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

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How To Get Insurance Reimbursement for Homebirth

Mom's Gum Chewing Can Help Baby's Teeth

When mom chews xylitol gum from 3 months postpartum to baby's second birthday, baby's cavities are reduced up to 70% by the time the child was 5 years old.
Giving baby the gift of dental health is tremendous!

even if you have an HMO or your plan doesn't cover homebirth or associated charges.
 
 

Overview

Remember the Basics

Pre-Arranging Coverage

Appeals Process Insurance Company Resists Pre-Arrangement

Timing the Filing of the Claims

Appeals Process if they Deny Coverage After Agreeing Beforehand

Transporting

Legal Recourse

Sample Letters

Overview - Basic Principle: Maternity Care is Expensive.  Homebirth is Less Expensive, has Better Outcomes and more Satisfied Customers

Here's one midwife's explanation of maternity care economics, which will help you to lobby better for yourself!

This graph shows 2003 facility charges for labor & birth.  Facility charges are JUST for the facility itself, i.e. either hospital or birth center.  The facility charges do not include:

To get the current bare-bones Medi-Care reimbursement rates for your area, go to the Medicare Physician Fee Schedule Look-Up, selecting the default "Single HCPC Code", "Pricing Information", and then changing the "Carrier Option" to "Specific Locality", and keeping the default "Default Fields (Pricing Information Only)".  Copy the Procedure code from each of the procedures above into the HCPC field, select the "Global" option for the Modifier field, and then select the Carrier Locality that applies to your area.  Remember, the prices shown on this web site are the bare-bones prices paid by the biggest, cheapest plans, such as Blue Cross and Blue Shield.  Higher-end insurance plans usually pay about twice the Medi-Care rate.

(In case you're unable to download this .pdf file, here are the Facility Labor & Birth Charges, U.S. 2003 By Site and Method of Delivery:  NOTE - These prices are nationwide averages.  The cost in the San Francsico Bay Area is about 3-4 times that of the least expensive areas.)

Remember the Basics - Basic Principle: You're Proposing to Save Them Money

You are proposing a course of "treatment" for pregnancy and birth that will likely save the insurance company money.  They should be enthusiastic about this.  If they're not, then just keep explaining to them that you're proposing to save them money, and keep asking to speak to supervisors until you are speaking with someone who appreciates that you're proposing to save them lots of money.  If necessary, you might ask how they think their stockholders would respond to their refusing to accept your proposal to save them money.  (One mom said she would go to the stockholder meeting and hand out flyers explaining that they had refused her proposal to save them money; it worked, and they agreed to cover her homebirth.)

Pre-Arranging Coverage - Basic Principle: The Squeaky Wheel Gets the Oil

There are a couple of different ways of pre-arranging to get coverage or better coverage:

Pre-Approval (probably best for Blue Shield or any other company that doesn't reliably cover all midwifery services): You send your insurance company a description of the services you expect to need, and they pre-approve them, so you know they'll be covered. This is probably best used with a customized description of services used with the procedure code: "59899 Unlisted procedure, maternity care and delivery".  The procedure would be something like "Comprehensive midwifery care providing all medically necessary care for mother and newborn" with a detailed list of the expected procedures.

In-network reimbursement rate for an out-of-network provider (Blue Cross calls this an out-of-network referral.)

  1. Call your insurance company and ask them for the names of in-network homebirth providers in your area. You can tell them that you haven't been able to find anybody within a 15-mile radius of your home who provides the special service that you need, i.e. homebirth with a licensed provider.
  2. If they have one - great, give them a call.  If they don't have one, or the provider isn't able to accept you as a client, then ask your insurance company how to go about getting in-network coverage of an out-of-network homebirth provider.  Ask them if they can make an exception about providing coverage for an out-of-network provider, which they routinely do for either medical or geographic exceptions.  A medical exception means that there is nobody in their network who provides the service you need (homebirth), and a geographic exception means that the providers in their network who provide homebirth services aren't close enough to you to be useful.
  3. Follow the instructions they give you.  Here is a reasonable list of diagnoses and procedures involved in the typical cycle of care:
  4. Diagnoses for moms under 35 on due date, having 1st baby

  5. Prenatal Diagnosis:
    V22.0 - Normal First Pregnancy - no complications
    V22.1 - Other Normal Pregnancy (i.e. not a first baby) - no complications
    V23.0 - Pregnancy with history of infertility
    V23.2 - Pregnancy with history of abortion
    V23.3 - Pregnancy with grand multiparity
    V23.41 - Supervision of pregnancy with history of pre-term labor
    V23.49 - Supervision of pregnancy with other poor obstetric history
    659.53 - Elderly primigravida (over 35 on due date), antepartum only
    659.63 - Elderly Multigravida (over 35 on due date), antepartum only

