The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Money and Paperwork

Subsections on this page:

• Most Important Resources
• Resources
• Why Money Is Important
• Comparison Pricing for Maternity Services
• Consumer Activism in Negotiating Coverage for Alternative Healthcare/Homebirth/Midwifery
• HIPAA Protections
• Setting Fees
• Fee Policies
• Credit Options
• Benchmark Fees
• Geographic Multiplier
• Getting Payment from Clients
• Health Insurance Plans - Getting Payment
• Gap Exception or Out-Of-Network Exception
• Mandated Homebirth or Midwifery Coverage
• Getting Coverage for Homebirth from Insurance Companies that Don't Cover Homebirth
• HMO Coverage for Homebirth
• 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
• Medical Necessity of In-Home Newborn Followup
• Medicare/Medicaid
• Homebirth Midwives as Contracted Providers, aka Preferred Providers
• Verification of Benefits
• Insurance Billing - General
• Diagnosis Codes - ICD-9 Codes
• Global Routine OB Care - Unbundling 59400
• Procedure Codes - CPT-4 Codes
• Modifiers and NDC Codes
• Educating Clients
• Billing for Assistants
• Ultrasound Procedure Codes
• Transports
• HCPCS - Medications and Supplies
• DME - Durable Medical Equipment
• HIPAA - Health Insurance Portability and Accountability Act
• Billing Services
• Web-Based Medical Billing
• Billing Software
• Where to Purchase HCFA Forms
• Billing Labs
• Military Births and Reimbursement
• Flexible Spending Statement
• Waterbirth/Tub Insurance Coverage and Reimbursement
• Lactation Consultant Reimbursement
• Doula Reimbursement
• Doula CPT Codes
• Appeals/Arbitration/Small Claims Court
• Legal Recourse
• Request for Refund
• Miscellaneous Financial
• Asset Protection

UPDATE - The ACNM wrote a great letter to Aetna about their homebirth exclusion policy.

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:

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"... "

Most Important Resources

This is how your midwife can create claims that properly describe the services she provides: Sample Billing Scenarios for a Homebirth Midwife

Here's how you can request pre-approval or followup: How To Get Insurance Reimbursement for Homebirth

Here's how you can specifically appeal with Blue Shield: Blue Shield Appeals Process

Here's how you can appeal individual claims: Appealing Denial of Individual Claims for Homebirth Maternity Care

Resources

First Things First - Get the Right Numbers for Business!

1. Get an EIN - I wish someone had told me to start out right away with getting a separate tax ID for my business so I wouldn't be flinging my SSN all over the place.  A separate, business tax ID is called an EIN - Employee Identification Number, and they're assigned by the IRS and are used like SSN's for business purposes.  Your income from the insurance companies will be reported to the IRS using your EIN.  At the end of the year, you'll have to file a 1099-MISC for any assistants to whom you paid more than $600.  You can order the forms online.   (The IRS has a nice Small Business and Self-Employed One-Stop Resource.)

 
2. Then, you'll need to have an NPI.

 
3. Then, in order to get payment from insurance companies, they need to have a W-9 on file for you for tax purposes.  So you have to figure out how to do this for each insurance company.  More and more, insurance companies have web pages and prefer to do things online, and you can usually fax them your information.  It's a pain, and it can take a while, but just take it one step at a time.

It's not hard to learn how to put together your own claims, although it may seem like a lot on top of all the other parts about starting up a practice.  One midwife I know learned from Wikipedia.  Even if you're having a billing service bill for you, YOU need to understand what is being billed and why.  In the end, if there's an audit, only YOU (not your billing service) are financially and legally responsible for any errors.

The folks at Aviva Institute are developing a Practice Management course at Aviva Institute, and will spend an entire week on billing. It is not scheduled to run for some time, but if there is enough interest we may be able to just do a course on billing, or run the whole course early.  It would be all at distance of course, so it could meet the needs of people all over with different schedules. Like many of our courses it is open to non matriculating students.
Daphne Singingtree, CPM
Academic Director
Aviva Institute
800-584-6235

Online Billing and Coding Series from the ACNM
ACNM: All Four Billing and Coding Modules

The Midwifery College of Utah offers a billing for midwives course, taught by one of the billers for/owners of Larsen.  This is a distance education course too, available for anyone.

Breaking Even on Four Visits Per Day - a practice model of not doing any insurance billing in-house and collecting fees at the time of service.

Billing for Physician's Assistants

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]
Attendance at Delivery & Stabilization from AAFP
Coding Newborn Care Services from AAFP

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.

 [My CPT notes]

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!

The Birth Cottage has a nice page on Insurance Billing: Superbill - Procedure Code Worksheet (pdf file)

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."

Med-Managers · yahoo group for Medical Managers for Physicians, started by Don Self.

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

Appealing Denial of Insurance Claims for Homebirth Maternity Care

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

justmypassion.com - Providing free source of useful information for Physicians, Office Managers, Medical Billers and Medical Coders.  This web site has lots of advertising, but it's also got lots of great resources.

How do I use the new Pap smear codes? from ACOG

Negotiated Settlements from Larsen Billing Service

I've been contacted a couple of times by an independent company for Blue Cross. The way they proposed it was very slick, and I kept asking questions, and when I finally understood what she was asking me, I said, "Now why would I do that? You're asking me to, just because you're asking me, reduce my fee, out of the kindness of my heart towards Blue Cross?" She said, "Uh, well, yes." I said, "What's in it for me? What do I get out of it?" She said nothing. So I said that I have no reason to do that. As it is, BC saved a lot of money by that client birthing at home probably about 75%, so that was their courtesy reduction in fees already, and that was as low as I was willing to go. She said ok and hung up.

I received checks 2 weeks later paying very handsomely. The second time, I understood right away why they were calling, and I just said that I already gave them a 75% discount by helping the woman birth at home, but if they wanted to pay me more to compensate for the greater amount of time I spent with her vs a physician, I was happy to take it.

Seriously? This seems rather nervy. And to think they hire an outside company (which cannot be cheap) whose job it is to go around and call to try to reduce what they have to pay out? Who says yes to this?

I get these all the time and *always* refuse them.  Why on earth would I cut the insurance company a break?

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
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

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.

An Introduction to COBRA/EMTALA

Intro:
The Emergency Medical Treatment and Active Labor Act (EMTALA) was created out of concern that patients were being denied emergency medical treatment because of their inability to pay. The initial intent of EMTALA was to address the allegation that some hospitals were transferring, discharging, or refusing to treat patients who did not have insurance. EMTALA was signed into law in 1986, as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).

The Centers for Medicare and Medicaid (CMS) issued revisions to EMTALA in 2003, which can be found in the Federal

Register on September 9, 2003.
Women in Labor
As defined previously, EMTALA stands for the "Emergency Medical Treatment and Labor Act."  Although EMTALA principles apply similarly to emergency medicine patients and women in labor, the definitions of "emergency medical condition" and "stabilization" are more clearly defined. The definitions below apply to women in labor.
All laboring patients are considered unstable and are thereby deemed to have an emergency medical condition.
Stabilization may be achieved an any one of the following 3 ways:
The physician declares the labor to be false.
Labor ceases.
The infant and placenta are delivered.
Transfer rules apply equally to women in labor. Therefore, a women in labor who has not been stabilized (achieved delivery of infant and placenta) may be transferred if the benefits of transfer outweigh the risks.

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.

Coding for Breastfeeding and Lactation Services from the AAP

Why Money Is Important

The issue of money in midwifery is very tricky.  Honestly, the work is so hard and can be so stressful that nobody with the skills and talents to be a midwife does it just for the money.  But earning a decent amount for each birth allows you to rest in between and not experience severe financial stress on top of all the other stresses of our life.

In addition, midwives need to earn more money per birth so that they can purchase the equipment they need (continuous electronic fetal monitors cost around $7000; each Doppler is about $700, the fancier instruments for clamping the cord and suturing run $50-$100 each.)  And they need to be able to pay membership fees to professional midwifery organizations.  You know how your clients always say that they want a midwife who is "professional".  Well, a professional midwife spends a lot of money on continuing education, membership dues, equipment, supplies, good assistant support, and, of course, pager/cellphone/computer access.

Most midwives I know complain about how little money they make.  However, they want homebirth to be "accessible" to as many clients as possible.  So they charge less and try to make it up by taking on more clients, but then they run themselves ragged (really, most midwives I know work 80 hours/week), and they have a high risk of conflicts, and they just don't have the emotional energy and time to provide the highest quality of midwifery CARE.  Yes, they still provide technically competent care, but they have a higher rate of transports, and they have little time for the introspection that's going to help them really understand the mysteries of birth.

It has been years of figuring out how to communicate better with the insurance companies, but I am now getting paid very well by all major insurance companies, including Blue Cross and Blue Shield.  It's really nice to be able to support myself well with a small caseload. I don't have to worry too much about conflicts, and my clients almost always get a well-rested, cheerful midwife.  And I don't feel that I'm shortchanging them because I'm overworked.  I still work more than 40 hours a week, but it's not over 80 hours/week anymore!

I have a feeling that all this talk about national healthcare and insurance shenanigans has helped with homebirth reimbursement because they KNOW we're saving them a bundle, and they know how bad it would look if somebody made a major fuss about it.

I urge other midwives to bill appropriately for their services.  You may feel that you're doing the client families a favor by undercharging, but you're not. You're doing a favor for the insurance companies, and they don't really need to be making their profits off the backs of homebirth midwives.

Remember, put your oxygen mask on first!

What Midwives Say About Themselves

Comparison Pricing for Maternity Services

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
Birth Center    $3500 - $8300
Hospital        $4300 - $16,000
Cesarean        $9300 - $26,000

from O'Mara, P. Having a Baby, Naturally, 2003. p. 322. Based on figures published in 1999.

Consumer Activism in Negotiating Coverage for Alternative Healthcare/Homebirth/Midwifery

This summarizes standard maternity costs

HIPAA Protections

See also: HIPAA - Legal Aspects of Midwifery / Health Insurance Portability and Accountability Act

From:  Frequently Asked Questions about Portability of Health Coverage and HIPAA
What is a preexisting condition?  A preexisting condition is a medical condition present before your enrollment date in any new group health plan.

