The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
Support the inclusion of Certified Professional Midwives in Medicaid and health care reform. Where's the Birth Plan? by Jennifer Block - Midwifery-style care saves money and provides excellence for the new family--a great two for one proposal! She clearly points out how the more humane style of care provided by midwives not only saves money, but also saves lives. A new economic analysis forecasts savings of $9.1 billion per year if 10 percent of women planned to deliver out of hospital with midwives. The
Debate on Healthcare Policy Reform by Faith Gibson, a healthcare historian
and policy theoretician
|
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:
Even though Aetna claims not to cover homebirth, they should still pay
the unbundled prenatal and postpartum care, which are not technically homebirth
services, even if provided in the home.
Fed Court - Whiney Aetna "Spanked" Again... Opinion by Consumer
Advocate Tim Bolen [3/9/06]
Aetna, being sued by Cavitat Medical Technologies on several counts,
has had a history, in this case, so far, of bad behavior you can read about
in my earlier articles - including the sending of thugs to my home in a
clear attempt to dissuade me from writing about them.
The Cavitat v. Aetna case is a "donneybrook" - a battle for supremacy.
It is the first outright challenge, by the public, of "the decision process"
Aetna insurance, and its affiliates, uses to determine exactly what health
care offerings they will pay, or not pay, for. Cavitat, in essence,
has accused Aetna, of using questionable standards, and dubious individuals
(the "quackbusters"), to evaluate health care offerings - and is being
very specific in those accusations. The case, if successful, will
force Aetna to use standards more in line with the reality of health care
- and Aetna is pulling out all of the stops to try and stop this attempt.
But Cavitat, last week, played a new card Aetna didn't expect.
They brought in well known California Litigator Carlos F. Negrete to take
over as lead trial attorney - and Aetna started to seriously "whimper"...
"
Resources
First Things First - Get the Right Numbers for Business!
It is best to do all this early on, so you have all your numbers in place
before filing insurance claims or signing up an electronic billing service.
If you sign on with a regular billing service, they'll usually handle the
third step for you, which is really nice.
The National Plan
and Provider Enumeration System (NPPES) to assigns unique identifier
for health care providers. Your National Provider Identifier (NPI)
is your standard unique identifier. As part of the registration process,
you'll be asked to classify yourself in the taxonomy
of providers. A taxonomy is just a set of hierarchical categories,
and it's important to make sure you're in the right group so insurance
companies will understand that you're a licensed healthcare provider providing
medically necessary services. For example, if you're in the same group
as veterinarians and funeral directors, you might not be in the right subgroup.
Here's a current listing
of the codes, plus more information about the Provider
Taxonomy Codes, including what
the levels mean.
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
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.
In any case, it does help to understand what it's all about. There are some good introductory books about insurance billing. I was very happy with Medical Billing Basics from Ingenix. This is an excellent overview of medical billing, and although the book doesn't have all the codes, it comes with a demo disk of Encoder Pro, which DOES have all the codes. (I found it at a discount at medetrac.com, or if you get coupons from MooreMedical, this is a good time to use them!) Encoder Pro has an excellent search facility, and this is how I familiarized myself with the diagnosis codes, which are tricky if you're looking for anything outside maternity/birth/newborn codes. (The demo expires after a few months, but you can just re-install it and continue to use it as a search resource. NOTE - I think they have the codes from 2004 in there - the only common diagnosis codes that changed were the Pap codes.).
Eventually, I purchased the AMA CPT Standard Edition, just to have the most complete definitions of the procedures. And just this year, I purchased the ACOG book, The Essential Guide to Coding in Ob/Gyn, to help fill in the gaps.
If you've got the budget for insurance billing resources, it makes sense to purchase the above overview, CPT and ACOG books. I've found the Encoder Pro and online diagnosis resources to be superior to the books, because you can search more quickly and more easily.
I also read through some good online resources:
American Academy of Family Physicians (AAFP) pages on Coding for Intrapartum Care and Other Obstetrical Services [My notes]
Official ICD-9-CM Offical Guidelines for Coding and Reporting [My notes] There are lots of online databases of diagnosis codes, because governmental agencies have a strong interest in accurate diagnosis coding.
From time to time, the complete ICD-9 and CPT-4 code sets have appeared online, although the CPT-4 seems to come and go more quickly.
I have tried to write up a good introduction with Sample Billing Scenarios for a Homebirth Midwife.
And the rest of these web pages have lots of links into solid references as well as lots of midwife hearsay.
Midwifery Today has had some articles about insurance billing, written by Linda Lieberman, a midwife in Oregon:
Midwifery Today #74 (Summer 2005). In the Business of Midwifery column titled "The Federal Register", there is a lot of detailed info on some of the tools for setting fees.
Good luck!
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
The recent call from the Institute of Medicine for government payers
to increase payments to health care providers who deliver high-quality
care is one of several signs that practicing doctors can expect some fundamental
changes in the way they are compensated.1,2 Health care insurers and purchasers
in the private sector have begun moving along a similarly ambitious path.
Many physicians are already familiar with quality incentives from their
experience with managed care; such incentives began as small payments for
higher ratings of patient satisfaction or for the use of preventive services
such as mammography.3 These incentives . . . [Full Text of this Article]
The Emergency Medical
Treatment and Active Labor Act (EMTALA) has specific regulations for
hospitals relative to women in active labor. The purpose of these
federal regulations is to ensure that patients with medical emergencies,
including women in labor, are not denied treatment based on any reason
other than those that reflect the hospital's capacity to examine, conduct
tests, and treat the emergency condition.
All women in true labor are considered to have an emergency medical
condition, and are therefore unstable. "Labor" is defined under EMTALA
as the process of "childbirth beginning with the latent or early phase
of labor and continuing through the delivery of the placenta."[1,5] The
presence of an emergency medical condition triggers all of the obligations
of EMTALA.
So if you end up transporting to a hospital that isn't a preferred hospital,
the care should still be covered as a preferred hospital because of the
emergency condition, i.e. active labor.
A Consumer Guide
to Handling Disputes with Your Private or Employer Health Plan - Kaiser
and Consumers Union have a great set of web pages about Consumer Rights
and Health Insurance.
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.
Facility
Labor and Birth Charges, U.S. 2003, By Site and Method of Delivery
- note that these are facility charges, meaning they do not include the
services of the midwife, anesthesiologist, pediatrician, OB or family practice
doctor.
Prices, as quoted by Alabama Birth:
Home Birth $2300-$5000
from O'Mara, P. Having a Baby, Naturally, 2003. p. 322. Based on figures
published in 1999.