    Labor/Birth Diagnosis:
    650 - Normal Birth (under 35)
    659.61 - Elderly Multigravida, delivered
    659.81 w/"IHPR" - Other specified indication for care or intervention related to labor and delivery, delivered, w/"In-home Postpartum Recovery, Coverage Mandated by State Law" in Box 19

    Postpartum Diagnosis:
    674.84 - Other complication of puerperium w/"Recently delivered mother at home less than 48 hours after delivery" or various other complications which often arise postpartum

    Newborn Diagnosis:
    V29.9 - Observation and evaluation of newborns and infants for unspecified suspected condition not found or various other complications which often arise in the newborn period, especially jaundice.
     

    Typical Procedures in a Cycle of Care:
    Care for Mom:
    99244 - New(>3yrs),comp OV/mod-60 min
    99211, 99212, 99213, 99214, 99215 - Office Visits of varying lengths
    99347, 99348, 99349, 99350 - Home visits of varying lengths
    99354 - Prolonged Face-to-face care - 1st hour
    99355 - Prolonged service in outpatient setting (each add'l half hour)
    59409 - Vaginal Delivery Only
    59020 - Fetal cont stress test-ea 0.5h
    59025 - Fetal non-stress test.

    Care for Baby:
    99464 - Attendance&initial stabilization (provided by assistant)
    99440 - Newborn Resuscitation (PPV,CPR) (if necessary)
    99344 - Home-New-Newborn Exam-Comp-60min
    99211, 99212, 99213, 99214, 99215 - Office Visits of varying lengths
    99347, 99348, 99349, 99350 - Home visits of varying lengths
    99354 - Prolonged Face-to-face care - 1st hour
    99355 - Prolonged service in outpatient setting (each add'l half hour)

    Newborn Screen (has 8 different procedure subcodes in California w/diagnosis V77.3 - Screening for phenylketonuria (PKU) - The State of California's NBS program recommends the use of diagnosis code V77.3 for the entire screening panel.) This whole panel costs $108.75, so it might not be worth the extra effort.
    82776 Galactose-1-phosphate uridyl transferase - $15.40 V773
    83021 Hemoglobin fractionation and quantitation; chromatography - $15.40 V773
    83498 Hydroxyprogesterone, 17-d (17-OHP) - $15.40 V773
    83789 Tandem mass spectrometry; quantitavie (MS/MS) - $15.40 V773
    84443 Thyroid Stimulating Hormone (TSH) - $15.40 V773
    82261 Biotinidase (BD) V773
    83516 Immunoreactive trypsinogen (IRT) V773
    36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) - Newborn Screen - fee limited by law to $7 V773

    Emergency Equipment, Supplies and Services as Necessary

  6. If they are not helpful, contact your employer's Human Resources Department if the insurance is through their employer.  Health insurance coverage is an employee benefit, and if you feel that it's not benefiting you in the way you need, your Human Resources staff will want to know about this - after all, they're the ones who help to shape the decision about which plan to buy next year!  Especially if your company is self insured, the HR people should be very helpful about reducing the overall expenses of maternity care.  It is helpful to point out that the insurance company (and ultimately the employer) will save $10,000 to $20,000 on a homebirth compared to a hospital birth.
  7. Be sure to get a copy of your health insurance company's approval for in-network coverage of homebirth in writing.
  8. If they refuse to grant an out-of-network referral, ask what their appeals process is.

Timing the Filing of the Claims

If your midwife is generating paper claims for you to file, you might want to be thoughtful in the timing of the filing.  First, you might want to learn a little bit more about the various claims involved in the cycle of midwifery care, which includes prenatal care, labor monitoring, the one hour right around the birth, the immediate postpartum recovery, the immediate newborn care, the followup postpartum care for the mother, and the followup newborn care.  Yes, this is complicated, and the more you look at all these claims, the more you'll appreciate how many hats your midwife wears and how complex her training must be in order for her to be able to provide the care normally provide by an obstetrician, a pediatrician, a neonatal resuscitation team, labor and delivery nurses, maternity nurses and newborn nurses.  Those midwives are pretty clever, huh?  It's really important for you to understand that your midwife has provided much more care than an obstetrician would normally provide, because your insurance company would really rather pay as little as possible, and they can play dumb about pretending that all your midwife did was provide the care that a hospital-based OB might provide, i.e. about 2 hours of prenatal care, about an hour of care at the birth, and about an hour of postpartum care - yep, just four hours total.  Yes, OBs really get paid $2000-$4000 for just two hours of care.  Then the hospital usually gets paid another $6000-$20,000 for the equipment, facility and the staff of nurses that provide care during the hospital admission.  And, of course, there are additional professional fees for the pediatrician who examines the baby at the hospital and the anesthesiologist who manages the epidural ($600 - $2000).  So don't sit back and take it when your insurance company wants to pay just $2000 for the 20-60 hours of care provided by your midwife, including all the equipment she brings to your birth.  (In case you're wondering, those continuous fetal monitors cost about $7000, and AquaDoula kits cost about $2000.)

