficient
statistical power to detect differences in rehospitalization risks between
early and late discharge groups. Braveman et al.’s review of 18 studies
published between1975 and 1994 concluded that “there are no data supporting
the safety of early discharge when there is no follow-up” but conceded
that while early discharge in combination with home visits may be safer
than long hospital stays, none of the studies was sufficiently large to
demonstrate this. Grullon and Grimes’ review of articles published between
1966 and January 1997 also concluded that “the current data do not support
or condemn widespread use of early postpartum discharge in the general
population.” Several subsequent studies produce conflicting results and
also have various methodological flaws."
The
safety of early postpartum discharge: a review and critique.
CONCLUSION: The current data do not support or condemn widespread use
of early postpartum discharge in the general population (class C recommendation).
Early postpartum discharge appears safe for carefully selected, consenting
patients. Whether these data can be extrapolated to the general population
of pregnant women remains unknown.
The Oregon statutes
say:
(d) Follow-up: Postpartum follow-up care must minimally include: visits
during the first 24 to 36 hours following birth, at 3 to 4 days to assess
mother and baby, and a visit or telephone consultation within 1 to 2 weeks
post-birth. The primary care giver must continue to monitor appropriate
vital signs, and physical and social parameters including adequacy of support
systems and signs of infection. Information must be provided regarding
lactation, postpartum exercise, and community resources available. Education
may be provided on various family planning methods. Those midwives who
are qualified to fit barrier methods of contraception may do so at the
six-week check up.
What does
the evidence say? about continuity of care.
Guidelines for Coding Jaundice Follow-up
Encounters - Key: Treat 'bili checks' as sick, not well visits. from
the Pediatric Coding Alert/Sept., 2005.
Breastfeeding-Associated
Neonatal Hypernatremia May Be Missed [Medscape registration is free]
(Reuters Health) Sept 08, 2005 - When breastfeeding is not properly established,
neonatal hypernatremic dehydration may occur and, according to a study
published this week, it is relatively common but can be difficult to recognize.
In the September issue of Pediatrics posted online, clinicians explain
that neonatal hypernatremic dehydration results from the inadequate transfer
of breast milk from mother to infant. Poor milk drainage from the breasts
leading to persistently high milk sodium concentrations may exacerbate
neonatal hypernatremia.
According to Dr. Michael L. Moritz of Children's Hospital of Pittsburgh
and colleagues, among 3718 consecutive term and near-term breastfed neonates
hospitalized during a 5-year period, 70 had breastfeeding-associated hypernatremic
dehydration -- an incidence of 1.9% -- which is "significantly higher than
the reported incidence of hypernatremia attributable to all causes among
hospitalized children, adults and elderly subjects."
It's likely that as more women initiate breastfeeding in response to
strong encouragement by the American Academy of Pediatrics, the "incidence
of breastfeeding-associated hypernatremia will increase and that currently
the condition is under-recognized," the authors note.
The vast majority of the infants with breastfeeding-associated hypernatremia
in the current series were born primarily by vaginal delivery to first-time
mothers who were discharged within 48 hours of giving birth.
Nonfatal complications occurred frequently. Most of the infants presented
with jaundice (81%) or sepsis-like symptoms such as fever and lethargy.
Sixty-three percent underwent a full sepsis evaluation with lumbar puncture.
None of the infants had bacteremia or meningitis.
Nonmetabolic complications occurred in 17% of infants, most often apnea
and/or bradycardia. Hypernatremia was of moderate severity, with serum
sodium concentrations ranging from 150 to 177 mEq/L and a mean weight loss
of 13.7%. None of the infants died.
Summing up, Dr. Moritz said that "new mothers, especially first-time
mothers, may have difficulty producing an adequate supply of breast milk
in the first week after birth because of physiological issues or because
the baby may not be able to latch on properly."
Pediatricians and parents need to be aware that when this occurs, the
risk of dehydration is much higher than previously assumed, he continued.
"If infants are becoming dehydrated, we strongly recommend that the breast
milk be supplemented with formula or breast milk from another source,"
Dr. Moritz said.