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.

Setting Fees

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!

Fee Policies

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]
Leigh Ann Backer
Fam Pract Manag 11(7):43-47, 2004

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

I really like this financial agreement from my acupuncture office:

You are financially responsible for all services rendered to you directly by me or by my assistant and for certain supplies.
Payment is made in full (100%) for each visit at the time of the visit, or otherwise stated.

We will be happy to provide you with a receipt for submission to your insurance company when payment is made.  Your insurance company will then reimburse you directly.

UNBEARABLE FINANCIAL HARDSHIP / DIRECT BILLING INSURANCE:

1. Discuss your financial situation with your Doctor.  You will need your Doctor's agreement for direct insurance billing.

2. Payment  must be made in FULL for first visit, and until your deductible is met.

3. If the insurance company does not pay for your treatments within 60 days of billing by our office, we reserve the
right to demand that you pay in full and that you assume the responsibility for collecting payment from your insurance company.

4. Insurance coverage is an agreement between you and your insurance company.  Billing your insurance is done solely as a courtesy to you.  We will bill them, but you are responsible for monitoring and pursuing payment from them.

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:

1. Write a financial consent form fully outlining and itemizing all your services and fees. I also set a global fee (less than added itemization) for clients who receive full care.
2. Decide when you need to be paid in full. I picked 34 weeks as I do not discuss money at a birth (wrong vibe!!!) nor do I want the new parents to think of money $$$ when they look at their precious new baby.
3. Give an incentive for early payment. It will help your cash flow and let you pay bills. I decided that for all clients paying by 28 weeks I would waive my "on call fee" of $200 off my global fee.
4. Decide how quickly you would be able to refund an overpayment and state that -- I refund within 30 days or less.
5. Insured clients have to have a letter from the insurance co and their deductible paid by 34 weeks.
6. Now the hardest part: be clear (with yourself first) with your clients that if they have not paid by 34 weeks you reserve the right to discontinue care and give them a referral elsewhere.
7. Give clients a blank financial agreement form and let them fill in payment amounts and dates. I tell them that this is an adult conversation and that they must pay a fair amount each month. If they are going to miss a payment I tell them (in writing also) that I expect them to call me and we will remake the agreement. If they say their "ship is coming in" and they will be getting a "large amount of money and will pay you all at once" I suggest that they borrow from family and pay them back, not me. After all they expect a full O2 tank, gas in a working automobile and all my equipment at their birth......

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.

Credit Options

PayPal charges a 3% surcharge for credit charges.

CareCredit -  patient/client financing

Benchmark Fees

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

Geographic Multiplier

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!!!

Getting Payment from Clients

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!

Health Insurance Plans - Getting Payment

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.

A Healthcare Insurance Reimbursement Guide For Breastfeeding Families from Medela Inc. - USING YOUR INSURANCE COVERAGE FOR BREASTFEEDING SUPPLIES & SERVICES. 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

Glossary of Industry and Product Terms Used At Blue Cross and Blue Shield of Oregon

Negotiating for Health Insurance Coverage

Homebirth Coverage as an Employee Benefit

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.

Medicaid Policies

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:

1. find out if this is a fully insured or self funded plan.
2. if it is fully insured, contact the insurance commissioner ASAP.  they carry very big sticks in most states.
3. if it is self funded, contact the insurance commissioner anyway, but they may not be answerable to the commissioner's office.   but there usually is a stick that can be used against administrators of self funded plans, and that is the threat of losing the business.  if the employer did not know of this clause, you can bet the  owner will not be happy when s/he finds out, by having their own claims denied.  if enough employees complain, it may be enough for the employer to negotiate with the administrator.
4. another weapon against third party administrators, which will only work if they are local-negative publicity.  if they are 6 states away, it will not matter.  but if they are fairly local, try and get the local paper to write about this.....anything to get the name of the company in the communities' mind in a negative way.

Your Insurance May Pay for Midwives Anyway

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.

What You Get For Your Money

Insurance Coverage - Equitable - Their Name Says It All

Insurance Coverage - Humana

Insurance Coverage - Blue Shield

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.

Ontario Health Care Covers Homebirth

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.

Gap Exception or Out-Of-Network Exception

Mandated Homebirth or Midwifery Coverage

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 :
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.

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.

ACNM wrote a great letter to Aetna about their homebirth exclusion policy.

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:

HMO Coverage for Homebirth

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
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.

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.

United Healthcare Denies Young Mother Choice for Labor and Delivery - brief discussion of Network Gap Exception

Medical Necessity of Care for "False Labor"

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

Medical Necessity of Care in the Immediate Postpartum

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.

Medical Necessity of In-Home Maternal Followup and Continuity of Care

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?
Ekstrom A, Widstrom AM, Nissen E.
Birth. 2006 Jun;33(2):123-30.

" . . . 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
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)

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.
Grullon KE, Grimes DA.
Obstet Gynecol. 1997 Nov;90(5):860-5.

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.

Medical Necessity of In-Home Newborn Followup

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?
Moritz ML, Manole MD, Bogen DL, Ayus JC.
Pediatrics. 2005 Sep;116(3):e343-7.

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?
Galbraith AA, Egerter SA, Marchi KS, Chavez G, Braveman PA.
Pediatrics 2003 Feb;111(2):364-71

"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.
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.

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.

Medicare/Medicaid

Agreement allows Medicaid to pay uninsured midwives
New Mexico Business Weekly - May 19, 2006
by Haley Wachdorf

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.

The Cost of Being Born At Home by Miriam Pérez on March 19, 2009 - About homebirth insurance coverage for low-income women.

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

Homebirth Midwives as Contracted Providers, aka Preferred Providers

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.

Verification of Benefits

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".

Insurance Billing - General

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
Sample Superbill

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.
He's also got a great links page.

COLLECTION & REIMBURSEMENT from The Professional Association of Health Care Office Management

JustCoding.com

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.

Medicare and HCFA links

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

Medicare Billing Guides

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.

California Association of Midwives - Insurance Research Committee

For contact information, call CAM at 800-829-5791 or write P.O. Box 460606, San Francisco, CA 94146-0606

Insurance Claim Forms for Sale

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).

For Google employees in the Mountain View campus, your CIGNA plan covers homebirth and monitrice/doula services very well.

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.

Secondary Insurance

In box 24F, enter your full fee.
In box 28, enter the full total.
In box 29, enter the amount the primary insurance paid.
In box 30, enter the remaining balance that the secondary owes.

Also:
In box 19, write "PRIMARY EOB ENCLOSED"
I also write the same at the top of the claim form.

Include the claim form and the EOB, with the EOB BEHIND the claim form, in their own envelope with no other claim forms.

What worked for me when I filed electronically was to file the claim normally with the primary insurance.  Then, after the primary insurance was processed, I submitted the secondary insurance with the exact same claims, but entered the appropriate dollar amount at the bottom, where it asks for "amount already paid".  They didn't require me to send the EOB, but these were both very mainstream insurance companies, and it was clear they were communicating with each other.

Some birth extras that you might not think to include:

97113     Hydrotherapy in tub with MW face to face, 1.5 hours,

96372x4 Sterile water papules, 4 injections
59899      Set up emergency, place protective covers, clean up, dispose medical waste

Waiving Co-Payment

Diagnosis Codes - ICD-9 Codes

2007 ICD-9-CM Volume 1 Diagnosis Codes from icd9data.com - This has great descriptions

Complications Of Pregnancy, Childbirth, And The Puerperium 630-677
Certain Conditions Originating In The Perinatal Period 760-779

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

• 11. COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (630-677)
• 15. CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD (760-779)

Official ICD-9-CM Offical Guidelines for Coding and Reporting effective April 1, 2005.

ICD-9 Provider & Diagnostic Codes

2006-2007 ICD-9 Changes

Medscape Summary

Official documents:

New Codes

Deleted Codes

Revised Codes

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 "

Another free ICD-9 database from cd9coding1.com

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
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.

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

ICD-9-CM from Duke University - This is a fabulous resource with lots of sub-diagnoses.

It also links to:

CDC FTP server with the ICD-9-CM source files

UC-Davis Web-based ICD-9  - Note that this may be out of date.

ICD-9-CM Coding: The EICD 1999 Edition  and HCPCS Coding: The EHCPCS 1999 Edition from Yaki Technologies

ICD-9-CM codes from Columbia University (with some helpful annotations and a really nice Alphabetic Index to Diseases)

CPT Codes and ICD-9 Codes for Genetic Counseling Services & Related Services

COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (630-676) from the government of New South Wales in Australia   - These are especially helpful in understanding which diagnoses are considered within the scope of practice in Australia, anyway.

ICD-9-CM International Classification of Diseases from the University of Newcastle in Australia
Codes relevant to antepartum, intrapartum and postpartum

Episode of Care

Global Routine OB Care - Unbundling 59400

Exceptions to Global Routine Care

[ref: p. 132, The Essential Guide to Coding in Obstetrics and Gynecology - Second Edition, published by ACOG]
"The global obstetric package does not include inpatient or outpatient E/M services or procedures performed to treat complications, illness, or disease unrelated to routine postpartum care."
Breastfeeding management to treat maternal complications is not included in routine postpartum care.

[ref: p. 132, The Essential Guide to Coding in Obstetrics and Gynecology - Second Edition, published by ACOG]
"The description of global obstetric services is used when on physician or group provides all the obstetric care (antepartum, delivery, and postpartum) for a patient."  This patient received prenatal care in multiple practices.

[ref: p. 132, The Essential Guide to Coding in Obstetrics and Gynecology - Second Edition, published by ACOG]
"Nonglobal Obstetric Services . . . This may occur when the patient: . . . Terminates or miscarries her pregnancy."
This patient miscarried on <date>.

Coding guidelines state that if another provider also rendered care during the global period, then the global code cannot be billed. That said, insurance companies have their own guidelines, usually a number of visits (4-7 is common) or time (three months of care is common). A quick call to the insurance company before you submit the claim will save you the hassle of a denied claim.