So, I hope you're motivated to spend a little bit of energy educating your insurance company about why they should reimburse more than just the basic birth fee.  One way to help them appreciate this is to submit the claims separately.  I encourage midwives to generate and submit claims separately to reinforce this concept, but if yours just gives you a single sheet of paper, you might ask her to itemize it more accurately. Here are some guidelines for her.

Generally, it helps to submit claims that total less than $1000 separately, and to wait a couple of weeks between filing claims.  However, be aware that some insurance companies require that you file claims within 120 days of the date of service, after which they may reject them based on timing alone.  So don't let the paperwork sit around until you're getting enough sleep.

Here's a simple timetable that might help to maximize reimbursement:

Initial visit and extra prenatal care - file these as soon as they occur.
The birth claim - file this as soon after the birth as possible.
Followup Postpartum Care within 48 Hours - These are the home visits to check on the MOTHER in the two days right after the birth; wait a couple of weeks to file these.
Followup Newborn Care within 48 Hours - These are the home visits to check on the BABY in the two days right after the birth; file these as soon as you get them.
Followup Postpartum Care after 2 Days - These are home and office visits from 3 days to several weeks after the birth.  Wait a couple of weeks after filing the previous set of MOTHER claims to file these.
Followup Newborn Care after 2 Days - These are home and office visits from 3 days to several weeks after the birth.  Wait a couple of weeks after filing the previous set of BABY claims to file these.
Claims for Labor Monitoring and Immediate Postpartum Care - These are the claims for all the additional time the midwife was there during labor and in the hours immediately after the birth.  Wait a couple of weeks after filing the previous set of MOTHER claims to file these.
Claims for Newborn Care - These are the claims for all the additional time the midwife was there providing care for the BABY in the hours immediately after the birth.  Wait a couple of weeks after filing the previous set of BABY claims to file these.
Prenatal Home Visit - I'll often file this last, just because it's a smaller amount and doesn't fit conveniently into the other bunches.

So, for a birth that happens on Jan. 1, you will have previously filed the claims for prenatal care, excluding the home visit. File the birth claim within a few days after the birth and then submit the other claims according to this timetable: [Note that this timetable is slightly different than that suggested for the midwife, just because it's easier for families to understand.  If you want to get fancy, you can follow the timetable suggested for the midwife.]
Jan. 15    Home visits on Days 1 and 2 for mother.  Separate claims for home visits for baby on Days 1 and 2.
Jan. 31    Home visits on Days 5 and 10 for mother.  Separate claims for home visits for baby on Days 5 and 10.
Feb. 15    Labor monitoring and immediate postpartum care for mother. Separate claims for immediate newborn care.
Feb. 28    File any remaining claims, such as prenatal home visit and assistant services.

I know it seems counterintuitive to stagger the filing of the claims, but I have found that this reduces the holds on the larger claims and actually gets everything tidied up sooner.  And it really does reduce the insurance company's misperception that everything's lumped in with the global fee.  It's also easier to file the handling of appeals when you deal with them in smaller sets of claims, where all the claims in that bunch are supported by the same reasoning.

Appeals Process Insurance Company Resists Pre-Arrangement - Basic Principle: You Have Rights to Press the Insurance Company to Accept your Proposal for Saving them Money by Planning a Homebirth

Some tips from Weighing Your Health Plan Choices - Consumer Reports, Sept., 2005

Your state may have a review process that allows patients to appeal denials of care - it's important to follow these steps, and keep copies of e-mail and regular mail correspondence, and to take notes about your telephone calls (date/time/name of rep./what was said.)  It's also important to do this promptly, as your rights might expire after 30 days.

  1. Try one last time with the insurance company and tell them you plan to file a formal appeal with them and, if necessary, a formal appeal through your state agency.
  2. File the formal appeal with your insurance company through whatever procedure they provide.
  3. If denied, then file the formal appeal through your state agency:
  4. Proposing a safe, less expensive alternative to hospital birth is very reasonable.  If the state agency isn't able to help you, then make a call to the office your local state representative or state senator.  They should have offices very close to you, and they should be glad to help you with something so obviously "right".