This is an excellent justification for the medical necessity of an in-home
breastfeeding assessment and neontal check-up around 5 days postpartum.
Breastfeeding-associated
hypernatremia: are we missing the diagnosis?
RESULTS: The incidence of breastfeeding-associated hypernatremic dehydration
among 3718 consecutive term and near-term hospitalized neonates was 1.9%,
occurring for 70 infants. These infants were born primarily to primiparous
women (87%) who were discharged within 48 hours after birth (90%). The
most common presenting symptom was jaundice (81%). Sixty-three percent
of infants underwent sepsis evaluations with lumbar puncture. No infants
had bacteremia or meningitis. Infants had hypernatremia of moderate severity
(median: 153 mEq/L; range: 150-177 mEq/L), with a mean weight loss of 13.7%.
Nonmetabolic complications occurred for 17% of infants, with the most common
being apnea and/or bradycardia. There were no deaths. CONCLUSION: Hypernatremic
dehydration requiring hospitalization is common among breastfed neonates.
Increased efforts are required to establish successful breastfeeding.
Newborn
early discharge revisited: are California newborns receiving recommended
postnatal services?
"The California Newborns' and Mothers' Health Act of 1997 mandates coverage
of home or office visits in accordance with the American Academy of Pediatrics'
recommendations for newborns discharged early. However, two-thirds of neonates
discharged early had untimely follow-up.
"The most common complications associated with early discharge, like
jaundice, poor feeding habits or birth defects, often are not detectable
until the third to fifth day of life, lead author Dr. Alison Galbraith
told Reuters Health.
"'The risk for these potential complications of early discharge could
be reduced if infants received follow-up from a healthcare provider sometime
between days three to five of life when many of the complications arise,'
Dr. Galbraith, from the University of Washington, said.
"
The Oregon statutes
say:
(d) Follow-up: It is recommended that follow-up care include: a visit
within 24 to 36 hours following birth, at 3 to 4 days, visit or telephone
consultation within 1 to 2 weeks post-birth, and a visit at 6 weeks of
age to monitor appropriate vital signs, weight, length, head circumference,
color, infant feeding, and sleep/wake and stool/void patterns. Information
must be provided about infant safety and development issues, immunization,
circumcision, and available community resources.
Changing Outcomes:
Managing Neonatal Hyperbilirubinemia and the Special Needs of the Near-Term
Infant - "The most common reason for readmission of a newborn to the
hospital in the first 2 weeks of life is jaundice."
Management
of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
- AAP Guidelines - [PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316]
"In every infant, we recommend that clinicians . . . provide early and
focused follow-up based on the risk assessment . . . "
Efficacy
of breastfeeding support provided by trained clinicians during an early,
routine, preventive visit: a prospective, randomized, open trial of 226
mother-infant pairs.
This study is about office visits, but I would think that it would be
an easy argument that a home visit is even more effective than an office
visit, plus it doesn't introduce additional risk factors in the mother's
and baby's expending the energy to travel and their being exposed to germs
in the health care office.
Agreement
allows Medicaid to pay uninsured midwives
A new agreement between the New Mexico Human Services Department, managed
care organizations and the state's midwives means that midwives will once
again be paid for delivering babies for Medicaid-eligible women outside
of hospitals without holding medical malpractice insurance.
I'm just starting a new practice, and since it will probably take a
while for me to get the Tax ID and UPIN numbers, I am wondering if any
of you billed BEFORE you got a UPIN from Medicare?
file with your social security # for a tax id #. upin is for medicare
and your not filing to medicare. in my state medicaid would try and
force you to get a medicare number but the medicare people said that i
didn't need a medicare # and the state (medicaid) was just using medicare
to qualify us so they didn't have to bother. i filed for years on
nothing but my ss#. and i did end up with a medicaid # and no upin.
Medi-Cal Coverage of Homebirth
I'm finally far along in the process of being credentialed as a contracted
provider. An insurance rep is scheduled to come tomorrow to do a
site visit to check things out. What will they be looking for?
You might want to have your state regs, license, and protocols ready
for her inspection.