This summarizes
standard maternity costs
See also: HIPAA - Legal Aspects of
Midwifery / Health Insurance Portability and Accountability Act
From: Frequently
Asked Questions about Portability of Health Coverage and HIPAA
Under HIPAA, . . . preexisting condition exclusions cannot be applied
to pregnancy, regardless of whether the woman had previous health coverage.
Newborn's
and Mother's Health Protection Act Statutory Text
Newborns'
& Mothers' Protections (Newborns' Act)
The Newborns' and Mothers' Health Protection Act (Newborns' Act) includes
important protections for mothers and their newborn children with regard
to the length of the hospital stay following childbirth. The Newborns'
Act requires that group health plans that offer maternity coverage pay
for at least a 48-hour hospital stay following childbirth (96-hour stay
in the case of Cesarean section).
From: Frequently
Asked Questions about Newborns' and Mothers' Health Protection
Q: Under the Newborns' Act, when does the 48-hour (or 96-hour)
period start?
If you deliver in the hospital, the 48-hour period (or 96-hour period)
starts at the time of delivery. So, for example, if a woman goes
into labor and is admitted to the hospital at 10 p.m. on June 11, but gives
birth by vaginal delivery at 6 a.m. on June 12, the 48-hour period begins
at 6 a.m. on June 12.
However, if you deliver outside the hospital and you are later admitted
to the hospital in connection with childbirth (as determined by the attending
provider), the period begins at the time of the admission. So, for
example, if a woman gives birth at home by vaginal delivery, but begins
bleeding excessively in connection with childbirth and is admitted to the
hospital, the 48-hour period starts at the time of admission.
I want to share my point of view and hope it's not too controversial.
I think many of us are VASTLY under-charging. Probably especially
those of us serving special communities with a lot of homebirthers (thus
a lot of competition), etc. I wish a given community of midwives
really could agree to a standardized price for a standardized service and
not worry about anti-trust violations (everyone else is doing it for heck's
sake). Extras should be extras - a birth assistant, a birth center,
extra home visits, etc, should cost more.
I say this gently... I think the idea of a "free birth" for purposes
of 'vocation' or mission work sounds nice, but in actuality does not serve
anybody. This is our livelihood. This work, the education,
the preparation, the supplies, the hours, the stress, the risk, most of
all - the personal investment, the time, the energy, the sacrifices we
make, and the love we give - it deserves compensation. For truly
impoverished families, I am comfortable with a very low fee. But
charging even just $50 or requiring real trade (in work or goods or whatever)
gives midwifery services value. It makes a point that I think is
very important for our clients to understand.
I live in an area where a lot of homebirthers have the bargain hunting,
yard sale mentality. People will come to me as say " Well I have interviewed
x and y midwife, and they only charge $1000 or $1100,or even a couple hundred
less then me. Will you give us the same price" . I politely say.
" I charge what I charge because I schedule my prenatal visits to be 1
hour long, I do CEDS testing at every visit, I include Prenatal Parenting
TM and Childbirth classes, all your supplies, and the birth tub as
part of my service. My service is worth a lot more then what I am asking,
you are actually getting a really good deal." Most of them say oh,
I see. Some of them never come back, but a lot do, even though they
may be paying me more. I have to tell you. I think when you charge
what you are worth, or at least not give your services away, your clients
respect your advice more, and you will not get as burnt out as fast.
I do not do free births. If someone really wants my services, and really
can not afford to pay me, they can do work for me. Most are more then happy
to do it. It make what you are giving them worth something to them
The clients that have the most problems with the fee, give me the worse
problems, don't take me seriously, and take the most amount of my time.
If someone from the beginning has a problem with my fee, I let them
go to the cheaper midwife. I never apologize for my price. You would think
I would have less business. The exact opposite is true. Since I have
raised my fees, and made no apologizes, my business has gone up dramatically
! I already have 3 times the number of births already signed up this
year!
The other thing I never do. Give discounts to last minute-ers
who have had no prenatal care. The only discounts I give are if another
care provider has provided prenatal care, and they can prove they are square
on their bill with their previous provider, then I will give a $50 discount
for each prenatal visit with a Maximum discount of $500.00. So my
fee is never lower then $1200.00. They must show me that they paid the
other provider so that I avoid the scenario of someone seeing someone
else, and then switching at the last minute leaving the other provider
unpaid, just to get a discount!
Birth Business - A workstation
of simple and practical techniques, information, links and resources for
the self-employed Birth Professional
Getting
Paid - Why Every Practice Needs a Payment Policy [Medscape registration
is free]
Should You Charge
Your Patients for "Free" Services? [Medscape registration is
free]
Ingenix will custom-make a Customized Fee Analyzer for you for about
$250.00. It is specific for your speciality and area. Expensive,
but well worth it every few years. Maybe a few midwives in the same
area could share one. Phone - 1-800-464-3649, but be
prepared for lots of sales calls. You must be firm with them.
Just tell them to send mail, absolutely no phone calls, or they'll call
every week. This is also a good place to get CPT, HCPCS, and ICD-9
code books, usually about $50 each, but sometimes they have a special going,
especially if you get more than one.
A
discussion of price fixing among medical professionals: "An agreement
among competing professionals on a minimum fee schedule, for example, is
a violation of the antitrust laws."
Midwife's Financial Agreement / Informed Consent
Home Birth Financial Agreement
Homebirth Disclaimer by Joan Mershon CP
In my homebirth practice, I charge primes $300 more and require a labor
doula. I think I should charge more!!! Of course, the requirement
for a prof doula is negotiable if she has excellent, experienced support
planned. Just as long as they understand that I am not going to be there
for 2 days rubbing her back.
FEES I observed a friend who is a naturopath in an initial visit once,
who straight forward told the clients his fee was $900 (at the time, mine
was $500--this was 1982, I believe) and he expected full payment by the
eighth month. His clarity was reflected in their immediate response, a
frank and open discussion about payment schedules, and he almost always
got paid.
We have the same approach with our clients. We also almost always get
paid. Infact, when we don't get paid, its usually because it has been agreed
to do the birth anyway.. out of a sincere need. Our fee must be paid in
full one month before the baby is due. Of course that fee is sometimes
adjusted to the needs of the individual.
However, the initial discussion of fees (including what's NOT covered
as well as what is) must be done by the midwife. I hate this conversation
but not as much as I hate getting stiffed! Here's my approach: Set a fee
you can be proud of, that reflects your effort and the going rate where
you live. (begin by estimating the avg time spent at a birth and giving
ap & pp care, plus all your supplies, phone calls, pager costs, mileage
at $.28/mile, etc.). The only one you have to justify your final charge
for services with is yourself. When you can look in the mirror and say
your fee without any apology, you're ready for the next steps:
This discussion about doula fees had many fine insights:
I live and usually work in San francisco. I do not know how fees here
compare but many doulas here do births for free in the beginning. (I personally
oppose doing births for free just because you are inexperienced. I think
even a new doula has a lot to offer and people value what they pay for.)
