What is essential in this whole process is the paper trail. My insurance at the time required a $3,000 copay for an in-hospital, in-network, unmedicated birth; the entire cost of my midwifery care (including prenatal and postnatal visits) was only $2,500. There are several points to keep in mind if you are trying to get your insurance to cover a home birth: 1. Unfortunately, while insurance will have a list of participating midwives, they will likely not know if they perform home births. Make sure everything is in order before you submit: Are the ICD diagnosis codes and CPT codes on the receipt? I keep hitting a wall with insurance, what can I do? Approvals of authorizations to Non-Participating Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Non-Participating Provider You requested. I am a practicing homebirth midwife in Georgia. Ultimately, though, some women feel–rightly so!–that the health insurance they pay so much for every month should cover the costs of their birth; since getting most health insurance plans to cover a home birth is tough, they resort to a nearly “free” hospital birth experience with all sorts of other hidden costs to them and their babies. It is not your fault, therefore you should not have to pay the difference between the allowed amount and the billed amount. I did not get callbacks, nor did things get resolved when I was told that everything was resolved. I accidentally submitted both under my wife, and it resulted in denials and other unforeseen problems. Find out the following: Is home birth specifically listed as a covered service? I found that supervisors (I believe they call them lead representatives with) were able to process claims while you were on the phone, whereas the 1st tier representatives could not, and usually told you things would take up to 30 days. by | | Pregnancy and Birth | 4 comments. If your insurance benefits specifically list home birth and midwives, you can make the argument that there is no in-network midwife for home births (as long as there isn’t) and that the contract requires they cover an out-of-network midwife for you. But in Atlanta, many hospitals have high intervention rates, little support for natural birth, and high c-section rates. If it doesn’t specifically list those benefits, you may need to research if there are laws in your state that require midwives or home births to be covered. If We determine that We do not have a Participating Provider that has the appropriate training and experience to treat Your condition, We will approve an authorization to an appropriate Non-Participating Provider. My practice, Birthing Way Midwifery works with a billing service that does insurance billing for home birth midwives. Your employer might offer it so check if it’s available and how much cover you can get. Your SIL should contact her insurers and ask for the specific clause in her insurance terms which lays out the exclusion of cover for homebirth damage, and when this isn't forthcoming, she then needs to tell them she is getting in touch with the Financial Ombudsman as the insurers should be able to tell her exactly where the relevant clause is, and it should be laid out explicitly and in plain English that that is the case The rest of the opinion deals with Healthy New York, which is a program to provide affordable health insurance, and may not apply to you. If needed, enlist help. Home birth isn’t as countercultural as it used to be, but it’s still pretty unusual. Is the newborn active under the insurance? Excellus called referred to this as being covered “up to charge.” The person you are initiating this request with may not know anything about this, or how this is handled. I submitted this to insurance without catching this, and three CPT codes were all incorrectly processed on the same date of service, leading two of the three to be denied. I asked if any of them performed home births, because if they did, Excellus would not need to cover our midwives. If there’s an open enrollment period between now and when your baby is due, then switch to the plan that will cover the birth you want. The Certified Professional Midwife is a certification program. This is an important paragraph to become familiar with. Other states may have laws that work in your favor. Your Participating Provider or You must request prior approval of the authorization to a specific Non-Participating Provider. Then you just need to fight for the out-of-network provider to be covered "up-to-charge" so insurance just doesn't say that the allowed amount is $X, and they will pay Y% of $X, with you picking up the rest. Is there a date of service on the receipt? I selected an out ofnetwork CNM/CPM because the insurance company had no in-network midwiveswho attended homebirths. Home birth is specifically listed as being a covered service in our health insurance. You may also tweet at your insurance company. You will likely have to have had something denied or processed unfavorably to get someone external to help. And although Intown Midwifery and See Baby have launched a project to create a birth center in Atlanta–which would provide a wonderful alternative to hospital birth–at the moment the only choice in Atlanta, other than a hospital birth, is a home birth. Check your insurance has the necessary healthcare cover or talk with your GP and insurer about how to get the right cover, and how this affects your travel. States provide licensure if they choose to, Georgia does not. If you can find the portion of your insurance contract that specifies the rules on this, it may give you some ammunition so they don't pull one over on you.4) That should be enough to get the approval (assuming they don't have a participating home birth midwife, which I doubt they do). Office visits may include house calls.". We do require the payment (just $3000) upfront because they are more likely to pay a global fee and that can’t be submitted until the service is complete. In the event an authorization is not approved, any services rendered by a Non-Participating Provider will be Covered as an out-of-network benefit if available.”