I once went through a site check, and they were looking for administrative
things such as labs' being initialed, forms attached to charts, drugs locked
up. They also wanted certain informed consents and a living will
in each chart.
Always call to reconfirm in the beginning of pregnancy care to verify
the client has insurance, what their deductible, if they've met it, what's
their co-pay, is there a cap that once has been gotten to, that the company
pays 100%., claim mail address -to save you time and effort later on .
At this time is when you ask them whether they accept global or itemization.
Some prefer global unless she has gone out of "normal prenatal care".
See also:
ICD Codes - "International Classification of
Disease" - These codes are maintained by the WHO and are accepted all over
the world. In the US, HCFA (Health Care Financing Administration)
has revised them into the ICD-9-CM. The next revision is ICD-10.
These codes are used for diagnosing rather than services rendered.
On the HCFA form they go under #21 and then the proper no. (1, 2, 3 etc.)
is placed to correspond with the proper diagnosis code.
CPT Codes - "Current Procedural Terminology"
- these are set by the AMA and can change yearly. Used for services
rendered.
Sample HCFA Statement - this contains
the essential elements for an insurance statement, in HCFA format
Instructions
for the 1500 claim form from medicare - the instructions are for both
the electronic and the paper versions
The Aetna Provider web pages have a nice HCFA-style
web-entry claim form with explanation!
Sample Billing Scenarios for a
Homebirth Midwife providing comprehensive prenatal, birth and postpartum
care. This includes the care normally provided in hospitals by nurses
for labor monitoring, the pediatric team for newborn resuscitation, the
nurses for postpartum and nursery care, and the pharmacy/supply room for
birthing tubs and medications.
Medela's Reimbursement
Guide is a good place to learn some basics about insurance billing,
although it's focused on lactation consulting.
Superbill
Step by Step Explanation - Evaluation & Management (E/M) Codes
I like this sample
SuperBill
I bill a global fee but also itemize things that aren't included in
global. When you bill global think "OB". What would that code cover
if you were an OB - things like your prenatal appointments, walking into
the delivery room with the head on the perineum, catching the baby, sewing
mom up and then checking on her again the following morning before discharge
and then again at 6 weeks pp. Then think about what things the hospital
would be charging the moms insurance for..... I always charge for
the supplies - OB supplies/set-up, sterile suture tray if done, any O2
supplies, needles for injections, the meds we use, etc. You
can also bill for educational materials you give, nutritional counseling
if the mom needed additional, even oxygen therapy. We also bill separately
for the baby - initial stabilization and attendance at birth, newborn exam,
newborn supplies and the visits after the birth. I feel like I have to
itemize all the extras just to help the moms get reimbursed adequately.
The insurance companies dock the global fee down so much below what we
charge it's ridiculous. I understand that they are comparing us to OB's
and that's like comparing apples and oranges. I tried for awhile adding
.22 for unusual circumstances and documenting the difference but it was
always a hassle and rarely got much more in return. Itemizing like
this seems to work much better - it's what the ins. co's understand.
59400
- a detailed description
Whenever I send in a claim, I send along a page with an explanation
for each line. When I've billed the G0154 I make note that "The delivery
code definition for 59400 does not include direct patient care and monitoring
provided in the hours before and after the birth (labor and postpartum).
I have charged for x hours of my time at the birth as an RN in addition
to the delivery code. If you would prefer that these be billed as
prolonged care by provider, I can resubmit at the higher rate."
I figure that although they might balk at paying for prolonged care
by provider that goes on for hours and hours at a normal birth, they should
have no excuse for not paying for nursing care. I subtract an hour
of the time I'm there from the G0154 to allow for he time that I
am doing the delivery part of the birth (which would be included with the
59400.
Licensed
Midwives Guidelines from Regence
Blue Shield [currently unavailable]
A
nice introduction or review about OB billing
Helpful
Hints for Filing Claims for respironics.com
Don Self's web
pages have lots of great forms related to dealing with insurance companies.