An experienced doula in SF charges between $1200 and $2000 for birth doula
services. For perspective, a one bedroom apartment in my neighborhood rents
for approx $2500 per month and parking is an additional $300 per month.
So no one is getting rich here either!
However, i just wanted to share something that has worked for me. I
have been a full time doula for a few years and what ultimately worked
for me was to say something like this... when a prospective client asked
what my fees were i would tell them and wait to see what their response
was. If the fee seemed to surprise them or they said they could not afford
it i would tell them that I believe that every women deserves a doula if
she wants one and I would not want money to be the reason that a woman
does not get the support she wants. I would then encourage them to interview
several other doulas, (not necessarily no fee/low fee - i think chemistry
is the most important piece) and stress that if after meeting a few other
doulas they feel i am the right doula for them i will creatively work something
out with them to make it work for us both. I also let them know that I
can afford to take one reduced fee/trade client per month and if they can
afford to pay it is important that they do so that those in true need can
take advantage of the reduced rate. i also state that i firmly believe
that doulas are worth far more than what we charge.
If they come back and want me to be their doula we work it out together.
I start by asking what they would like to do. I have been surprised by
the number of folks that want to pay just $100 less than what i was asking.
I have also worked out creative payment plans where folks take a year to
pay me, add me to their baby shower registry, pay me in complete trade,
(I have gotten fancy haircuts and color for a year, frequent flyer miles,
gelato, meals at restaurants etc.). While trade wont pay the rent, I have
never felt like i got a bad deal. I have even gotten my final payment on
a baby's first birthday and never had anyone skip out on a payment.
I have found that some people are just bargain hunters and will try
to get a deal whenever they can. They are usually very willing to pay full
price when I explain myself to them. In fact, several folks who originally
asked for a discount actually offered to pay a little more to fund more
of my pro bono/reduced rate work! I have never asked clients to prove their
need to me, I just take their word for it.
PayPal charges a 3% surcharge
for credit charges.
CareCredit - patient/client
financing
Medicare
Participating Provider Program Enrollment Package and Fee Schedules
[from CIGNA] - These fee schedules will give you a good relative sense
of costs associated with different services. As a rough guide, the
Tennesse guide for 2001 non-par FS is roughly equivalent to the benchmark
fees from 1998.
A benchmark fee table is a table of fees that shows the relative values
of different procedures; you'll need to figure out your Geographical
Multiplier to know what are considered Reasonable and Customary Fees
in your area.
The 2005 conversion factor for 2005 is $37.90. The conversion factor
for 2004 was $37.34.
Medicare Physician
Fee Schedule Look-Up
Benchmark
Fees and codes for different procedures - type in maternity
or newborn [currently not available?]
North
Dakota Medicaid Fee Schedule as of 7/1/04
CPT
codes and Fee Schedule for Arizona Health Care - Maternity Care And
Delivery
Check out ACOG's
2005 Benchmark Fees w/explanation of geographical multiplier
Geographic Multiplier -- A factor used to make geographic adjustments
to the Medicare Fee Schedule or any other fee schedule. The term "geographic
factor" is also used.
Midwives and clients alike need to understand that comparing the cost
of midwifery services in Alabama, New York City and San Francisco makes
no sense unless you include a "geographic multiplier" to adjust for the
relative cost of living. Obviously, every midwife is going to offer
a different level of quality and services, but identical services in the
San Francisco area might cost twice the services in a rural area.
Here are some resources to help you understand this better:
THE SALARY CALCULATOR
- compare salaries necessary in different cities to maintain the same standard
of living. The reason your midwife in the Silicon Valley area charges
more than your net-friend's midwife in St. Paul, Minnesota is that the
cost of living is almost double in Silicon Valley.
Methodology
Used To Calculate The Median Price Of Dental Services In 300 US cities,
which includes a relative
cost calculator
ReloSmart
- This page gives comprehensive comparisons of many aspects of relocating,
including differences in salary necessary to maintain the same standard
of living.
National Physician
Fee Schedule Relative Value File contains the geographic practice cost
indices (GPCIs)
In 2005, Independent homebirth midwives in the UK were charging about
$2500-$3000 for comprehensive maternity/newborn care; this translates into
$4400-$5300 US $$, and I think this was in suburban areas. While
on the subject, here's the care offered by an
independent hospital-based OB in the UK - $3200 for repeat clients
to $4000 for first babies. Interestingly, he charges only $1000 for
a single consultation and cesarean surgery. This is the first time
I've seen such a high value placed on a vaginal birth!!!
My question is- how do you get 100% payment from 100% of the clients?
Everyone I know has a list of clients who never finished paying. I have
about $5,000 dollars of unpaid fees out there somewhere. What is your secret???
It's pretty simple. I expect it. At the consult, I discuss finances
at the end of the visit. I explain that their commitment to pay me equals
my commitment to show up. I state that I really don't like talking about
money in relation to midwifery, that I must be paid to afford to keep being
a good midwife. I have a financial agreement. I allow them to decide their
own financial plan within two parameters...a $500 deposit at the first
prenatal, total fee paid by 36 weeks regardless of time of registration.
They can choose however they want to pay the rest in between, but it must
be decided, written down, signed, returned to me by the next prenatal visit,
and the contract must be adhered to. I explain that I never want to be
put in the position to ask for payment and that I never want money to interfere
in our relationship-building, which I consider very important. I've never
had to ask for a payment. They come with the checks in hand...a couple
of times, families have forgotten their checkbooks, and both these times,
the check was in the mail that week to me. The consultation is usually
the first and last time we discuss fees.
I do OCCASIONALLY (few times a year) reduce my fee. I never tell that
to someone. If they complain, I respond that they need to decide how much
a priority it is for them to have this birth this way. I suggest ways to
find the money. I leave them to take the responsibility to say something
like, "I really want a homebirth, and I really want you to attend me, but
I just cannot find a way to afford this. Please, let's work something out."
If they do, I may negotiate a lesser fee, but I insist it is paid in full
before the birth--I accept no agreements to pay after the birth. I would
prefer to reduce my fee by $500 and know I have it in hand before the birth
than to agree to accept the full fee but in payments after the birth.
I find that, for the most part, I have really respectful and responsible
clients. I think this plan weeds out the more problem people; however,
the vast majority of families that interview with me choose my practice.
I suppose all that will change now that our cease and desist orders are
officially in hand in IL. [sigh] Any openings for a good, experienced midwife
somewhere legal where the winters and summers aren't brutal and where clients
pay their midwives?