As for postpartum care, there are no written guidelines as to the number of postpartum visits included in the global fee. It is understood to mean all normal postpartum visits, usually two or three. [Ed: These two or three visits would typically be in the hospital; these are usually a five-minute pop-the-head-in-the-door type visit and maybe a quick scan of the chart to see the vitals which the nurses have charted.  This is completely different from a midwife who makes a home visit and spends two hours helping a mom with breastfeeding and the numerous other changes that happen in the immediate postpartum.]

Midwives see a lot of "variations of normal", and tend to bill these postpartum visits as "normal". You should be coding and billing these with the issues you are dealing with. Breast-feeding problems, breast pain, breast engorgement, cracked nipples, mastitis, PP depression and perineal wound disruption are some of the more common diagnoses we see. Coding to the problem with the modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) has been very effective for us.

That said, we have noticed a new trend with the insurance companies (who continue in their quest to find reasons to deny claims). The global code 59400 is defined as "normal prenatal care, normal labor and delivery and normal postpartum care" in our code books, with the instruction to bill everything outside of normal with the appropriate codes. The new trend is to include *everything related to pregnancy* in the global code. This would include such things as all postpartum complications and conditions, everything that occurs during labor and delivery regardless, and all the issues that come up during prenatal care. Only those conditions that have absolutely no relation to pregnancy are being accepted as "outside the global fee".

Of course we continue to appeal these denied claims, but it is becoming a real hassle, especially with the BCBS plans.

Feb., 2010

The global OB code (59400) has gone through a few changes over the years.  It used to be that it was the gold standard, and the coding books told us all that we were required to use the global code for most of the claims we billed.  This was also when the "unbundling=insurance fraud" scare was very real.  This has changed.  Coding guidelines now specifically state:

"Obstetric care can be coded as a global package or can be broken down when necessary into antepartum, delivery and postpartum care."

So when is it necessary to break down the package deal?  When there is anything--anything--outside of the very narrow definition of normal.

If you are billing 59400, then also billing for additional services, chances are high that most of those additional claims are being denied. The reason is that when you use 59400, you are telling the insurance company that you are only billing for routine, normal OB services. If you need to bill for other services outside the global package, you should NOT use 59400, but break it down into antepartum, intrapartum and postpartum care. This also makes it much easier to appeal if the claims should deny.  That said, insurance companies have the right to not follow accepted coding guidelines and choose how they will process claims.  There are some insurance companies who require the global code if the midwife caught the baby, no matter how many AP visits there were.  And place of service can become a sticky matter for some insurance companies if you break down the global code completely. The insurance companies have the last say as to how they will accept and process claims. Always, always always verify insurance benefits as soon as possible, including any restrictions on place of service and coding policies.

If you own a birth center, the admission and discharge is included in the global facility fee only if she has her baby at your birth center.  If you transport to a hospital, then you should bill for the admit exam and the discharge exam, in addition to your facility fee.

Billing the global code is certainly the easiest way to send a claim to the insurance company.  Coding is not taught in midwifery schools and only a few even offer courses on insurance billing.  If you break the global into components, you must know the difference between the office visit codes, home visit codes, prolonged care and critical care codes (fetal distress is prolonged care, PPH is critical care).  You must also know how to document your care to support the level of coding you submit.  This is where the vast majority of midwives are sorely lacking and it can really come back to bite them when insuance companies request chart notes. How do docs do it?  They have a billing department who audit their charts, then gives them coding lessons so they will stay within the Medicare guidelines. They dislike all the rules and regulations as much as the next provider (I used to work in an MD office).

Insurance billing for midwifery care is a challenge and some claims can take time before they're processed.  This is just another reason why it is so very important that you get paid before the baby is born! Midwives are worth their weight in gold, yet they undervalue themselves much too often.  Get paid before the baby is born, call it a deposit for your insurance clients, give discounts to those who need it, send the insurance claim after baby is born and the new parents get a reimbursement.  As long as you are not contracted with the insurance company, this is legal, ethical and the best business model for a sustainable midwifery practice.

Kelli Sugihara
Certified Professional Medical Biller
Midwife Billing & Business, LLC

The global fee is for global ROUTINE OB care.

Nothing I do comes anywhere close to routine OB care.

I used to bill the global fee and then bill everything extra on top of that.  But it confused the insurance companies because it didn't really make sense.  If I was providing routine care, why was I also providing all this extra care? And they could reasonably quote chapter and verse as to why they shouldn't pay anything beyond the global fee if that's what I was claiming.

So, I stopped using the global code completely because it does not properly describe what I do.

Instead I bill everything separately: every prenatal appointment, every NST, every postpartum visit (separately for mother and baby) the birth itself (as 59409), the first hour (99350) and then every extra hour (99354) and then every extra half hour (99355) at the birth.  I file a separate claim for my assistant's services, with a note in the virtual Box 19 with something like, "Med Bd requires NRP asst" or "Regs require NRP asst".  (This is for California.)

I also bill a rental fee for the equipment that would normally be provided by the hospital and for the AquaDoula. (Not everyone pays these.)

The global fee accounts for about 4 hours of a provider's time.  I typically spend 40-60 hours with each client, and I file claims for all this time.  It's been years since anyone has suggested that I'm "unbundling" the components of the global code.  I tell them that this is a cycle of care for a homebirth, and that it is completely different from routine OB care.  (Oh, yes, Blue Shield still tries to pretend that all the care I provide is included in 59409 or 59400; they don't have a leg to stand on, and they know it, and they cave as soon as the client starts talking about filing a complaint with the Insurance Commissioner.  California has specific laws requiring coverage of care for labor and birth and 48 hours afterwards.)

The global fee is based upon the surgical model - for any surgical procedure there is a global fee that includes the pre-op visit, the procedure, the hospital visits, and the post-op visit(s).  Visits to the surgeon for issues outside of that are billed as separate visits, each with a separate diagnosis code and a Evaluation and Management (E&M) code.   The global fee for prenatal care, delivery and post partum, is built upon a model that includes a complete physical exam at the onset of pregnancy, 10 antenatal visits, delivery care including daily rounds while the patient is in the hospital, and 1 PP visit which includes a focused physical exam.  Most docs would prefer to be able to bill non-globally  as they would be able, on the average, to collect more money for their services.  But a global fee allows the families to budget (if they are self pay) and the insurance companies to delay payment (taking full advantage of the time value of that money especially with the high rate of medical inflation) until after the last PP visit.

"Sick visits" during pregnancy (anything outside the regular schedule of PN visits) are not part of the global fee and are charged separately.  So a mom who calls with a vaginal discharge or abdominal pain or vaginal bleeding can be charged as an office visit with the stated diagnosis and the appropriate E&M code.  Moms with High Risk pregnancies who require more frequent visits can also be coded with the diagnosis and E&M codes outside the prenatal global fee.

Unbundling [This is OLD information but here for historical purposes]

"...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);
59430  Postpartum care only (separate procedure)

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.

Procedure Codes - CPT-4 Codes

Medicare Physician Fee Schedule Look-Up

Benchmark Fees and codes for different procedures - type in maternity or newborn [currently not available?]

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.

CPT codes and Fee Schedule for Arizona Health Care - Maternity Care And Delivery

Search 2009 AHCCCS FFS Program Capped Fee Schedule, Effective 2/1/09

ICD-9 Coding Tools From Family Practice Management

The FPM Superbill is a great tool of the most common CPT codes

Evaluation & Management Code Definitions

Coding "Routine" Office Visits by Peter R. Jensen, MD, CPC  [9/28/05 - Medscape registration is free]
Before choosing 99213 for routine visits, consider whether your work qualifies for a 99214.

I rarely use 59400; 'type of license' should not be a 'recognition' issue if one is providing maternity/well baby care within the legal scope of practice.

Procedure codes associated with place of service will vary depending on setting in which they are performed/provided; for instance, you could perform a 99440 in a private residence, birth center, home or by the freeway median strip and should still be reimbursed if you are a licensed clinician billing a plan which has covered benefits.

Search for "CPT CODES FOR WAIVED TESTS" in these Medicare pages or you can find them here.

Billing for Medications

Billing for E-mail Correspondence

I have used it and gotten as high as $45.00 for this code.

Insurance Coverage for Cord Blood Collection

Modifiers and NDC Codes

CPT Modifiers

In order to be paid for your lactation consulting services in addition to the routine postpartum checkup, you can bill another visit (office or home visit), and add modifier -25, "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service."  It's important that the different procedures be associated with different diagnoses.  For example, the lactation consulting could be associated with diagnoses:

Common diagnoses include:  FTT 783.4
                           Feeding problem, newborn 779.3
                           Feeding problem, infant  783.3

Reimbursable nutrition services that support breast feeding include,*but are NOT limited to* Persistent discomfort to the woman while breastfeeding, Infant weight gain concerns, Milk extraction, suck dysfunctions of the infant"

[NOTE - Modifier -21, "Prolonged Evaluation and Management Services," became obsolete in 2008?]

Discussion of CPT Modifiers from American Academy of Family Physicians

In general, I use three modifiers:

24 - "Unrelated Evaluation and Management Service by the Same Physician During a Post-operative Period" - for postpartum home visits for lactation consulting and postpartum followup beyond what an OB would do for a hospitalized patient with no complications, i.e. poke their head in the door, glance at the chart, and say that everything looks fine.

25 - "Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure" - for additional care on the same day as the birth . . . everything beyond the one hour around the time of birth described in 59409, including a separate visit earlier in the day for "false labor".

32 - "Mandated Service"

Modifiers from Boston Scientific

Web pages about modifiers seem to jump around a lot, so here's a pre-fab search for relevant information.

I've had a lot of trouble finding an official definition for modifer 32 - "mandated services".  But the Blue Cross and Blue Shield of Rhode Island's Human Leukocyte Antigen (HLA) Testing Mandate specifically addresses this issue as if 32 means that coverage for the services is mandated by state law.  For example, California mandates coverage of medically necessary care for mother and baby for labor and birth and 48 hours afterwards.