COLLECTION &
REIMBURSEMENT from The Professional
Association of Health Care Office Management
Coding Resources
- a collection of links to helpful sites.
Coding for Birth
Professionals from birthwithlove.com
Medscape articles about coding:
Getting Paid: Are
You Coding Accurately?
Correct Coding
Helps You Get Paid What You're Worth
Search
for other "Coding" articles
Pocket Guide to Clinical
Coding - used to be available for $14.95, now appears to be available
only in a large, expensive set?
Risk-Based Coding
from Tray Dunaway, MD
Here's ACOG's page on Coding
and Nomenclature
Codes Collected from the Midwife Lists
- a lot of these are old and are here primarily for backward compatibility.
You're advised to find more recent and reliable resources.
Completion of the
HCFA-1500 Claim Form - basic guidelines for completing the HCFA form
CIGNA's
Notice to Paper Claim Billers - more good tips for completing the HCFA
form. CIGNA also has a customer service line to answer questions
regarding the completion of the HCFA 1500 claim form - 615-251-8182.
Medicare Offers FREE
National Education and Training Program , including a
module on Women's Health
Healthcare Professional Publications, including the Medicare
Part B Reference Manual (in HTML) and Medicare
Part B Reference Manual (in PDF Acrobat format)
L)Medicare
Part B - Physician Fee Shedule
CIGNA HealthCare
Medicare Administration
Modifiers
for Medicare Billing
HCFA
Place of Service Codes (11- Office, 12 - Home, 21- Inpatient Hospital,
25 - Birthing Center) [NOTE - When you use Home as the Place of Service,
do not include facility address.]
A
table of which services should occur where.
California Law - Midwife Payment Through Preferred
Provider
Health Care Financing Administration
(HCFA), the federal agency that administers the Medicare, Medicaid
and Child Health Insurance Programs.
American Academy of Family
Physicians (AAFP) pages on Coding for Intrapartum Care and Other
Obstetrical Services
They have a terrific description of 59400 -Routine obstetric care including
antepartum care, vaginal delivery (with or without episiotomy, and/or forceps)
and postpartum care
"The word routine and the fact that these codes are for use only in
situations where one physician provides all three components of the global
service indicates the limits of these codes. Family physicians can best
understand these "global care codes" by understanding their three component
parts: (1) antepartum care; (2) delivery; and (3) postpartum care.
"According to CPT, routine antepartum care includes initial and subsequent
history, physical exams, recording of weight, blood pressure, fetal heart
tones, routine chemical (dipstick) urinalysis, monthly visits up to 28
weeks gestation, biweekly visits between 28 and 36 weeks, and weekly visits
until delivery. Under the CPT definition, a physician should not submit
more than seven maternity care visits in the first 28 weeks. Instead, the
physician should code any other visits (even routine maternity care visits
more frequent than once a month) separately. The same applies for biweekly
visits between 28 and 36 weeks.
"The CPT manual states that delivery services include admission to the
hospital, the admission history and physical exam, management of uncomplicated
labor, vaginal delivery (with or without episiotomy, with or without forceps),
or cesarean delivery. Please note that the manual specifically refers to
"uncomplicated" labor. If there are any complications, then one should
use additional codes." [Ed: Please note also that "labor management"
in this context is not the same as what a homebirth midwife means by "labor
management", i.e. personally being there to assess vitals and guide the
progress of labor, which is a task performed in the hospital by nursing
staff.]
"The CPT manual states that postpartum care includes hospital and office
visits following vaginal or cesarean section delivery. Of course, this
includes not only the routine post-delivery hospital care offered by a
family physician, but also the postpartum visits in the office. However,
this code does not include any laboratory services provided at the postpartum
visit (e.g., PAP, blood work)."
Unusual Insurance Billing Codes extracted
from above.
For contact information, call CAM at 800-829-5791 or write P.O. Box
460606, San Francisco, CA 94146-0606
They are for sale -- 20 forms for $7.50 pp.
I'll also send a sample one filled out, the code numbers for prenatal
care, classes, labor support, delivery, lactation consulting, doula care,
gynecological care, as well as hints from the person who taught our workshop.