My contract reads that payment is to be made in full by the 36th week
of pregnancy or 4 weeks prior to delivery. If not done so, contract is
null and void and there is no obligation for the midwife to attend said
birth and I have the parents read and sign. I tell them I hate to discuss
money and it is their responsibility to pay me and that after the baby
is born, the baby will have needs like diapers, immunizations, check ups,
etc. and that it is very unlikely that I will get the balance owed me after
the baby is born because of the babies needs are greater. Verbally I am
a little more giving. If they ask for help or an extension I will generally
give it. Usually the only ones I have a problem from are "friends".
I hear about how much everyone is not getting paid; well I'm curious,
how much are your charging for your services???
It's interesting to note that in life, in general, people often value
what they pay more for....maybe this would be a good tactic.
I always have clients pay in full by 36 weeks. My philosophy is that
my relationship is with my clients; their relationship is with the insurance
company. I explain that my priority is to keep my practice intimate and
have time for open ended appointments. With a smaller practice, I
can't have a reasonable cash flow if I do not get paid by the insurance
co until after the birth, 8+ months. I also explain that I am like
a savings account for them, as they will get a lump sum from the insurance
company that can be used for the baby's special account or such.
I totally let them set their payment schedule and barter as possible.
In my college town, I have about 30% self pay, low income but resourceful
people, and this prepay plan has not been a problem.
I get all fees upfront, and if they have insurance, I will bill for
them, despite being an amateur at it. That takes me hours, but I often
end up with additional money I would not have gotten if they didn't have
insurance, and the client gets the reimbursement which keeps them happy
about homebirth, so I keep doing it. I knew a midwife once who told
her clients that if she gave discounts, or if they didn't pay her, or if
she extended their ability to pay beyond the birth, that was equal to HER,
the midwife, PAYING to support that family, because it meant food off her
table, bills of her own that SHE couldn't pay, and that she could only
afford to support one family: her own. She said when she posed it
that way, she had no more problems with payment from people. I've
never had to use that tack, but once when I had someone deliberating about
their ability to afford a homebirth, she told me: "Oh, but to pay for it,
we'd have to take out a new credit card, and we just don't like to have
debt." My response was very gently put, "OH, I so understand! When
I don't get paid enough, I have to take out a new credit card to pay for
my living expenses, too, and I just don't like to have debt, either!"
That really hit home with her and personalized me in a light for her that
she could understand (because it was exactly what she would have to do
herself to afford something she didn't have cash for), that I was also
a regular person just trying to make it in the world, that I had bills,
a mortgage to pay, food to buy, a child to support. She took out
a 0% interest credit card (so readily available these days if their credit
isn't bad) and paid me in full.
Sometimes my clients act as if they think I'm unskilled labor that just
shows up to tidy up some of the blood and help the mom into the shower.
I've found it helps if I include something in my paperwork about "the going
rate" for healthcare fees and how they got to be so high. I emphasize
the years of training and internship during which I wasn't earning any
money (and for which I'm personally still paying off the loans!).
I try to make sure they understand also that I spend a lot of time on their
"case" even outside our appointments and the birth - time spent reviewing
labs, writing notes, consulting with other care providers as necessary,
researching special circumstances. Not to mention general work required
to keep a practice going: supplies ordering and re-stocking; paperwork
revision, copying and organization. Professional obligations required
to stay current with the field and your license - reading journals (whether
paper or online) and attending conferences and getting CEUs. And,
of course, everyone's favorite - insurance paperwork!
See also: For Parents - How
to Get the Best Care/Money and Insurance Issues
How To Get Insurance Reimbursement for Homebirth
I emphatically recommend that no one (client/patient and/or provider)
EVER call an insurance company and ask if they 'pay for homebirth' since
there is no such CPT procedure code; and place of service associated with
any code is an entirely separate issue.
Claims
Resolution Services for Healthcare Providers - too busy to follow up
on denied claims? Hire these people!
The ACNM's pages on Midwifery
& Midwife Practice have a great Sample Letter - Payment for Midwifery
Services for clients to submit to their insurance plan to get in-network
coverage rates.
100% Coverage: My Struggle Having a Homebirth
Paid for by the Insurance Company by By Karen E. Wallace, a homebirth
mom's story.
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 Patient
Advocate page.
Glossary of Industry
and Product Terms Used At Blue Cross and Blue Shield of Oregon
Negotiating for Health Insurance Coverage
In some cases, larger companies may "self insure" meaning that the company
itself is actually paying your medical expenses, even though it may be
administered by a health insurance company. If this is the case,
the people in the Human Resources Dept. should be ecstatic when you come
to tell them you're having a baby and would like to save them many thousands
of dollars by having a homebirth.
In any case, if you are not happy with the coverage your insurance company
is providing, let your employer know that this "benefit" that they're paying
lots of money for hasn't been as much of a benefit as they might think.
Ideally, your employer could specifically ask about homebirth when re-negotiating
next year's contract or in selecting another health insurance company.
It's a great idea to write to your insurance company about homebirth,
whether they pay readily or like Scrooge.
Also, it really helps to communicate your happiness and unhappiness
to the people who pay your health insurance premiums, usually your employer.
Talk with the people in Human Resources and tell them how important
it is to you that homebirth be covered by health insurance. It's
great if you've got some supporting materials regarding relative costs,
etc. But the most important thing is letting them know it's on your mind.
Especially in areas where companies are begging for labor, employees
bargain for all sorts of special deals on their employment, including vacation
packages, conference privileges, etc. Why not also bargain for homebirth
coverage.
Every time open enrollment comes up, ask which plans cover homebirth.
It's great to say thanks! to the insurance companies and employers who
cover homebirth sensibly, but remember, it's the squeaky wheel that gets
the oil, so get out there and do some squeaking!
Also, if your insurance company drags their feet, you can take them
to Small Claims Court. I've heard more than one person say that their
insurance company sent them reimbursement almost immediately after getting
the notice about filing in Small Claims Court.
Remember, you are the consumers. You'd expect that insurance companies
would be gung-ho about homebirth because of its cost effectiveness, but
many insurance companies are owned by doctors, and they don't like money
to leave their system. So they're not going to do it because they're
good hearted. They're going to do it because they're losing customers
to other insurance companies that cover homebirth more readily.
We have challenged insurance companies that would not pay for homebirth
and won several times. Get lots of info together and go before their board
presenting them with the info on statistics and cost analysis. It works.
Filing a complaint with the insurance commissioner is the most powerful
weapon you have. contact them by phone first. i know
of many companies that will reverse a decision simply when you mention
the insurance commissioner. they do not want to deal with the scads
of paperwork, etc. that this type of complaint generates. ESPECIALLY
if the insurance company (is it fully insured or a self funded program?)
has withheld vital information like that. i am not positive, but
i think that would fall under the category of bad faith.
to reduce it to barest bones:
Don't automatically assume that just because the midwife is not listed
on your insurance that they will not cover it. Midwives weren't listed
on my insurance or my friends and they are covered....they just didn't
"advertise" it.