Then again, this is from More on Modifiers By Jim Meeks, PA-C
"Modifier 32

On occasion, an insurance company or other third-party payer sends a patient to a provider for a second opinion, for a specific evaluation or for a determination of disability. When the provider is aware of one of these circumstances, modifier 32 is used to indicate that this is a "mandated service."

The use of modifier 32 is not appropriate when the patient, family members or other parties request second opinions or other services. A common circumstance in which this modifier might be appropriately used is when a patient is sent to a provider by a workers' compensation carrier asking for a second opinion. Another might be when children in state custody are sent to your office for health examinations after being placed in temporary custody or foster care.

Generally speaking, when an encounter is requested by a third party (insurance company, state agency, law enforcement, etc.), consider it a mandated service. "

and from Productive Provider Newsletter, October 2005, Volume 3, Number 9, © MPECS 2005

Modifier 32, Mandated Services;
There may be occasions when an insurance company or some other “third-party payer” sends a patient to a provider for a second opinion, for a specific evaluation or determination of disability. When the provider is aware of one of these circumstances, modifier 32 is used to indicate that this is a “mandated service.”
It is not appropriate to use it when the patient, family members or other parties request second opinions or other services.
A common circumstance where this modifier might be appropriately used would be when a patient is sent to a provider by a workers’ compensation carrier asking for a second opinion. Another might be when children in state custody are sent to your office for health examinations when placed in temporary custody or foster care.
Generally speaking, when an encounter was requested by a third-party (insurance company, state agency, law enforcement, etc.), consider it to be a mandated service.
 

From The Mississippi Workers' Compensation Commission:
32 Mandated Services
Services related to mandated consultation and/or related services (eg, PRO, third-party payer, governmental, legislative, or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.

CPT Modifiers

The list below provide modifiers applicable to CPT 2008 codes. See the Current Procedural Terminology (CPT®) 2007 Professional Edition (Appendix A) for full definitions.1

-22 Unusual Procedural Service
-23 Unusual Anesthesia
-24 Unrelated Evaluation and Management Service by the Same Physician During a Post-operative Period
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service
-26 Professional Component
-32 Mandated Service
-47 Anesthesia by Surgeon
-50 Bilateral Procedure
-51 Multiple Procedures
-52 Reduced Service
-53 Discontinued Procedure
-54 Surgical Care Only
-55 Postoperative Management Only
-56 Preoperative Management Only
-57 Decision for Surgery
-58 Staged or Related Procedure or Service by the Same Physician During a Post-operative Period
-59 Distinct Procedural Service
-62 Two Surgeons
-63 Procedure Performed on Infants less than 4 kg.
-66 Surgical Team
-76 Repeat Procedure by Same Physician
-77 Repeat Procedure by Another Physician
-78 Return to the Operating Room for a Related Procedure During the Post-operative Period
-79 Unrelated Procedure or Service by the Same Physician During the Post-operative Period
-80 Assistant Surgeon
-81 Minimum Assistant Surgeon
-82 Assistant Surgeon (when qualified resident surgeon not available)
-90 Reference (Outside) Laboratory
-91 Repeat Clinical Laboratory Diagnostic Test
-99 Multiple Modifiers
CPT Modifiers Approved for Hospital Outpatient Use

The list below provides modifiers approved for hospital outpatient use (Level 1 [CPT]). See the Current Procedural Terminology (CPT®) 2008 Professional Edition (Appendix A) for full definitions.1

-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service
-27 Multiple Outpatient Hospital E/M Encounters on the Same Date
-50 Bilateral Procedure
-52 Reduced Service
-58 Staged or Related Procedure or Service by the Same Physician During a Post-operative Period
-59 Distinct Procedural Service
-73 Discontinued Out-Patient Procedure Prior to Anesthesia Administration
-74 Discontinued Out-Patient Procedure After Anesthesia Administration
-76 Repeat Procedure by Same Physician
-77 Repeat Procedure by Another Physician
-78 Return to the Operating Room for a Related Procedure During the Post-operative Period
-79 Unrelated Procedure or Service by the Same Physician During the Post-operative Period
-91 Repeat Clinical Laboratory Diagnostic Test
-FC Partial credit received for replaced device
-FB Item provided without cost to provider, supplier, or practitioner (examples, but not limited to: covered under warranty, replaced due to defect, free samples)

Modifier 25 Fact Sheet

When using modifier -52, the insurance carrier determines the amount of the reduction based on documentation supplied with the claim.  Documentation, such as the operative note, should be filed with the claim and should include the reason for the reduction in service.

If the modifier is being used to indicate the service was performed due to a lesser procedure (such as a code that states bilateral in the description, but only a unilateral procedure was performed) then a brief statement should be included to explain why the service does not reflect the "norm" for the code.

Modifier -59, according to the American Medical Association's CPT manual, is "used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different surgery or procedure, separate incision/excision, separate lesion, or separate injury."

"Mutually exclusive does allow for reporting that code pair if the definition of modifier -59 is met," notes Heller. "You can override that mutually exclusive edit, just like you can the comprehensive with the use of a modifier."

But don't automatically add the modifier just for the sake of getting paid for both services. "One of the things I hear and read about is people seeing a bundling edit so they automatically add the modifier. You want to be careful about that. The documentation really needs to support that these are two distinct procedural services," Heller adds.

NDC Codes

HCPCS - Medications and Supplies

Alpha-Numeric HCPCS  from cms.hhs.gov

Here's a nice DME list

APN Healthcare, Inc. and Quality Medical Supplies - They list HCPCS codes for lots of supplies.

Sample Order for Durable Medical Equipment for Birthing Tub (AquaDoula)

HCPCS Overview - Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.

HCPCS Level II Coding Process & Criteria

DME - Durable Medical Equipment

See also: Waterbirth/Tub Insurance Coverage and Reimbursement

CMN - Certificate of Medical Necessity, the official MediCare term for an order for DME.  Here's the official CMN for a TENS unit, which you can tailor to your own use.

Here's a generic version of my personal form for "ordering" DME for my clients from my own rental service.

Lots of DME publications, including DME Fee Schedules 2007

HCPCS E Codes - Coding for Durable Medical Equipment

APN Healthcare, Inc. - They list HCPCS codes for lots of supplies.

DME is just like any other billing, except that for Medicare you will need to bill to your local DMERC (and your provider will have to get a separate supplier number if they haven't already, possibly a different number for Medicaid, too, depending on your state) which will probably be a different contractor than your local carrier.  For your commercial billing you'll bill it right along with all your other charges unless except for a few managed care plans that have a DME carve-out.

TENS Rental -  A written order prior to delivery of the TENS must be kept on file and available upon request.
Code E0731 requires the brand name and model number within the narrative section of the claim and documentation supporting medical necessity within the suppliers file.

For example, E0731- RR BabyCare Femme Obstetric TENS - the RR modifier denotes rental

Pulse-Oximeter Rental - E0445 - Oximeter device for measuring blood oxygen levels non-invasively

Sample Order for Durable Medical Equipment for Birthing Tub (AquaDoula)

Educating Clients

Our health education nurse is an RN. When she sees patients who are diabetic or are smokers and counsels these patients about their risk factors, which ICD-9 and CPT codes should she use?

She should use 991 for the CPT code and an ICD-9 code in the V65 series. Code V65.3, for example, is specific to dietary counseling for diabetes.

Billing for Assistants

I've had more trouble getting reimbursement for unlicensed assistants since the NPIs became mandatory.  With NPIs, it's clear to the insurance companies if assistants are unlicensed.  And there's no accurate taxonomy designation for them, so the insurance companies aren't rushing to reimburse for them!

For unlicensed assistants, you could still file claims on paper and then argue that the state requires you to have an assistant there, so that they're "medically necessary" and that they're not covered by 59400.

For a licensed assistant, just bill for her time on her own.  I do think you're more likely to get reimbursed if you don't bill the same procedures (home visit plus
prolonged codes) as for the main midwives OR have the other bill come directly from that midwife's office.

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."

Or maybe this one is more appropriate:

Personal Emergency Response Attendant - 146D00000X: "Personal Emergency Response Attendant - Individuals that are specially trained to assist patients living at home with urgent/emergent situations. These individuals must be able to perform CPR and basic first aid and have sufficient counseling skills to allay fears and assist in working through processes necessary to resolve the crisis. Functions may include transportation to various facilities and businesses, contacting agencies to initiate remediation service or providing reassurance."

I really don't know the answer to this.  If you do, please let me know!

Ultrasound Procedure Codes

76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation

76802 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation

76810 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses

76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818 Fetal biophysical profile; with non-stress testing

76819 Fetal biophysical profile; without non-stress testing

76820 Doppler velocimetry, fetal; umbilical artery

76821 Doppler velocimetry, fetal; middle cerebral artery

76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

Transports

Hospital Transfer from Planned Homebirth

Here is the url to the AAFP website where they show a sample letter describing care and the need for a c/s.

The key, of course, is the diagnosis code(s).  Do NOT use 650 or V22.- anywhere on these problem claims!  Use ONLY the pregnancy complication codes in the 600 section of your code book. If you did not catch the baby, you will use the fifth digit -3 (AP complication).

We have had very good results billing for prolonged care in the hospital, too:
99234 (hospital visit, used for the first hour of care)
99356 (first hour of prolonged care)
99357 (each additional 30 minutes of prolonged care)

Again, use ONLY the pregnancy complication codes from the 600 section of your code book. If labor resulted in a C-Section, you will use the fifth digit -3 (AP complication).  If you were with her through her delivery, you will use fifth digit -1 (delivered). If you only offered prolonged PP care, you will use fifth digit -4 (postpartum complication or condition).

In our experience and also what we've learned in coding conferences, most insurances will only consider eight hours of prolonged care per calendar date.  You are welcome to bill all 24 hours per calendar date, but they most likely will not be considered. It is our policy to bill for a maximum of eight hours per date.

Be prepared for denials when you use these codes, especially when there is a hospital involved.  The billing department in any hospital is a crazy-busy place and they will default to the global code without thinking twice. This means your prolonged care codes will deny as "included in the global fee". Usually a phone call can clear up the confusion, but you may need to send an appeal letter informing them that you did not bill the global fee. Do not let them talk you into contacting the hospital to have them correct their coding before they can process your claims--that's the insurance company's job.