She's a former midwife, now insurance billing specialist in her husband's
chiropractic office.
MMA, 4220 E. Loop Road, Hesperia, MI 49421
Patrice Bobier, Treasurer of the Michigan Midwives Association
I order my forms from Medical Arts Press 1-800-328-2179. As low
as $26.95 for 100.
I call the insurance co. after the first visit and ask how they expect
to be billed. Most want global billing and almost all will pay only after
the delivery. Global billing is easier - one code v22.2, or The ICD-9 .(
I think that's 95400). I usually include both the diagnosis code and the
ICD-9, to cover all my bases. I like to send a bill of some kind early
on in the pregnancy, or do the midwife equivalent of the "pre-admit". It
gets them into the computer and should shorten the waiting period between
billing and collecting. Insurance companies seem to be very expert at the
run around, so I like to include everything possible with each bill- the
codes, my tax ID#, my social security #, and every piece of info I have
on my client's ID info. They will certainly use confusion on levels of
midwifery practice as an excuse to delay payment. It's a good idea to call
the office to pre-register. It will probably be obvious who knows what
they're talking about and who doesn't understand midwifery. Get names and
try to stick with one knowledgeable person. After you send the bill, follow
up to see how the processing is going.
Which, if any insurance companies, reimburse? What codes do you use?
If you are not licensed in your state, do you use SS#?
I have received reimbursement from some insurance companies - CIGNA
is one (I think they thought I was a CNM) but that was only once, the second
time claim was rejected; Transport Life, Guardian (submitted itemized bill).
CIGNA is the only insurance company I've had much trouble with --I can't
stand CIGNA! Very little problems with Blue cross Blue Shield, Globe, Aetna,
Prudential, Principal Mutual, Travelers. American Medical Securities is
very easy to deal with. I don't know if Brokerage services is a state HMO,
but they can be a pain. It takes a while, but you'll get paid.
A lot of them only reimburse CNMs. That hasn't been a problem for me
as I sometimes work with a CNM and she can supervise the care for those
guys. But I think that often, an insurance co. (like everyone else) is
poorly informed on midwifery. I do send a copy of my license, and a letter
of explanation to any insurance company who initially refuses to cover
my services. I include a cost comparison, and some info on my statistics.
I've never had an insurance company who covers OB costs refuse to cover
my services after getting the info.
Insurance reimbursement for me is iffy. Some companies do sometimes,
and some never do. We always have the client pay us, then we submit the
reimbursement form for her to get reimbursed. I make up a "bill" on the
computer. It has all the "numbers" that have ever been associated with
reimbursement in my experience. It includes my social security number ,
and a TIN taxpayer identification number which I can't remember how we
got but was required by one insurance company about five years ago. About
ten years ago, an out-of-state Blue Cross company reimbursed us (referring
to us as CNMs which we are not and never implied). They gave us an ID number.
It goes on all our bills now. We are licensed as lay midwives, and those
numbers go on the bill, too, in addition to the newly acquired CPM numbers.
Then we also list the codes. In a regular bill for full services, the code
is 59400.
The problem I have is that I think that the insurance companies only
pay the midwife fee, such as what the ob/gyn bills, and doesn't pay for
the "birthing fee"...which I feel should also be billed and paid for since
in a hospital birth there are many charges for monitoring the baby and
mother, labor sitting, supplies (my client's buy a birth kit but I supply
things like O2, sutures, laboring herbs and remedies, etc.) and of course
all those many post-natal contacts and visits. For instance, on my last
billing to an insurance company I billed the standard 59400 for $2400 and
received $1300!!! This is pretty much the average I receive. This is even
less than my cash rate, and there is no way that I think that is a fair
fee for giving someone nearly a year of care until being paid!!!
I guess I have learned my lesson and I will start to bill using every
code and fee I can come up with! Anyone have a sample of one of their bills
that include all these other fees?? Marguerite...are you there...how does
your center bill????