Supportive Documents

If the insurance company tries to deny your appeal on the basis that homebirth is experimental, you can point out that doctors and midwives have been attending homebirths for over 2000 years.  If their medical review board states that homebirth is unsafe, ask them to cite references supporting this.  (They don't have any reputable references - hospital birth has never been shown to be safer than homebirth or low-risk pregnancy.  See this web page about Homebirth Safety.)

In particular, here are critiques of the flawed studies that are sometimes used by obstetricians who claim that homebirth is unsafe:

Pang Study, Washington State, 2002 (showed that unattended homebirths are less safe than attended births in the hospital)

Australian Outback Study, 1998 (showed that high-risk births taking place far from a  hospital are less safe than in a hospital)

Basic documents to support homebirth as a reasonable "treatment" for pregnancy and birth:

Outcomes of planned home births with certified professional midwives: large prospective study in North America [Full-text article]
Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager
BMJ  2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.1416

Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. [NOTE - CPMs are equivalent to Licensed Midwives in some states.]

California legislative finding about the appropriateness of homebirth: "The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth."

Appeals Process if they Deny Coverage After Agreeing Beforehand - Basic Principle:  Again: The Squeaky Wheel Gets the Oil

Here are some articles from Medical Economics magazine:

Prodding insurers? Use patient power
May 20, 2005
By: Gail Garfinkel Weiss
Can't get a health insurer to pay up? It's customers might get better results.

Enlist employers in claims fights
May 20, 2005
By: Gail Garfinkel Weiss
Insurance companies are more likely to pay you after they hear from the folks who pay them.

Claims denials: Don't take No for an answer
May 6, 2005
By: Betsy Nicoletti
Your office should be appealing denied claims, and learning from them.

There's a separate section about Appealing Denial of Insurance Claims for Homebirth Maternity Care.

Transporting

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.

Governmental Recourse - Insurance Commissioner - Basic Principle: Get them to do the hassling

Many states have an insurance commissioner who will investigate complaints against health insurance carriers.  Here's the California Insurance Commissioner's Complaint page and their main page.

Legal Recourse - Basic Principle: Just a Little Bit of Agitating Should Get Your Reimbursement

Your ultimate tool is Small Claims Court - this is a system where you can easily represent yourself and present your "case" to a judge:

Small Claims Court is your trump card.  Don't be afraid to use it.  It's actually quite easy.

Sample Letters


<Date>

Appeals Resolution Team
<Address>

Re:  Member ID# ???  Claim for <Midwife Name>, CPM, LM  <Dates of Service>

Dear Sirs:

This is a formal letter of appeal to the above referenced claims.  Aetna’s assessment that the prevailing costs for homebirth services in my geographical area is entirely unfounded and inaccurate.  Certified Nurse Midwives do not provide homebirth services in our area.  The appropriate providers for such services are Licensed Midwives and/or Certified Professional Midwives.

Please refer in our file to a homebirth claim for services rendered by <Midwife Name> for my baby's birth on <Date of Birth>.  We believe that the $<amount> fee assessed for my prenatal exams and birth for <Midwife Name> were more than fair for services provided.

Homebirth is a low cost safe alternative to hospital birth.  Please see the attached study by the British Medical Journal.  I am a small woman who has had three very large babies – naturally, and safely.  Had I elected to have my second and third births at the hospital, I would have been a likely Cesarean Section, episiotomy or other intervention candidate, due to the babies’ sizes and length of labors.  This would have significantly increased all of our costs by tens of thousands of dollars.  Aetna should be supporting homebirth for healthy mothers because pregnancy is a normal condition, not a medical condition.

I believe your studies regarding homebirth are flawed and cite references that are unproven and unfounded.  Should Aetna be interested in saving shareholders’ money by supporting families who chose a safer alternative to hospital interventions, I refer you to the following for a list of appropriate and widely recognized studies:

http:

We expect full and prompt reimbursement for expenses incurred by <Midwife Name>.  If this claim is denied again, we will undertake the following steps:

1) Our benefits coordinator at <Employer> has already been contacted
2)  We will file a formal complaint with the State Department of Insurance and Banking
3) We will attend your annual stockholder meeting to inform Aetna stockholders that Aetna is not interested in saving stockholders’ money by supporting lower cost healthcare options.
4) We will pursue this matter in small claims court
5) We will continue to be advocates for families under Aetna plans who elect safer lower cost alternatives to the medical model (including choice on childhood vaccinations) and we will not stop until changes are made.

Please contact us at <phone number> if you have further questions.



This Web page is referenced from another page containing related information about Money and Paperwork

 




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