Can't really get much if you code for a complicated home visit. You can use 59410.52  This is the code for vaginal delivery with a modifier.  Pretty much says you did all except the delivery.  Have charged up to $1000 for "labor management", which you can put in the description for the modifier.  Be sure to use all the ICD-9 codes to explain the reasons for transport!

Our bill will contain a statement describing the reason for the transport and that it was required by our licensure regulations. Then a statement that our entire fee is due regardless of the transport, and lists the number of prenatals done, the number of hours spent with her in labor, and the number of postpartum visits.

Example: Midwife attended a really tough labor and was in attendance from 9:30 am 1/6 to 10am 1/8 with baby born at 2:02am 1/8 via c-section after transport at about 9 am 1/7. Which codes have you used to get reimbursed?

This contains an excellent description of the prolonged services codes as revised in 2008.
Threshold Time for Prolonged Visit Codes 99354 and/or 99355 Billed with Office/Outpatient and Consultation Code.
Here is the more official document, SUBJECT: Prolonged Services (Codes 99354 - 99359), which is harder to read.

Prolonged codes 99354 1st hour $175.00
99355 ­ each 30 minute increment is 1 unit. ie 4 hours = 8units $75.00 perunit.
Use modifier 25 for each separate exam
Code everything that you have documented, down to team conference calls 99371 $35.00 or 99372 $50.00, 99373 - $75.00
NOTE - 99354/99355 must have companion codes: 99201-99205, 99212-99215, 99241-99245, 99341-99345, 99347-99350

Prolonged Services (Codes 99354 - 99359) with good description of companion codes.

The companion E&M codes for 99354 are:

• Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215),
• Office or Other Outpatient Consultation codes (99241 – 99245),
• Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337),
• Home Services codes (99341 - 99345, 99347 – 99350);

We use 59899 and include notation.

Actually, we find it's very effective to bill the first hour with an E&M code - like 99350 or 99215.  We bill the second hour as 99354 and each remaining half hour unit as 99355.  This has worked very well for us.  Last week I saw a statement where they paid these codes for 4 days of labor management before transport.  Often times, we see greater reimbursement for many hours of labor management before transport than we do for an uncomplicated homebirth, and that's how it should be.  We always put "Labor Management before Transport" in box 19, and often times they don't ask for further documentation.  We only use 59899 when there are absolutely no other options.

HIPAA - Health Insurance Portability and Accountability Act

See also: HIPAA - Health Insurance Portability and Accountability Act

That is a huge law passed by the Federal Government. HIPAA is Health Insurance Portability and Accountability Act.  Many practitioners know HIPAA by the new privacy standards implemented. However it also affects reporting and the right to choose proven alternative medical interventions. All of your great outcomes and cost are being shoveled in with physician's statistics because we are being forced to use CPT- 4 codes that are designed for physicians.  It is a fundamental duty of our government to track the cost and outcomes of medical techniques.  In 1998, 23 billion was spent on physician related outcomes, compared to 27 billion in alternative related health encounters like chiropractors, home birth. Because the codes are designed for physicians, the 27 billion was largely unreported and cash was paid.

The ABC codes will pave the way for midwives to see how great they really are, because it will break out the cost comparisons so that everyone will see.  This is only if the Department of Health and Human Services approves the use of the codes and makes all insurance companies report outcomes using them.  Go to Alternative Link on the web and check it out.  I already have the coding manual and it has 10 pages for midwives. There is even a code for carrying oxygen from your car into the home, birthing room prep, clean up, tear down and more.

Billing Services

Midwives beware!  There are some insurance billers out there who can be very unpleasant to deal with.  If they talk a lot about suing other people, then consider that they might be more inclined to threaten to sue YOU!

I cannot personally vouch for all the midwife billing services listed here, so please be very careful in choosing a billing service.  Ideally, get a recommendation from another midwife that you know personally, and wait until she has worked with the billing service for half a year or so before you start to work with them, too.

Questions to ask a billing service:

--What do you provide that we can't do ourselves?
--What are the fees?  Can a midwife generally expect better reimbursement using a billing service than she can doing it on her own?
--What is the usual turnaround time?
--Is there a minimum monthly dollar amount of billing required?
--Can a client submit their claims to you directly?
--What is required from a midwife client on setup and for each claim (step A-Z detailed)?  A common question is: how do I inform the biller of the details of the services for each client without having to do so much paperwork I might as well submit the claim myself?
--what kind of experience does the biller have, and what are the
statistics of reimbursement vs. submission?

Here one midwife lists the problems she had with an insurance billing service:

Dear Midwife Colleagues,

I'm a recently licensed midwife in my state.  During my preceptorship and schooling I learned nothing about medical billing/coding.  On the recommendation of a colleague I enlisted the services of a billing service. I experienced some serious mishaps with this initial service and would like to share some of what happened and some recommendations for anyone considering employing the services of a billing service.

I cannot begin to list the numerous and egregious errors generated by this particular billing service, so I'll hit the highlights:  HCFA submitted for a patient that was not my patient;  HCFA mailed to the wrong insurance company; incorrect address for myself listed on the HCFA; another midwife's license copy & SSN sent out with a HCFA for my patient; incorrect place of service listed (-11 office visited listed on prolonged code for newborn care immediately after the birth); neonatal jaundice coded for an hours-old newborn that did not have jaundice (I did not code this, nor did I authorize this); and numerous typos where codes were translated incorrectly.  All of these errors and more were generated for only three patients claims.  Some of these issues could easily be construed as fraudulent.

The end result was that the several claims submitted by this billing service had to be resubmitted by another service and I've yet to get paid. It's cost me hundreds of dollars (resubmitting claims through another service) and a lot of grief.

I recommend getting complete information about any service you use including a complete resume with references.  See if you can get a copy of the individual's school transcripts, references from instructors or former employers.  Take the trouble to follow up on checking references, making sure that the references are not personal friends or relatives, etc.  Maybe even do a background check on the individual offering billing services. Have the billing service you're checking out submit one very simple claim. Then wait and see how that goes.

Now I'm enrolled in classes through a local medical assistant program which include medical billing, electronic billing, and ICD-9 and CPT coding. I plan to continue using a billing service to optimize my time spent providing care to families, but I have a lot more confidence about discerning the quality of work of any outside billing services I employ.

Free Electronic Billing with Office Ally

Practice Prescriptions: Should You Consider Outsourcing Your Billing Needs? by Debra C. Cascardo [Medscape registration is free] - 9/1/04

Christine Larsen, Certified Medical Biller, Larsen Billing Service, 2627 N 200 E, N Logan, UT  84341, (866) 726-8522 Toll-free, Fax:
(435) 752-9414, Email:, Christine84321@aol.com

They now offer consulting services and have a great web page about Laws and Links, including Insurance code by state and Insurance Commissioners by state.

Midwife Billing & Business, LLC

Caroline Silva, Express Claims in Naples, Florida  239-649-4070.

A biller suggests what to look for: "It is important to understand the different services offered by billing companies.  Someone that simply fills out a HCFA and sends it in for you, is not doing you much of a service.  My experience shows that midwives want someone to take the "whole," insurance headache away, they want an insurance "aspirin."  As busy as most of you midwives are you don't have the time to examine, correct, and follow up your claims.  I would advise finding a "complete," billing service that will bill your customers (if you desire), fill out HCFA's, perform follow-up, examine E.O.B's, correct and resubmit any coding errors.  In addition, the billing service should post payments, offer reports, communicate regularly on the status of pending claims, and show a genuine interest in your success."

Midwife's Billing Service, Inc. specializes in billing insurance companies for homebirth. The service was started by a midwife in Massachusetts who took the time and trouble to learn the ropes and has figured out how to get insurance reimbursement for homebirth in most cases.

MBSI -  is now being run by Marnie.  You can e-mail her at marnie@midwifesbillingservice.com or phone her at  800-874-2540 or 978-544-3551.

There's a reasonable one-time setup fee, plus transaction fees.

This billing service has gotten reimbursement for homebirth midwifery services regardless of license status, and sometimes regardless of legal status.  In very rare cases, she has even gotten reimbursement from an HMO.

We all know that it makes good financial sense for the insurance companies to be covering homebirth, since it's so much less expensive than hospital birth.  But, from their point of view, it's even cheaper for the family to have a homebirth that the insurance company doesn't pay for.  It's unfair, and unjust, but they're in the business of making and keeping money, not being fair and just.  So, it often does take some haggling.  Parents trying to get reimbursement from their insurance company for homebirth may find it well worth paying this company's fees to relieve them of the hassle of haggling the insurance company to pay for homebirth.

Deborah at A & M Billing, 1263 S. 5th St, Independence, Or 97351.

Maria VanderJagt   (say Vander-Jack), 713 Antelope Way, Las Vegas NV 89145, Voice (702) 838-5402, Fax (702) 838-8507, jj_vanderjagt@hotmail.com
Can communicate via phone or fax or email or whatever - willing to do pre-authorizations and lost-causes.

Risk Free Billing Services - We only offer 1 type of service - that is complete and end to end to get the claim paid quickly. You send us your electronic Superbills generated from RFHS - we convert them to electronic claim forms, our experienced claims professionals code audit the claim against what is contained in the RFHS EMR for that claimed patient encounter - and suggest corrections if required prior to transmission to payors, we then submit the claim through our own clearinghouse.  Fee - 6% of reimbursements.

Medical Claims Resolutions - Resolving Medical Claim Issues - OUR FEES. Our fees are either contingency based or charged by the hour depending on the type of service rendered.

The HBMA (Healthcare Billing Management Assoc) is a large educational group of billing companies that maintains a directory of billers.

Web-Based Medical Billing

NueMD® - They have various monthly subscription tiers designed specifically for billing companies, and their support and training is ongoing and terrific --- all included in your monthly price, which I find to be very reasonable. There are some features that tend to be a bit cumbersome at first, but once you get the hang of it, it's just fine. The main key for me was the support and training.

Claim gear is pretty good.   Kareo if I recalled, was a bit pricey too.