This is my biggest gripe with insurers. We beg and scrape for every
cent we get when as midwives we provide: labor mngt/support, supplies,
delivery, postpartum, PP home visits, etc., etc. Spend many more
hours
than an OB that shows up at complete & pushing! The insurers don't
seem to bat an eye at the hospital costs and we have to explain every little
thing -- "What do you mean by supplies?" Like chux, gloves, cord clamps,
O2 ... !! Duh! Not to mention the birth assistant, who types the birth
cert and does the billing, etc.
I think it just irritates me the most when they give us such a hard
time when we are SAVING them money! Why doesn't this make sense to them?
One ins co told my client that they'd pay 80% if she delivered at the hospital
with an OB, but only 70% if she delivered OOH with a midwife! So they'd
rather pay more for her to go to the hospital? I just really don't see
how this makes sense.
There are a couple of ins co's, that I know of, now saying they'll pay
100% if the woman goes to a birth ctr (Great West, John Hancock). I hope
more of them will wise up, get smart.
What I do is bill or precertify as soon as the client starts prenatal
care. Then we know whether they honor LMs. If they don't, I send them a
form letter about my services, and I also suggest that the client challenge
her insurance company's policy. I've never had it fail in the end.
"...unbundling occurs when a single procedure with two or more explicitly
described components is broken into its component parts and reported with
several CPT codes instead of the single CPT code for the combined service.
A simple example of this type of unbundle can be illustrated with the procedure
for a combined abdominal hysterectomy with colpourethrocystopexy.
Because the two components of this procedure are frequently performed together,
a combined code 58152 has been assigned to describe this service.
However, it is also possible to perform each of the components separately
(abdominal hysterectomy 85150 and colpourethrocystopexy 51840 or 51841).
When the combined procedure is performed during a single surgical session,
it must be reported with the bundled CPT code 58152. If it is reported
with code 58150 in conjunction with 58140 or 58141, it is considered to
be unbundled.
Unbundling, whether intentional or not, is considered by payors to be
a form of fraudulent or reckless billing. The rationale is simple.
Unbundled services will frequently net more reimbursement than reporting
the single bundled CPT code.
HCFA has adopted Correct Coding Initiative unbundling guidelines, an
evolving list of codes that cannot be reported in combination with other
codes for Medicare claims. CPT does not have a specific guideline
for unbundling. Instead, payors and other interested parties have developed
guidelines for bundled procedures from information that is listed in CPT...Payors
interpret the rules and guidelines for separate procedures differently.
Payors may base payment guidelines on definitions established by outside
consultants or by their own internal sources. Some payors strictly
interpret CPT while others may be more lenient in how they interpret separate
procedure guidelines....The following may be considered unbundled:
59409 Vaginal delivery only (with or without episiotomy and/or
forceps);
Suppose the physician performed the delivery but did not plan on seeing
the patient for postpartum care. However, the patient came in for
postpartum care when the claim for the delivery had already been submitted
to the payor. The claim for the "postpartum care only" could be denied
by the payor. The payor may weigh the fee for 59430 against the difference
between the cost of 59409 and the fee for delivery including postpartum
care (59410). If the difference in the amount was not more, the payor
may reimburse for 59430. For accurate coding, the claim should have
a corrected billing sent, reported as:
59410 Vaginal delivery only (with or without episiotomy and/or
forceps); including postpartum care"
Whew! Sorry that was so long. Anyway, if you unbundle with
private payors, they may consider it fraud, but most likely they will either
reject the claim or bundle it back up for you. However, if you unbundle
with public payors such as Medicaid, and they feel it is a pattern, there
may be jail time in your future, because it's a criminal offense.
2007 ICD-9-CM
Volume 1 Diagnosis Codes from icd9data.com - This has great descriptions
Complications
Of Pregnancy, Childbirth, And The Puerperium 630-677
ICD-9
Code List from tdrdata.com, Timely Data Resources, Inc., a gateway
to our integrated, on-line epidemiological databases. This includes
a great searchable
database.
ICD-9
searchable database from chrisendres.com. This has the Tabular
Index to Diseases, with the relevant sections for
Official ICD-9-CM
Offical Guidelines for Coding and Reporting effective April 1, 2005.