My midwife charged $2400 for all prenatal (except lab work), the delivery,
and the post-natal up to and including the 6-week check-up for me and the
baby, all breastfeeding advice, etc. When I added up all the prenatal visits,
the labor/delivery charge for hospital, the post-partum, the pediatrician,
etc. for the conventional route, it came to well over $9871.00 if I did
NOT have a c-section. That was cost to the insurance company, not including
my $1000 deductible, $20/visit co-pay and my 20% co-pay for the hospital.
I challenged my insurance company to a "cost-comparison" and threatened
to appear in person at one of their board meetings to discuss how interested
the stockholders and newspapers would be to find out they would rather
spend 4 times as much for a practice I didn't want if they refused to cover
the midwife at the same 80% as the hospital. They agreed that I was correct
and paid my midwife 80% of the total $2400 global charge.
Actually, if I hadn't had to transport (eventual emergency c-section),
they would have paid all but $20 of her fee as it was a one-time charge
for the delivery, which would have been at my home and therefore fell under
the classification of "home health care", like elderly or injured patients
who have a day nurse come in. Apparently, if she billed it all as a visit
on the day of birth, it would count as one visit with a $20 co-pay.
I've been trying to get Blue Shield PPO to pay the preferred rate after
paying the preferred rate for my son. The "grievance counselor" or
what ever her term was was rather biased against homebirth and they wouldn't
pay the benefits saying I could have received the same care in the hospital
with an OB. I took my appeal to the department of managed healthcare
along with a 2 page letter explaining what happened and how homebirth is
different from hospital birth. A few days ago I received a
concession letter as well as a check for not only the $800 I was asking
for but also 1000 beyond that. They paid the preferred rate based
on the billed amount rather than the "usual and customary" Of course
they wrote a letter saying that this was a one time exception etc.
I will fight again the next time I have a baby though. So, in the
case of PPOs, it pays for your clients to fight too.
I'm in California & our insurance company (Blue Cross Prudent Buyer)
covers homebirth the same as a hospital birth
I had Blue Shield with my last pregnancy. During my pregnancy they told
me they would only pay what they normally pay an OB. After the baby was
born I sent them a letter stating that since I saved them a 10,000 hospital
bill that I believed I should be reimbursed the rest of the fee. They agreed,
and sent me a check for the balance.
I had the HMO, but it was the federal version. It was called Blue Shield
Access Plus. I had to file an appeal twice. First I had to file an
appeal for an out of network provider, and then I went back and asked for
the money for the balance. My baby was almost 3 years old by the time they
paid up, so they weren't exactly accommodating. It took a year just to
get the first half. I'm not sure what it was that made them pay. I just
pointed out the money they saved and that I should hardly be penalized
for saving them a bunch of money.
Another bonus (in addition to government funding) of legislation is
that midwives have hospital admitting privileges. That means if a woman
chooses a hospital birth or a non-emergency transfer from home to hospital
is necessary, the midwife remains the primary care-giver (no nursing or
medical staff is involved) unless a problem comes up that requires a consultation
with an obstetrician.
There are still hospitals/physicians etc. that are reluctant to accept
midwives, but at least the legal framework is there for midwives to practice.
I'm looking forward to getting out there and doing it!
How do others handle insurance payment? I am currently back to client
paying up front with me providing reimbursement paperwork because I got
totally sick of the hassle and "lost" claims submissions by almost all
the companies. May try again once I get computer shareware for submitting,
have heard claims get pd within 2 wks (8-10wks pp has been my avg.)
We also ask the client to pay on a regular schedule throughout the pregnancy,
with final payment due at 36 weeks. None of the insurance companies will
accept a claim before the birth, so it's not even filed until after the
birth. The insurance company reimburses the client. Sometimes it happens
within a couple of months. One Champus reimbursement took 11 months.
We tell the client in the beginning that we cannot guarantee that insurance
will reimburse our fee. LDEMs are not even acknowledged by insurance companies.
However, if they list reimbursement for CNMs then they usually reimburse
LDEMs. Still, the client has to want a home birth whether or not insurance
pays for it. Most folks with insurance can afford our fee even if it's
not reimbursed, and it also gives them more options for back-up arrangements
if they have insurance.
Thank you for some new codes. How do you go about coming up with fees
for each? Do you check with each company beforehand to see what is customary
in your area? The "customary" fee seems to differ so much between companies:
$2250-3500 before deductibles, etc. is normal here.
I've been doing a flat fee, then listing all the codes I had under,
but obviously have ripped myself off with this approach.
The whole insurance thing never ceases to humble me. In terms of coming
up with fees, figure out what you want as a flat fee for your services
and then set the fee. The insurers, medicaid included, will reimburse you
or whatever they allow, whichever is lowest.
You might call various and sundry offices in your area to see what they
are charging (or have a friend do it) to get an idea of what the common
charge is for services. This info is not always easy to get. I did this
once for my old employer to find out where we were falling in the spectrum,
explaining that I needed to have whatever it was (an office visit, physical,
pap, etc.) and would need to pay for myself as I had no insurance. It was
still hard to get a quote -- most of the offices tried to steer me toward
the Basic Health Program in WA (here for people who are uninsured) rather
than tell me their prices! But I did succeed in collecting data.
Unfortunately, due to anti-trust laws, we are not all supposed to go
around comparing our charges or sharing that info -- this is due to concerns
about price fixing. This is another reason why you can't just call various
practices outright and ask what they charge practitioner to practitioner.
Another way of setting your charges is to look at what it costs you
to provide the particular service. Having been through this, I think that
it may be the wisest course. None of us want to cheat ourselves, but ultimately,
how we do business and what we charge has to be based in part on what it
is costing us to provide the service.
And some insurers will send you a list of what they reimburse on common
codes you use if you send them your list with what you charge for each
category.
I just wanted to tell you all that, at least in CA, it is illegal to
charge more to people with insurance than those without. This is where
a sliding scale comes in handy.
I also wanted to say that the first practice I trained in went out of
business because they were billing insurance and having to wait and fight
for every bill. They were, in effect, loaning their money to the insurance
company. I now have the people pay on a regular basis and then have their
insurance reimburse them. The companies reimburse the parents MUCH faster
than they do the providers.