I have not heard anything negative about AdvancedMD but I wanted to also suggest that you check out Kareo (www.kareo.com).  We are switching over to them right now after a year of reviewing many different demos.  Their product is also web-based system and it's actually designed for medical billing companies.
I spoke with 8 other billing companies that use Kareo (none of which were home-based companies) and they were all very happy with the software.  As a billing agent, I personally felt that AMD was a bit pricey considering our claims volume.  You might want to check them out!  Good luck!

Aetna is offering web-based claims submission through their provider web pages.

Billing Software

eTramway - free online medical billing software.  I have mixed feelings about having private medical information on the Internet, and I'm suspicious of their motivations for offering free services.  If it's just because they have a great high-value audience for ads, that's OK, but I'm suspicious.

In any case, it looks as if they make it easy to create HCFA claims and to keep track of them.  This could be a win for you!

This would also be a fabulous training opportunity, as a way of learning to put together a good HCFA claim form!

I can heartily recommend "

eTramway Medical Billing  - FREE website helps you create CMS 1500 (HCFA) forms.

ClaimGear™ from WebMBS - Web and Internet medical billing software, without any upfront costs, for medical practices and medical billing services.

It seems that the people who write these programs are assuming that they will be used by businesses that are large and can easily absorb the huge costs of purchasing their programs. I probably file about 10-15 claims a year, and though it's growing, it's not enough to justify spending $500-1000.

i have found that a simple program (Just claims that allows you to enter and save hcfa claims.  it cost about $50 and i just slide store-bought hcfas in my printer.  i believe i got both the program and the hcfa forms from medical arts press.  it works very well with minimum fuss for little money.  it makes my claims look professional and they get paid without problems, though these days usual and customary is lower and lower.

I purchased Just claims.  Medisoft is a more complete package and very easy to use and has support. Order from Medical Arts Press - 1-800-328-2179

Where to Purchase HCFA Forms

I bought the HCFA forms from the AMA in Chicago for $52 for 50.

You paid too much!  I bought them through Staples catalog for about $22.00 for 500 - and they delivered them to my house for free.  Look under forms - health forms.

I got mine from auctions on e-bay.  Just type in HCFA 1500 on the search.  I paid 9.99 + shipping for 500 forms.

Billing Labs

I have a question about the lab codes....I was under the impression that you could use them only if you ran them and got the results (i.e. if you were a lab) or for things like urine "dips" and urine pregnancy tests, HCT's if you had the machines, and chemstrips(blood sugar) - or if you are billed personally for the processing by the lab and use these for reimbursement.....

Do most of you in private practice include the cost of labs in your "package" fees and then send them off to the labs for results/running?

or do you draw the blood and have the lab bill separately for the processing to the client? or to you?

Just wondering what the easiest / simplest thing seems to be...

I sent my clients to the lab, then have the lab bill my company. One time an insurance company was taking forever to pay. The husband called them and was told they were waiting for the rest of the bill! Needless to say, our prices are remarkably cheaper!

Military Births and Reimbursement

I called CHAMPUS today and they told me no, a midwife was not covered. I specified "Certified Nurse Midwife" and they still said no since Wilford Hall is there they won't pay for anything else. I then said I thought there had to be more to it and that I need more info, so she gave me the regional office ph #. I asked and the nurse I talked to said she didn't think it was covered either but she would look it up. Well, it CNMs ARE covered - she gave me the policy manual chapter and section reference and is going to mail me a copy!! Now the bad part - before CHAMPUS will pay for it, you have to get a "Non-Availability Slip" (NAS) from the OB-GYN office on base, which would be almost impossible AND there are NO CNMs in all of San Antonio except those who work for doctors anyway.

I have been calling all around and there are only direct entry midwives, which is fine with me, but I would really like my birth to be covered by insurance. And your medical backup for a homebirth would not be covered at all so if you had to get transferred to a hosp, you would have to pay out of pocket. Of course, you could not mention the homebirth part to the military health care providers, continue to go there for your prenatal visits, and drive across town if you have an emergency. So there is some good and some bad - I'm going to see how difficult it would be to get a NAS. Hopefully, some things will be changing soon.

If Normal Birth Isn't a Medical Event, Why Should It Be Covered By Health Insurance?

Flexible Spending Statement

I usually just make up a billing statement on my letterhead (with my license number).  I put the following info:

Responsible party (either client or dh)
Clients name
Clients address/phone/DOB
Itemization of services with date, description (Birth Supplies, Midwifery Services, Assistant Fee, etc) and cost of service.
Total amount Due
Amount Paid
Balance Due

When I write the itemization down I put it in columns; date, service, charges, credits, balance. Also, from what I understand a FSA will only reimburse charges that the person has already paid.  They will only reimburse the client, not pay you, so you must have them pay you first and then get reimbursed themselves.

Waterbirth/Tub Insurance Coverage and Reimbursement

See also: DME - Durable Medical Equipment

Sample Order for Durable Medical Equipment for Birthing Tub (AquaDoula)

CPT code E1399  is "Durable medical equipment, miscellaneous - Purchase or Rental"
In Box 19, put "Four-week rental of AquaDoula portable warm water immersion tub"

Statement of Medical Need

What codes can be used for billing insurance? from Sidmar's (hydrotherapy tables) Frequently Asked Questions for Healthcare Professionals

Here is the code for Aquatherapy-97022 which is with a diagnosis of pregnancy  and back pain (what pregnant mommy doesn't have that?). The amount to bill for varies from $100 to more than twice that much. Of course, your success at getting this out of insurance companies may vary, but it can't hurt to try.

Lactation Consultant Reimbursement

The Lactation Consultant's Clinical Practice Manual: A practical guide to establishing a lactation practice from Marie Davis, R N, IBCLC

While lactation consultation is not specifically addressed in plan policy, skilled services are defined as:
“A health service is determined to be skilled based upon whether or not clinical training is necessary for the service to be delivered safely and effectively and on the need for physician-directed medical care. Examples of clinical training include registered nurse, licensed practical nurse, respiratory therapist, physical therapist, occupational therapist, and speech therapist. This list is not all-inclusive.”

Based on this definition, lactation consultation would be skilled.  Lactation consultation requires a specific certification, typically given along with RN, CNM, or LPN licensure.  It cannot be provided by relatively untrained people such as certified nursing assistants."

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
Sample Superbill

A Healthcare Insurance Reimbursement Guide For Breastfeeding Families from Medela Inc. - USING YOUR INSURANCE COVERAGE FOR BREASTFEEDING SUPPLIES & SERVICES. Medela's discussion of getting insurance payment for lactation consulting applies well to all interactions with insurance companies.

Diagnosis Codes for Lactation and Newborn Feeding Problems

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.

Doula Reimbursement

See also: Doula CPT Codes

Here's a sample of an insurance statement for doula services.

Plain and simple - if you don't want to learn much about insurance reimbursement but want to generate a meaningful statement, you can use this HCFA form with this CPT code:

59899 Unlisted procedure, maternity care and delivery

Debbie Young keeps a list of carriers that have covered. I have embedded the most recent list I got from her. I give it to my clients. Even if theirs is not listed, they can use it for ammo for their request......you know, competition.

Insurance Carriers That Have Reimbursed Members for Certified Doula Services - Debbie Young, CD (DONA)

3rd Party Reimbursement Chairperson
805 Washington Ave.
PO Box 336
Lowden, IA 52255

1. Oschner HMO, Louisiana

2. Aetna Healthcare

3. Travelers

4. Fortis Insurance

5. Qualchoice

6. Blue Cross/ Blue Shield PPO

7. Blue Cross/Blue Shield

8. Cigna

9. Foundation for Medical Care

10. AltPro

11. Wausau Benefits, Inc

12. Professional Benefits Administrators

13. Humana Employers Health

14. Glencare Managed Health Inc.

15. Summit Management Services, Inc

16. Lutheran General Physician's Organization

17. Elmcare, LLC, C/O North American Medical Management

18. Prudential Healthcare

19. Great-West Life & Annuity Ins. Co.

20. United HealthCare of Georgia (San Antonio, TX)

21. HNTB, Peoria, IL

22. Houston New England Financial, Employee Benefits, Fort Scott, KS

23. Maritime Life

24. Degussa, a German Chemical Company

25. Baylor Health Care System/WEB TPA

26. Medical Mutual

27.United Health POS

This list continues to grow. If your Insurance Company is not listed above, you may want to write to the CEO and ask "why not"?

DONA and Third Party Reimbursement

DONA's Doula Sample Letter for Insurance Reimbursement

Doula Reimbursement

Doula Reimbursement Forms

Forms for a Doula Business

Doula Letter To Clients About Reimbursement

Postpartum Doula Reimbursement

A printable form used by many doulas

Physician's "Prescription" for Doula Care
<Client name> is under my care for pregnancy, due on or about <due date>.  This will be her first baby.  Pregnancy has been uncomplicated. [Or list complications - VBAC, previous vacuum extraction, epidural, whatever]

I have advised her to engage a professional birth assistant for home care before and after the birth and for labor support in the hospital.

I have recommended <doula's name here>, who is a professional childbirth assistant and a <Licensed Midwife/Lactation Consultant/Childbirth Educator/whatever additional credentials you have.>

I feel that this support is medically necesssary because of  her desire to have an unmedicated birth and because of limited nursing support in the hospital."

Doula programs can improve perinatal outcomes, reduce costs for MCOs from the Mining Co. Guide to pregnancy/birth

How did you get insurance companies to reimburse?

It just takes hard work and persistence. Have the mothers send in your form to their insurance companies. Usually the companies then contact you for more information. give it to them and keep your fingers crossed. Debra Pascali (DONA) has had 16 different insurance companies cover her work as a doula.

Most doulas can give you an invoice to submit to your insurance carrier.  If you are really, really persistent, there's a chance you can be reimbursed for at least a portion of the cost.  But be aware that the request for reimbursement will be turned down automatically the first time and probably the second time you submit it.... keep submitting it until it reaches a person who can make a decision - then you've got a chance!!! 