ICD-9
Provider & Diagnostic Codes
Arnold M. Epstein, M.D., Thomas H. Lee, M.D., and Mary Beth Hamel,
M.D.
NEJM, Volume 350:406-410, January 22, 2004, Number 4
Comparison Pricing for Maternity Services
Birth Center $3500 - $8300
Hospital $4300 - $16,000
Cesarean $9300 - $26,000
Consumer Activism in Negotiating Coverage for Alternative
Healthcare/Homebirth/Midwifery
HIPAA Protections
What is a preexisting condition? A preexisting condition is a
medical condition present before your enrollment date in any new group
health plan.
Setting Fees
Fee Policies
Leigh Ann Backer
Fam Pract Manag 11(7):43-47, 2004
Credit Options
Benchmark Fees
Geographic Multiplier
Getting Payment from Clients
Health Insurance Plans - Getting Payment
Homebirth Coverage as an Employee Benefit
If your health insurance coverage is through an employer, that employer
is intending that the insurance coverage be a benefit to you. Often,
the people in your employer's Human Resources Dept. or Personnel Dept.
can help you negotiate with the insurance company to get the coverage your
employer intends for you to get.
Your Insurance May Pay for Midwives Anyway
Insurance Coverage - Equitable - Their Name Says It All
I am in California. For my 3rd baby and current pg, I have different insurance
that will cover homebirth. In both cases there was/is a need to pay the
midwife upfront and be reimbursed by the insurance co after the birth.
For my 3rd baby, my insurance was to pay 80%, but ultimately they paid
100% because
they were righteous and saw how much money they saved
and waived my deductible! (Equitable) Currently, I have Blue Cross and
they have agreed to pay 80% of the "usual and customary fees". Hummmmm
Insurance Coverage - Humana
Humana has paid me twice for attending a homebirth, and they paid very
nicely.
Insurance Coverage - Blue Shield
Blue Shield does allow homebirth, but since there are no homebirth providers
on their PPO, they only cover 70% of allowed costs.
Ontario Health Care Covers Homebirth
Midwifery legislation passed in January 1994 in Ontario. Since then, midwifery
services (including home births) are funded by the government so that anyone
who can find a midwife has access to one. The down side is that the demand
is overwhelming so midwives get booked quickly and is someone doesn't call
early in their pregnancy they may not be able to get one. There are also
many communities that do not yet have a midwife to serve them. Since a
new batch of registered midwives should graduate each year, we hope to
slowly remedy that problem.
Mandated Homebirth or Midwifery Coverage
The Office of General Counsel issued the following opinion on April
13, 2005 representing the position of the New York State Insurance Department.
Conclusions:
1) The services of a nurse midwife must be covered by a health insurer,
including a Health Maintenance Organization.
Getting Coverage for Homebirth from Insurance Companies
that Don't Cover Homebirth
HMO Coverage for Homebirth
probably tell her that there is none in network, but they have plenty
of other options. She will have to stipulate to them that she has
researched
the treatment plan and decided that the midwifery model is her preferred
treatment plan. Then she will need to say since there are no "in-network,"
providers I want a "transfer of care (TOC) exception number, or waiver
for the services." (different terms for the same thing.) Many
company insurance specialists will have the form. If they refuse
to consider a TOC you can file for a review for the denial at that point,
then appeal, and finally arbitration or State Insurance Board.
Medical Necessity of Care for "False Labor"
Medical Necessity of Care in the Immediate Postpartum
Medical Necessity of In-Home Maternal Followup
and Continuity of Care
Ekstrom A, Widstrom AM, Nissen E.
Birth. 2006 Jun;33(2):123-30.
Anette Ekström, PhD, RNM and Eva Nissen, PhD, RNMTD
PEDIATRICS Vol. 118 No. 2 August 2006, pp. e309-e314 (doi:10.1542/peds.2005-2064)
Grullon KE, Grimes DA.
Obstet Gynecol. 1997 Nov;90(5):860-5.
Medical Necessity of In-Home Newborn Followup
Moritz ML, Manole MD, Bogen DL, Ayus JC.