There is a company that will pay before the birth IF you give a 10%
discount on the bill; they cover the "usual and customary" for my area,
leaving a decent reimbursement once deductibles etc. are paid. I like to
tell clients about their coverage because they are reasonable for families
and will send out info if requested. Good Samaritan, (317) 894-2000. This
is one of the companies with a flat monthly fee, a newsletter and prayer
list for members, etc. I do know they are easy to work with.
There is supposedly computer shareware available for billing insurance
that produces faster results on collections: 2wks avg I have been told.
The mw's husband who said he'd do an in-service on collections got busy
and forgot, I have several calls into him and will continue to bug. This
guy has a private therapy practice and approached me with the info.
I have had success with a variety of companies in collecting fees IF
time isn't considered as part of the equation. I do use my SS#, codes and
list OV/HV etc. I have also begun to give all clients with insurance our
state insurance board booklet with rules/regs governing insurance payment.
The board says they want to hear from clients, not the provider, on their
complaint form when a problem arises. Reading the rules was enlightening:
most of the companies I have dealt with do not follow the rules re: notification
of receiving the bill or the time frames required to pay the bill. It amazes
me how often they "lose" certified mail.
There is a policy that covers mw care and pays before the delivery if
you provide a 10% discount on the total fee: Good Samaritan. This company
has been pleasant to work with. It has been worth it for me to do this
rather than wait the 3 mo avg after care-f/u.
Can someone explain how they get around "usual and reasonable" where
we are compared to OB pricing?
I am currently in a phase of expecting payment at 36wks with bill and
supporting paperwork (documentation, IRS W-9) provided to the client. Having
9 outstanding insurance bills all at once 2m ago did me in emotionally---I
hate the endless f/u hrs spent on insurance. However, learning to better
navigate the insurance maze might change my mind.
As a licensed midwife in Arizona I think about 50% of insurance
companies pay for licensed midwives for homebirths. Prudential, Aetna,
Blue Cross Blue Shield and many more. Not the State health care though.
In my practice I do mostly hospital births but also attend home births.
In Washington state most insurance companies cover homebirth. Medicaid
does not, but the rumor is that they will start in January 1999 (of course
there have been semi-annual rumors for two years). One of my clients
on a managed care program through state medicaid has received approval
for a homebirth from the HMO already, and I understand that another HMO
on the west side of the state also pays for homebirths for the medicaid
clients. Due to a state law sponsored by our WONDERFUL insurance
commissioner Deborah Senn, if the insurance company covers births they
must cover all categories of providers who do births - meaning LMs and
CNMs and MDs.
Jan., 2008: Both
the House and the Senate in New Hampshire have passed bills that mandate
insurance companies to cover home births! The two bills
were slightly different, so not quite ready for the Governor’s signature,
but the bills passed by big margins. This is a terrific development for
home birth and perhaps and example that will be useful for other states.
Here is a
decision from the NYS Insurance Department :
2) Such coverage is available through the Healthy New York program.
3) The practice of midwifery is regulated by the Education and Health
Departments.
Florida
law requires that maternity care coverage include the services of certified
nurse-midwives and midwives licensed pursuant to Chapter 467 and the services
of birth centers licensed under ss. 383.30-383.335.-- emphasis supplied
[See Florida Statutes, s.626.6406; s.627.6574; and s. 641.31(18)].In requiring
such coverage, Section 467.002, F.S. specifically recognizes the need for
a person to have the freedom to choose the manner, cost and setting for
giving birth. The law requires that maternity coverage include midwifery
services and provides that an insured or enrollee be given the option of
choosing the setting for receiving such services. Therefore, no HMO contract
or insurance policy may directly or indirectly deny reimbursement for midwifery
services rendered in a home birth setting.
A
Florida web page that lists all their mandated coverage clauses:
"A policy or HMO contract that provides coverage for maternity care
must cover the services of certified nurse midwives and midwives licensed
under Chapter 467, and birth centers licensed under SS. 383.30-383.335."
bc/bs HMO will pay me, they are mandated by law to pay for alternatives
to their providers. Montana has laws that state the any co. selling
insurance here must pay licensed providers except the blues.
Improving Access
to Nurse-Midwifery Care Act (S. 911 and H.R. 872) is federal legislation
to increase the reimbursement rate that midwives receive from Medicare
to 100% from the usual 65% of what a physician receives for the same services.
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:
I have some wonderful news on how to get HMO’s and PPO’s to pay for
midwifery charges. Recently, I billed a HMO $6,995.00 for a long
delivery. The HMO denied charges stating that the provider was not
included “in-network.” So I called the insured (dad) and ask him
if he knew his benefits manager personally. He did and gave me her
number. I called the benefits manager in Human Resources and she
was extremely nice and adored the pictures of the new baby. When
I informed her that the insurance company was denying charges, she said,
“let me make a call then call them back in about 2 hours.
When I called back they told me that a note “now” appeared with the
claim(s) and that now they are being processed at 100% billable charges
and that I should be receiving the check before Christmas. Merry
Christmas, Ms. Midwife!
So, if you have clients that have “self-funded,” plans (insurance plans
where the employer pays for medical out of pocket), ALWAYS get the benefits
manager involved. Bring up the Mother’s and Newborn’s Protection
Act 1996, and Florida’s clarification 627.6574 and the warning bulletin.
Of course, it is up to the good will of the Benefits Manager, so have the
insured call or you call and give them a brief explanation of why the home
birth treatment plan is desired and the blessings to the family (employee)
One of my midwife friends had a client go to her insurance board (arbitration?),
and she got coverage for her homebirth by telling them she wanted someone
who would honor her desires for a home birth. So they paid.
In 2003? there was a Supreme Court ruling that required HMO's to enter
into contracts with all kinds of providers. If you have more information
about this, please e-mail
me. Thank you.
To get payment from an HMO, I would have the mother call her insurance
carrier and request an "in-network midwife." They will
Sometimes you can get around the HMO limitations by obtaining a 'referral'
or 'transition of care' letter but it requires an inordinate amount of
work on the front end and very few docs will cooperate. I have probably
been paid but somewhere in the neighborhood of 60-70%? I would have to
go over my records to know for sure since individual plans have variants.
United
Healthcare Denies Young Mother Choice for Labor and Delivery - brief
discussion of Network Gap Exception
8/18/06 - The
final rule changes existing regulations to revise the definition of
'labor' in §489.24(b) to state that: "a woman experiencing contractions
is in true labor unless a physician, certified nurse-midwife, or other
qualified medical person acting within his or her scope of practice as
defined in hospital medical staff bylaws and State law, certifies that,
after a reasonable time of observation, the woman is in false labor."
Background information
As of June 14, 2006
See also: Discharge Time or Duration
of In-Home Monitoring for International Protocols
Most midwives are so committed to their work and their clients that
they would never leave the birth home before the mother and baby are stable.