There is a great article on third party reimbursement in the Summer 95 issue of Childbirth Forum. It has examples of women who get reimb., how to bill for services, code #, etc. Barbara Hotelling is a co-author. Can mail in by regular post if you don't have access. Or newsletter info available from ON TARGET MEDIA AT 1/800/950-0078 8:30-5:30 EST.

I made a simple form on my computer which has gotten at least one client reimbursed. I created a simple table with the following information:

Business name, address, phone
Tax ID number (you can use social security number if you don't have a tax id)
Date of invoice
Patient's name
Patient's address
Date of service: (you can also put the edd here)
Service performed at:
Diagnosis: V22.1 Intrauterine pregnancy (this is important)
Evaluation Management Services (Labor Support) CPT code: 99499
Provider's signature:
Fee for services:
Amount received:
Amount due:

I had one client reimbursed, after we submitted documentation to John Hancock several times. I wrote a letter reminding them that the clients were Orthodox Jews, and therefore the husband was not able to act as a "coach". It also just happened that this woman did not use an epidural, which would have cost them much more than the measly $500 they paid for my services!

I really believe the key is persistence. This client was willing to keep bugging them until they paid.

The other thing, which was brought up at the last DONA Region 5 meeting here in Los Angeles, is to send a letter to the nurse who reviews the claims that have been refused the first time, asking her to re-evaluate the claim, along with some research showing the efficacy of labor support.

Send a copy too of the bill to your insurance company and tell them.." I wanted to have a repeat c/section, and because of this woman's support, I didn't. Therefore you (the insurance company) saved thousands of dollars." Then when they refuse to pay, send the letter to your state insurance commissioner. I'd even go so far as to send it back to the insurance company a second time.

My insurance has the following policy for doulas, midwives, etc.: If they bill through a hospital or another participating provider such as a clinic, etc. they will pay for it. If they bill independently, it is not covered. The issue for me is getting hospitals to use midwives and doulas so the insurance will pay! I believe this policy applies to home birth as well.

I recommend asking a lot of questions, like, if the doula results in a non-interventive birth which costs the insurance less, will they cover her cost?

I have heard of people negotiating with their insurance companies to have their labor assistants fees covered...especially in the cases of VBACs.

Basically you provide the statistics of a labor assisted birth, then compare the cost of the labor assistant and VBAC to the cost of cesarean...if you get your VBAC the insurance company pays for the fees, and if you have a cesarean, you pay the fees.

The Cutting Edge web address is http: helpful stuff...

Getting Reimbursement for VBAC Clients

You could add the cost of an extra day in the hospital for both mom and baby.

You can order the superbill through Cutting Edge Press (713) 497-8894 or Fax (713) 492-7223. The cost is $31.95 (including shipping) for 100. Cutting Edge Press has a website with lots of good doula stuff-sorry I don't have their address, but if you search for up "doula supplies" you should be able to find it or look up their name.

You can purchase the super bill from M&M Productions run by Cheri B. Grant. Her snail mail address and phone are listed below:

Special Birth Memories - M&M Productions, P.O. Box 14003, Tulsa, OK 74159-1003, (918)288-7667

They come bound by quantities of 100 for $29.95 and she also has a great New Client Registration Card that also comes in a quantity of 100 for 20.95.

I really like her book "Labor Support Forms: A Guide to Doula Charting" ; it is filled with just about every possible form you could need for running your doula business and its cost is $29.95

DONA has a third party reimbursement committee, which has been working hard for a few years but hasn't come up with any magic formulas yet. Actually, at one of our DONA Region 5 meetings here in Los Angeles last year, a childbirth educator who works for Prudential spoke informally and gave us a lot of insight into the insurance process.

Forms are not really that important. As long as they have the required information on them, it doesn't matter if they are on NCR paper or look like they came from a doctor's office. The insurance company only wants to know if the service is a covered benefit.

If it is not a covered benefit, the customer can request them to evaluate the service and cover it anyway. The two reimbursements that my clients have had were both the result of sending lots of documentation to the insurance companies.

I'm sure you could order a superbill from any printing company that makes them for doctor's offices, but why spend that kind of money when your volume is going to be very low and you don't need to "Press hard - you are making 12 copies"?

Past issues of the International Doula (the DONA journal) have had articles on this topic, and I am sure there will be more. There's certainly a lot of interest in this topic!

Doula CPT Codes

The most specific code for doula service is:

59899 Unlisted procedure, maternity care and delivery

May, 2004 - A Monitrice client just got reimbursed by Blue Cross / Blue Shield of TN after I filed using ABC codes for labor support services!!

From time to time, I see someone suggesting that doulas should use CPT codes 59430, 59425, 59410 and 59515.

Here are some official listings of the CPT codes, along with their benchmark fees:

 59410 Maternity         Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care     $924.49

 59515 Maternity         Cesarean delivery only; including postpartum care       $1,073.86

 59430 Maternity         Postpartum care only (separate procedure)             $86.80

 59425 Maternity         Antepartum care only; 4-6 visits          $280.91

59410 and 59515 specifically mean that the person filing the claim was the primary birth attendant.  In the case of 59515, it would mean that they were the surgeon who performed the cesarean.

59430 implies very specific clinical procedures outside the scope of a doula.

59425 is specifically antepartum care and implies very specific clinical procedures outside the scope of a doula.

It is actually a crime to file insurance claims incorrectly, and whoever is spreading this misinformation needs to be more responsible about this.

I'm still confused about CPT code and Diagnosis Code. Do I need both of them? The numbers seem to be different.

Yes, you definitely have to have BOTH the diagnosis code AND the CPT code. They are two separate things which insurance companies and hospital billing offices use to know how much to charge. I work in a doctor's office in a hospital and when we do the billing, if both codes aren't there the sheets get bounced back to us. 

For doula services, the code (According to Cherie Grant's book) is:

Evaluation and Management Service
Professional Labor Support/Doula Services 99499

If I do private instruction, I also use:

Home Medical Service - Private Class
New Patient - Intermediate Visit 99342

The CPT code is 99499 (Evaluation Management Service). This is for labor doulas.

I have attached information from the Childbirth Forum article I referred to. It lists different billing codes (DRGs) that insurance companies use for relevant service reimbursement. I know there's another article somewhere listing innovative ways to list your services so that insurance companies will reimburse. I'll keep looking.

Meanwhile: Question for list - how are you all going about submitting to insurance companies for reimbursement of services (midwifery)? 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).

Appeals/Arbitration/Small Claims Court

See also: How To Get Insurance Reimbursement for Homebirth

New Tools Help Fight Health Claim Denials - AARP Bulletin - Sept., 2010

The Health Claim Game: Fight Back When Insurers Deny Claims - AARP Bulletin - Sept., 2009

California has laws against repeated, unfair denials of claims.

AB 1455 Provider Claims & Dispute Resolution California Code of Regulations Summary from the Blue Shield Provider web pages.

Blue Shield's Claim Settlement Practices and Provider Dispute Resolution - p. 2, discussing changes now that AB1455 has become law.

The Department of Managed Health Care (DMHC) oversees Blue Cross of California and Blue Shield of California PPO health plans. The California Department of Insurance oversees most other PPOs in California.

NOTE - Neither the plan nor the plan's capitated provider that pays claims shall impose a
deadline for the receipt of a claim that is less than 90 days for contracted providers and
180 days for non-contracted providers after the date of service, except as required by
any state or federal law or regulation.

STATE OF CALIFORNIA
DEPARTMENT OF MANAGED HEALTH CARE

STATE OF CALIFORNIA
DEPARTMENT OF MANAGED HEALTH CARE
TITLE 28, CALIFORNIA CODE OF REGULATIONS
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICES PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
PROPOSED REVISION OF SECTION 1300.71
PROPOSED TEXT
Control No. 2006-0782

(8) A "demonstrable and unjust payment pattern" or "unfair payment pattern" means any
practice, policy or procedure that results in repeated delays in the adjudication and
correct reimbursement of provider claims.

From
SUPERIOR COURT OF CALIFORNIA
COUNTY OF SACRAMENTO
DATE/TIME JUDGE
: 9:00 a.m. 11/21/07 : HON. MICHAEL P. KENNY
DEPT. NO CLERK
: 31 : LEE
CALIFORNIA MEDICAL ASSOCIATION et al., Petitioners and Plaintiffs,
VS.
DEPARTMENT OF MANAGED HEALTH CARE et al.,
Respondents and Defendants.

Health and Safety Code § 1371.39 provides:
(a) Providers may report to the department’s Office of Plan and Provider Relations . . . instances in which the provider believes a plan is engaging in an unfair payment pattern.

Rule 1300.71 (a) (8) provides guidance for establishing that a Plan has engaged in an unfair
payment pattern. It states that a "demonstrable and unjust payment pattern" or "unfair payment
pattern" means any practice, policy or procedure that results in repeated delays in the
adjudication and correct reimbursement of provider claims.

Technical Assistance Guide For Assessment of Health Plan Management of Claims - see page 7
 

CA Health and Safety Code 1371.37(a) and (c)

Blue Shield is the worst when it comes to "playing dumb" about homebirth midwifery fees.  They claim that *everything* is covered by 59400, including extra prenatal care, labor monitoring, postpartum recovery care, postpartum home visits, and all the baby care.  Sigh.  Here are some tools for dealing with Blue Shield:

Appealing Denial of Individual Claims for Homebirth Maternity Care

Appeals Letter - this great letter is simple, but it got an extra $7000 reimbursement.  Here's a comprehensive approach to dealing with Blue Shield.

Appeal Solutions - Medical Claims Recovery Services - Appeal Solutions provides services to healthcare providers focusing on resolving denied/disputed medical insurance claims, covering denial issues such as timely filing, medical necessity, refund requests, stalled claims, and more.  Our only focus is on assisting the healthcare community become more effective at overturning denied or incorrectly reimbursed medical insurance claims.  They have some sample appeals letters.

AppealLettersOnline.com is your source for resources to assist you in obtaining proper payments from insurers, Medicare, health plans and HMOs.  Visit AppealLettersOnline.com today!