Pediatrics. 2005 Sep;116(3):e343-7.
Galbraith AA, Egerter SA, Marchi KS, Chavez G, Braveman PA.
Pediatrics 2003 Feb;111(2):364-71
Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon
N, Schelstraete C, Vittoz JP, Francois P, Pons JC.
Pediatrics. 2005 Feb;115(2):e139-46.
Medicare/Medicaid
New Mexico Business Weekly - May 19, 2006
by Haley Wachdorf
Homebirth Midwives as Contracted Providers, aka
Preferred Providers
Verification of Benefits
Insurance Billing - General
Sample
Superbill
He's also got a great links
page.
Medicare and HCFA links
An Online version
of HCFA-1500 form, the universal health billing form, or you can buy
them through the Staples catalog for about $22.00 for 500.
California Association of Midwives - Insurance Research Committee
The committee is collecting information about insurance providers and whether
or not they are currently reimbursing midwives for services. Please list
the insurance carriers who have paid your fees, indicating whether they
did so through your client or directly to you. If possible, please send
a copy of the "Explanation of Benefits" which accompanies all reimbursements.
Also state whether you are a LM, a CNM, etc.
Insurance Claim Forms for Sale
The Michigan Midwives Association purchased a box of HCFA-1500 insurance
forms (have to buy 1000 at a time) for resale. These are the standard forms
used to file claims with all insurance companies. We are trying to all
file with these forms the same way (same code #s) in hopes that being more
consistent with forms will help with more consistency with payment.
Unbundling
"Unbundling" is defined, according to my "Code it Right" book, as "breaking
a single service into its multiple components to increase total billing
charges." It goes on to describe:
59430 Postpartum care only (separate procedure)
Diagnosis Codes - ICD-9 Codes
Certain
Conditions Originating In The Perinatal Period 760-779
2006-2007 ICD-9 Changes
AAFP
Summary
Official documents:
New
2007 ICD-9-CM Codes Applicable to Pediatrics
ICD-9 Notes - These were notes I took while
going through the Official ICD-9-CM
guidelines from the National Center for Health Statistics (NCHS) Web
site.
THE CODING EDGE® ARCHIVES from 10/15/00 have a great article on
"
Faye Brown has some good college level books on coding and advanced
coding. A great book that explains what you will need to know to
do you own billing is Insurance Handbook for the medical office.
Obstetric
and Newborn Coding Guidelines Reviewed for ICD-9-CM Coding Issues from
ADVANCE for Health Information Professionals
NOTE - This piece claims that "Codes from category V27 should not be
assigned if the delivery occurred outside the hospital."
Blue Cross has just informed me that V27.0 is a discontinued code for
"live newborn." I have used it successfully until now. Is anyone
else having this problem? Are you using V30.2?
I have not heard anything about the V27.0 code being for hospital use
only. It is for the mom’s record only. Most all of the V27, V28,
V29, and V30 categories of codes must have a 4th digit for more specificity,
but I have not had any returned or delayed claims with this problem.
I did have a claim returned the other day because I coded 650(.)
Because I put the . behind the 650 the computer scanner forced a zero,
and it produced an error stating that the code was not specific or was
discontinued. This may be the same problem.
Newborn ICD # is V30.2 single liveborn , born out of hospital,
Use this on claims for the baby's care.
As for the idea of using a code for the "outcome" of the birth, you
don't need to give a code for outcome of the birth to
A
Primer on ICD-9-CM Coding (search for "Coding Primer")
Index to
the most comprehensive descriptions of diagnosis codes I've found online,
from The Philadelphia Medical Mall.
Flashcode has a free 30 day trial.
Just go to www.icd9coding.com and read about it. You can do basic icd9
coding online for free also.
ICD
(International Classification of Disease) Finder from CDC
WONDER
get paid! There are codes to use for infant or neonatal deaths or complications.
Unless these codes are used and /or they get a newborn claim, they assume
that the outcome is fine. I have never used it in over 22 yrs of
successful insurance billing. Was never needed or required.