But many insurance companies simply cannot understand why midwives bill
for more than "routine obstetrical care", which assumes the doctor leaves
the birth once the placenta is out and the suturing is done. This
section discusses the specific reasons why homebirth midwives stay longer
at a birth than a doctor practicing in the hospital.
In Kansas City the free standing birth center regulations are 6-24 hours
PP. They need to be nursing okay, voided, eaten and showered as desired.
The state made the rules on time frame not the midwives.
In our southern California birth center, we see go home around 4 hours
PP. They have to have good vitals, have showered, urinated, eaten
a meal and have nursed. I also then come to their home at about 24
hours PP.
See also: Preventing Postpartum Depression
After the
Afterbirth: A Critical Review of Postpartum Health Relative to Method of
Delivery by Noelle Borders, CNM, MSN
"Clinicians must initiate the discussion about postpartum health antenatally
and encourage women to enlist needed support early in the postpartum period.
Flexibility in the schedule of postpartum care is essential."
Does
continuity of care by well-trained breastfeeding counselors improve a mother's
perception of support?
" . . . the mothers were more satisfied with emotional and informative
support during the first 9 months postpartum. The results lend support
to family classes incorporating continuity of care."
A
Mother's Feelings for Her Infant Are Strengthened by Excellent Breastfeeding
Counseling and Continuity of Care
CONCLUSION. . . . guaranteed continuity of care strengthened the maternal
relationship with the infant and the feelings for the infant.
The Postpartum
Visit: Is Six Weeks Too Late?
"Although quality evidence may not exist that the six-week postpartum
visit is beneficial, evidence does suggest that some women may benefit
from an earlier visit. While "better late than never" may be true in some
situations, physicians need to recognize that the traditional timing of
the postpartum visit may limit their ability to help some women. Further
research is needed on the timing and content of the hallowed postpartum
visit."
2006/036 New NICE
guidelines on postnatal care will give babies best start in life
It recommends personalised care for mothers—in which an individual care
plan would be drawn up soon after birth—and a move away from the more common
"tick box" approach.
From: Health
Benefit Mandates:
"There is a sizable literature that focuses on early discharge and various
measures of birth outcomes. Three systematic literature reviews have been
conducted (Britton, Britton and Beebe 1994; Braveman et al. 1995; and Grullon
and Grimes 1997). The 1994 review covered literature going back as far
as 1943, concluding that “almost all published studies suffer from substantial
methodological limitations” including the problem of having insufficient
statistical power to detect differences in rehospitalization risks between
early and late discharge groups. Braveman et al.’s review of 18 studies
published between1975 and 1994 concluded that “there are no data supporting
the safety of early discharge when there is no follow-up” but conceded
that while early discharge in combination with home visits may be safer
than long hospital stays, none of the studies was sufficiently large to
demonstrate this. Grullon and Grimes’ review of articles published between
1966 and January 1997 also concluded that “the current data do not support
or condemn widespread use of early postpartum discharge in the general
population.” Several subsequent studies produce conflicting results and
also have various methodological flaws."
The
safety of early postpartum discharge: a review and critique.
CONCLUSION: The current data do not support or condemn widespread use
of early postpartum discharge in the general population (class C recommendation).
Early postpartum discharge appears safe for carefully selected, consenting
patients. Whether these data can be extrapolated to the general population
of pregnant women remains unknown.
The Oregon statutes
say:
(d) Follow-up: Postpartum follow-up care must minimally include: visits
during the first 24 to 36 hours following birth, at 3 to 4 days to assess
mother and baby, and a visit or telephone consultation within 1 to 2 weeks
post-birth. The primary care giver must continue to monitor appropriate
vital signs, and physical and social parameters including adequacy of support
systems and signs of infection. Information must be provided regarding
lactation, postpartum exercise, and community resources available. Education
may be provided on various family planning methods. Those midwives who
are qualified to fit barrier methods of contraception may do so at the
six-week check up.
What does
the evidence say? about continuity of care.
Guidelines for Coding Jaundice Follow-up
Encounters - Key: Treat 'bili checks' as sick, not well visits. from
the Pediatric Coding Alert/Sept., 2005.
Breastfeeding-Associated
Neonatal Hypernatremia May Be Missed [Medscape registration is free]
(Reuters Health) Sept 08, 2005 - When breastfeeding is not properly established,
neonatal hypernatremic dehydration may occur and, according to a study
published this week, it is relatively common but can be difficult to recognize.
In the September issue of Pediatrics posted online, clinicians explain
that neonatal hypernatremic dehydration results from the inadequate transfer
of breast milk from mother to infant. Poor milk drainage from the breasts
leading to persistently high milk sodium concentrations may exacerbate
neonatal hypernatremia.
According to Dr. Michael L. Moritz of Children's Hospital of Pittsburgh
and colleagues, among 3718 consecutive term and near-term breastfed neonates
hospitalized during a 5-year period, 70 had breastfeeding-associated hypernatremic
dehydration -- an incidence of 1.9% -- which is "significantly higher than
the reported incidence of hypernatremia attributable to all causes among
hospitalized children, adults and elderly subjects."
It's likely that as more women initiate breastfeeding in response to
strong encouragement by the American Academy of Pediatrics, the "incidence
of breastfeeding-associated hypernatremia will increase and that currently
the condition is under-recognized," the authors note.
The vast majority of the infants with breastfeeding-associated hypernatremia
in the current series were born primarily by vaginal delivery to first-time
mothers who were discharged within 48 hours of giving birth.
Nonfatal complications occurred frequently. Most of the infants presented
with jaundice (81%) or sepsis-like symptoms such as fever and lethargy.
Sixty-three percent underwent a full sepsis evaluation with lumbar puncture.
None of the infants had bacteremia or meningitis.
Nonmetabolic complications occurred in 17% of infants, most often apnea
and/or bradycardia. Hypernatremia was of moderate severity, with serum
sodium concentrations ranging from 150 to 177 mEq/L and a mean weight loss
of 13.7%. None of the infants died.
Summing up, Dr. Moritz said that "new mothers, especially first-time
mothers, may have difficulty producing an adequate supply of breast milk
in the first week after birth because of physiological issues or because
the baby may not be able to latch on properly."
Pediatricians and parents need to be aware that when this occurs, the
risk of dehydration is much higher than previously assumed, he continued.
"If infants are becoming dehydrated, we strongly recommend that the breast
milk be supplemented with formula or breast milk from another source,"
Dr. Moritz said.
This is an excellent justification for the medical necessity of an in-home
breastfeeding assessment and neontal check-up around 5 days postpartum.
Breastfeeding-associated
hypernatremia: are we missing the diagnosis?
