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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Appealing Denial of Insurance Claims for Homebirth Maternity Care

In an ideal system, there would be a lot of economic support for homebirth maternity care, because it costs less and has better outcomes.

In the system we currently have, insurance companies are in the business of making and keeping money.  Their first choice is for you to have a homebirth and pay for it all yourself.  Their second choice is for you to have a homebirth and for them to pay a minimal amount.  Their third choice is for you to have a homebirth and for them to pay a fair amount.  It should be their last choice for you to have a hospital birth, since that is about twice as expensive as a homebirth.  If you factor in the cost of the additional complications caused by planning a hospital birth (tripled c-section rate means tripled cost of hospital stay!), a properly reimbursed homebirth costs only about 25% of the average hospital birth.

Still, they will do everything they can to keep their money, and they know you're busy with a new baby.  Here are some ways to respond to denials of insurance claims for homebirth-related services.  This will help you to lobby better for yourself!

Many insurance companies deny claims for midwifery care beyond the standard procedure called "Global routine obstetrical care (code 59400)".  This code describes the four hours TOTAL of care typically provided by an OB for a hospital birth . . . about 2 hours total for prenatal care, 1 hour at the birth, and another hour of postpartum followup.

Anything beyond that those four hours of care is NOT included as part of total obstetrical care.
Obviously, this does not include home visits, and it obviously does not include baby care.

You can learn more about how midwives put together claims for the care they provide.  This includes the specific procedure codes that you may see on the paperwork you get from your insurance company.
 
 

Prenatal Care

Yet this is the standard of care.

The better insurance companies will pay for longer appointments . . . 40 minutes for a routine appointment, and up to two hours if there are any complications that require significant discussion or time to help baby shift position.

You can make these arguments with your insurance company, and it is true that the squeaky wheel does get the oil.  So lobby for the kind of prenatal care you deserve!
 

The Birth, coded as Global Routine Maternity Care or Global Routine Obstetrical Care

     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: "Management" of labor means management by phone while the nurses provide the hands-on maternal assessments, fetal monitoring, and nursing care.  It does not assume that the care provider is in face-to-face contact, which can be billed separately.]

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). It
is important to note that only one physician may bill for postpartum care. If both the family physician and a consultant who provided cesarean delivery see the patient postpartum, it must be
determined which physician will bill for the postpartum services.  [Ed: Note that this does not include home visits.]

Extra Time At The Birth - Mother Care

Extra Time At The Birth - Baby Care

Obstetrical care does not include any baby care.

Postpartum Mother Care

Postpartum Baby Care

Obstetrical care does not include any baby care.
 
 
 
 

Transporting

Legal Recourse

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