. Only a few states require insurers to cover at-home births, including New Hampshire, New Mexico, New York and Vermont. With Excellus, you can even file a pre-service grievance before the birth takes place (but wait until the authorization is approved or denied), which may be helpful if you get stonewalled about the allowed amount versus billed amount issue. "Helpers" might prompt a nod of agreement, though. This issue falls under a couple different governmental departments. Does your insurance cover house calls? We were denied the pre-cert because they listed other providers in the area as in-network, but obviously none could perform home birth services. Then the insurance provider lets you know the applicable plans to cover the baby. Make sure these are all filled in. Skip on expensive baby items like cribs and strollers; get cheap cloth diapers and hand-me-down clothes. Is the midwife’s name, address, NPI on the receipt? You can also have a “birth shower” instead of a baby shower and ask friends and family to contribute toward the cost of your home birth. Excellus’ claim form is on the website under Claims > Submit a Claim, and can be uploaded electronically. More often than not, when something happened to the claim, it happened incorrectly. Remember the Basics - Basic Principle: You're Proposing to Save Them Money. Had I hit a dead end, I would have worked more with the Health Care Bureau, because I think I would have eventually been directed to someone more familiar with the laws on maternity coverage. Qualifying periods. They will likely try to pay the in-network percentage of the allowed amount for that service. Even better options: birth assistants, labor companions, labor support professionals, or labor support specialists. New York also may have additional laws, but I was unable to find any beyond what is quoted above. http://www.dfs.ny.gov/insurance/ogco2005/rg050409.htm, https://www.health.ny.gov/health_care/managed_care/complaints/, How to get Insurance to Cover a Home Birth. My contract with Excellus had the following under “Access to Care and Transitional Care”: “Authorization to a Non-Participating Provider. Some states may have legislation dictating that home births or midwives are covered, making it a moot point as to whether it is spelled out in your contract. Are midwives specifically listed as covered providers? Make sure you have a PPO plan that does not have a homebirth exception. The best thing to do is interview several so you can find someone you connect with. Is it possible to get insurance coverage for your home birth? If you know there will be any other procedures outside of the birth, for instance a Rhogam injection, you might as well include the CPT code for this. There is also a whole page of contacts for New York state residents at, Health Care Bureau under the New York Attorney General’s office, New York State Department of Health’s Bureau of Managed Care Certification and Surveillance, New York State Department of Financial Services’ Customer Assistance Unit. My Insurance company is saying that they will not cover an at home birth through a midwife, although they do cover midwife care. The representative did not know. With pregnancy insurance, UK providers will not usually pay for most routine care and treatment during pregnancy. Somehow I didn’t think they were going to reimburse me more than my in-network copay would have been. Have you confirmed that insurance is going to be covering up to the billed amount and not using an allowed amount? Preferably, ask the midwives for the receipt after the home visits are completed so that the date of the receipt is after all the dates of service. What stipulations does your contract have regarding situations when there is not an in-network provider for a covered service. If We approve the authorization, all services performed by the Non-Participating Provider are subject to a treatment plan approved by Us in consultation with Your PCP, the Non-Participating Provider and You. Medicaid is a government-sponsored health insurance program for low-income families who have no medical insurance or inadequate insurance. What is your deductible? At one point they did try to direct me to in-network midwives. Granted, "covered at the in-network rate" is a little ambiguous and they may try to just apply the allowable amount, but you'll just have to keep reminding them that you shouldn't have to pay more because they don't have an in-network provider for a covered service. Excellus representatives will only give you their first name and first initial of their last name. 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