Many insurance companies really drag their feet when it comes to paying for "alternative" birth services, including doulas and homebirth. These choices
typically cost less than a standard epidural/pitocin/vacuum extraction route, but insurance companies will do anything to avoid paying money, and they
seem to think people are more likely to give up more readily regarding payment for alternative services.  Well, ha!  This is your chance to put your
maternity leave to good use and learn more about the American legal system.  Take your insurance company to Small Claims Court.  You can collect
up to $2500 per claim for a maximum annual collection of $5000.  Perfect!  That's $2500 for you and $2500 for your baby.

Here's an Alta Vista search for "Medical Claims Resolution" or "Medical Claims Recovery"

Legal Recourse

Small Claims Court for Health Insurance Reimbursement (in California)

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.  This includes an explanation of how different regulations (federal or state) apply to different types of health plans.

Some years ago (2001?), Gail Johnson and Bonnie Kitchen were planning to tackle Aetna (and others) in a class action law suit for their refusal to pay midwives for homebirth.  817-268-6200

Settlement of National Class Action between Aetna and 700,000 U.S. Physicians
Statement of Bohn D. Allen, MD, President-Elect, Texas Medical Association

Judge’s Ruling Slows Cigna’s Attempt to Sidestep Global Class Action Suit
700,000 Doctors Win Critical Decision Against HMO

I'm gathering information for filing a complaint against Anthem Blue Cross and Blue Shield of California.
I'm going to focus initially on:

1) Extra time at the labor (in excess of one hour)

2) Extra time postpartum

3) Extra time for baby care

4) Newborn Screen lab fee

5) Followup newborn care

Please DO NOT send me any private information, i.e. NO NAMES, NO DOB.
Instead, please send me YOUR information, i.e. NAME, TIN, NPI and then for each claim

Category (#1-5), Claim #, Date of Service, Amount Denied

At this point, I'm only looking at claim items that are denied outright.
I'm not looking at claims that are allowed at a lower amount.
I AM interested in claims for 99355 where they allow only 1 unit when you claimed more.

Request for Refund

How to Survive a BC/BC Audit

ERISA & Overpayment Disputes

Self-funded plans are covered under ERISA and are not subject to state insurance laws.

And another nice one from SuperCoder.com


Ask the Patient Advocate: Managed Care and Insurance Q&A
From the Interdivisional (29/39/42) Task Force on Managed Care and Health Care Policy
Ivan J. Miller, Ph. D.

Q. An insurance company sent a letter asking for reimbursement of an “overpayment” of their liability for services that I provided last year. They are asking me to return the money and state that if I do not, they will deduct that amount from future payments to me. Does this mean that I should bill the patient for the refunded amount? Should I agree to the refund?

A. Many practitioners and their billing offices have faced this dilemma, and there are many reports that assertive professionals have successfully refused reimbursement. First, realize that if you do reimburse the insurance company, and indeed what you received was a proper payment for services provided, the patient may be the one who stands to lose. Unless otherwise prohibited by a contract you signed with the insurer, you would certainly be within your rights to recoup the fee from the patient. If you do not do this, you have taken a loss for services that you did provide and for which you would have billed the client at the time services were rendered.

Second, if you do not reimburse the requested amount and reimbursement for future clients is reduced, those future clients may also stand to lose. Again, unless the contract you have with an insurer prohibits this, future clients whose reimbursement is reduced could be responsible for greater payments than they might otherwise owe.

The following does not apply to Medicare and Medicaid. If these payers send a ‘recoupment letter,’ your best strategy is to comply, check your facts, and appeal later as appropriate. These particular payers can legally invoke serious penalties beyond recoupment. However, an indemnity insurance company or HMO may not be entitled to recoupment at all.

A number of jurisdictions have ruled on this issue and held that no recoupment is allowed if services were provided and the practitioner received payments in good faith, and the practitioner could not reasonably have known there was an overpayment. An assertive letter, and a convincing threat to follow up legally should “recoupment” from future reimbursement occur, may be all that is necessary. The following is a powerfully written legal format used by one professional.

Dear [Insurance Company],

We are in receipt of a refund request in the amount of $[ ] for client [ ].

We have reviewed this account thoroughly, and according to our records, the claim has been paid and the account is closed. You will be pleased to know we find no balance due from your company, nor do we find any payment that you are entitled to recoup. We have applied all appropriate contractual adjustments, if they apply, and the patient has been balanced billed for their responsibility, if any.

According to federal law, as a third party creditor, we cannot be held liable for mistakes on the insurer’s part. We obtained the patient insurance information at the time of service and there was every indication we were entitled to 3rd party payment from your company, based on the patient’s representation.

If you are claiming an overpayment, we received your payment and your Explanation(s) of Benefits dated [ , copies enclosed] in good faith. Based on your payment and Explanation of Benefits, we did not bill the patient for the portion covered by the insurance. We have provided services in good faith, and the funds received have been exhausted.

There are several court decisions that bear on this situation. In 1992, the California Court of Appeals held that, if a provider bills in good faith, and the insurance company accidentally pays too much based on the insurance company’s own calculation, the company cannot collect a refund from the provider, so long as there was no misrepresentation or fraud on the provider’s part in billing (City of Hope Medical Center v. Superior Court of Los Angeles County (1992) 8 Cal.App.4th 633). The discharge for value rule, or the innocent-third-party-creditor rule, has also been applied in an analogous situation. Numerous courts have held that an insurer is not entitled to recover payments erroneously made to an insured’s health care provider. See National Benefit Adm’rs, Inc. v. Mississippi Methodist Hosp. & Rehabilitation Ctr., Inc., 748 F. Supp. 459, 464-65 (S.D. Miss. 1990). See also Time Ins. Co. v. Fulton-DeKalb Hosp. Auth., 438 S.E.2d 149, 152 (Ga. Ct. App. 1993); St. Mary’s Med. Ctr., Inc. v. United Farm Bureau Family Life Ins. Co., 624 N.E.2d 939 (Ind. Ct. App. 1993); Lincoln Nat. Life Ins. Co. v. Brown Schs., Inc., 757 S.W.2d 411 (Tex. Ct. App. 1988).

Similarly, your company, as the insurer, made a payment to discharge a debt owed by the patient, and we are not required to refund the payment based on your calculations and which we received in good faith.

We feel that we have been properly reimbursed for services rendered and no refund will be issued. If, in the future, you elect to deduct the so-called overpayment from benefits payable on behalf of other beneficiaries of yours to whom we provide services, we will see that our legal counsel insures that our rights, and the rights of those beneficiaries as supported by the law, are preserved. Please do not hesitate to call me if you have any questions or need additional information. You can contact me at [Days, times, number].

Sincerely,
Patient Billing Administrator

Of course if you issue this letter you must be sure you had no other reasonable notice at the time services were rendered or payment received that you were not entitled to the payment as received. In the event that the insurance company reduces future payments, you can choose whether to follow through legally. In that event, enlisting help of the future patients whose benefits are short-changed based on so-called overpayment by other beneficiaries, and who become responsible for a larger bill, could be quite useful. In all probability their contract with the insurer does not allow for this possibility. Finally, should you deny repayment in this manner, you of course should judge the relative impact this might have on a potential referral resource or company for which you see many beneficiaries. If these are minor factors, you are on solid ground asserting your right to refuse “repayment.”

I had this happen once where they asked for money from a long time ago. I asked them for an EOB and a copy of the check that paid for it. They couldn't produce either so I told them I wouldn't pay it without that information. They dropped it.

I'll be the first to say I'm not an ERISA expert.  But I can say with confidence that it is not as cut and dried as "if it's ERISA, then state law doesn't cover it".  If it has to do with how they process claims and pay benefits, then yes, ERISA trumps state law.

But if it has to do with the "business" of administering an insurance plan, then state law can come into play.

Again, I'm no expert, and this is just a generalization, but ERISA is not always the final word.

Don Self's web pages have a great letter to use in responding to an insurance company's request for refund.

This same letter shows up on other sites:

www.care4cancer.com

Here's an embellishment of this subject from Gordon Herz, Ph. D.

This opinion claims that this ruling does not apply outside California.  Who knows?

Here's an Alta Vista search on the subject.

What to Do When They Have Legitimately Overpaid

and someone else concurs with:
"My billers call the insurance company, explain the error, and have them send a request for the refund. That way I know it gets to the correct place and we get credit for having sent it back. "

and here's a testimony as to why CIGNA is so great!
"It depends on the Ins co. CIGNA is almost impossible to refund to, in fact they keep paying us for claims that are not even ours. Each time we send the $$ back with explanation, and without fail get paid again on the same patient. Why?> IDK. Others except MedicareB, I have a 90 day "holding" period. If the $$ is not requested, after 90 days, it is sent with an explanation. FL MCD does not take refunds nor ask for repayment, they take the $$ from future claims. We
have a new MCD fiscal agent so it remains to be seen what their policy will be.
The problem with MCR 2ndary is the fact that  MCR will crossover to however many INS it has on file for the pt. That creates double payment and is a big pain in the neck. Even though we are not responsible for requesting the double payment, we are responsible for refunding it."

Miscellaneous Financial

Loans to Women's Businesses

The program will offer unsecured revolving loans of $5,000 with no fixed terms and a variable interest rate based on the prime rate, the group said.

Loans of up to $25,000 can be applied for by calling 1-800-359-3557, extension 120.

Asset Protection

See also: Malpractice Insurance

Hopefully, good attention to insurance claims will generate enough income that you have something left over after you've paid for your equipment, supplies, gas and therapy.  You might even have a profitable business that generates more net income than you need to support yourself at the most basic level, and you might start acquiring assets. This, unfortunately, makes you an attractive target for lawsuits.

It is so sad that I need to add this section, but I'm hearing crazy stories about grandmothers trying to sue midwives if the baby's father takes the baby out of the country, or if the birthing woman's sister is traumatized by witnessing the birth and so becomes infertile, or if the grandmother thinks the baby looks cross-eyed.

Sheesh!  Whatever happened to working hard to improve your financial situation instead of trying to cheat midwives out of their hard-earned assets.

Oh, well . . . welcome to the 21st Century in the United States.  :-(

Asset Protection for a Homebirth Midwife

Asset Protection for Physicians and High-Risk Business Owners from The Asset Protection Law Center