RESULTS: The incidence of breastfeeding-associated hypernatremic dehydration
among 3718 consecutive term and near-term hospitalized neonates was 1.9%,
occurring for 70 infants. These infants were born primarily to primiparous
women (87%) who were discharged within 48 hours after birth (90%). The
most common presenting symptom was jaundice (81%). Sixty-three percent
of infants underwent sepsis evaluations with lumbar puncture. No infants
had bacteremia or meningitis. Infants had hypernatremia of moderate severity
(median: 153 mEq/L; range: 150-177 mEq/L), with a mean weight loss of 13.7%.
Nonmetabolic complications occurred for 17% of infants, with the most common
being apnea and/or bradycardia. There were no deaths. CONCLUSION: Hypernatremic
dehydration requiring hospitalization is common among breastfed neonates.
Increased efforts are required to establish successful breastfeeding.
Newborn
early discharge revisited: are California newborns receiving recommended
postnatal services?
"The California Newborns' and Mothers' Health Act of 1997 mandates coverage
of home or office visits in accordance with the American Academy of Pediatrics'
recommendations for newborns discharged early. However, two-thirds of neonates
discharged early had untimely follow-up.
"The most common complications associated with early discharge, like
jaundice, poor feeding habits or birth defects, often are not detectable
until the third to fifth day of life, lead author Dr. Alison Galbraith
told Reuters Health.
"'The risk for these potential complications of early discharge could
be reduced if infants received follow-up from a healthcare provider sometime
between days three to five of life when many of the complications arise,'
Dr. Galbraith, from the University of Washington, said.
"
The Oregon statutes
say:
(d) Follow-up: It is recommended that follow-up care include: a visit
within 24 to 36 hours following birth, at 3 to 4 days, visit or telephone
consultation within 1 to 2 weeks post-birth, and a visit at 6 weeks of
age to monitor appropriate vital signs, weight, length, head circumference,
color, infant feeding, and sleep/wake and stool/void patterns. Information
must be provided about infant safety and development issues, immunization,
circumcision, and available community resources.
Changing Outcomes:
Managing Neonatal Hyperbilirubinemia and the Special Needs of the Near-Term
Infant - "The most common reason for readmission of a newborn to the
hospital in the first 2 weeks of life is jaundice."
Management
of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
- AAP Guidelines - [PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316]
"In every infant, we recommend that clinicians . . . provide early and
focused follow-up based on the risk assessment . . . "
Efficacy
of breastfeeding support provided by trained clinicians during an early,
routine, preventive visit: a prospective, randomized, open trial of 226
mother-infant pairs.
This study is about office visits, but I would think that it would be
an easy argument that a home visit is even more effective than an office
visit, plus it doesn't introduce additional risk factors in the mother's
and baby's expending the energy to travel and their being exposed to germs
in the health care office.
Agreement
allows Medicaid to pay uninsured midwives
A new agreement between the New Mexico Human Services Department, managed
care organizations and the state's midwives means that midwives will once
again be paid for delivering babies for Medicaid-eligible women outside
of hospitals without holding medical malpractice insurance.
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
I'm finally far along in the process of being credentialed as a contracted
provider. An insurance rep is scheduled to come tomorrow to do a
site visit to check things out. What will they be looking for?
You might want to have your state regs, license, and protocols ready
for her inspection.
I once went through a site check, and they were looking for administrative
things such as labs' being initialed, forms attached to charts, drugs locked
up. They also wanted certain informed consents and a living will
in each chart.
Always call to reconfirm in the beginning of pregnancy care to verify
the client has insurance, what their deductible, if they've met it, what's
their co-pay, is there a cap that once has been gotten to, that the company
pays 100%., claim mail address -to save you time and effort later on .
At this time is when you ask them whether they accept global or itemization.
Some prefer global unless she has gone out of "normal prenatal care".
See also:
ICD Codes - "International Classification of
Disease" - These codes are maintained by the WHO and are accepted all over
the world. In the US, HCFA (Health Care Financing Administration)
has revised them into the ICD-9-CM. The next revision is ICD-10.
These codes are used for diagnosing rather than services rendered.
On the HCFA form they go under #21 and then the proper no. (1, 2, 3 etc.)
is placed to correspond with the proper diagnosis code.
CPT Codes - "Current Procedural Terminology"
- these are set by the AMA and can change yearly. Used for services
rendered.
Sample HCFA Statement - this contains
the essential elements for an insurance statement, in HCFA format
Instructions
for the 1500 claim form from medicare - the instructions are for both
the electronic and the paper versions
The Aetna Provider web pages have a nice HCFA-style
web-entry claim form with explanation!
Sample Billing Scenarios for a
Homebirth Midwife providing comprehensive prenatal, birth and postpartum
care. This includes the care normally provided in hospitals by nurses
for labor monitoring, the pediatric team for newborn resuscitation, the
nurses for postpartum and nursery care, and the pharmacy/supply room for
birthing tubs and medications.
Medela's Reimbursement
Guide is a good place to learn some basics about insurance billing,
although it's focused on lactation consulting.
Superbill
Step by Step Explanation - Evaluation & Management (E/M) Codes
I like this sample
SuperBill
I bill a global fee but also itemize things that aren't included in
global. When you bill global think "OB". What would that code cover
if you were an OB - things like your prenatal appointments, walking into
the delivery room with the head on the perineum, catching the baby, sewing
mom up and then checking on her again the following morning before discharge
and then again at 6 weeks pp. Then think about what things the hospital
would be charging the moms insurance for..... I always charge for
the supplies - OB supplies/set-up, sterile suture tray if done, any O2
supplies, needles for injections, the meds we use, etc. You
can also bill for educational materials you give, nutritional counseling
if the mom needed additional, even oxygen therapy. We also bill separately
for the baby - initial stabilization and attendance at birth, newborn exam,
newborn supplies and the visits after the birth. I feel like I have to
itemize all the extras just to help the moms get reimbursed adequately.
The insurance companies dock the global fee down so much below what we
charge it's ridiculous. I understand that they are comparing us to OB's
and that's like comparing apples and oranges. I tried for awhile adding
.22 for unusual circumstances and documenting the difference but it was
always a hassle and rarely got much more in return. Itemizing like
this seems to work much better - it's what the ins. co's understand.
59400
- a detailed description
Whenever I send in a claim, I send along a page with an explanation
for each line. When I've billed the G0154 I make note that "The delivery
code definition for 59400 does not include direct patient care and monitoring
provided in the hours before and after the birth (labor and postpartum).
I have charged for x hours of my time at the birth as an RN in addition
to the delivery code. If you would prefer that these be billed as
prolonged care by provider, I can resubmit at the higher rate."
I figure that although they might balk at paying for prolonged care
by provider that goes on for hours and hours at a normal birth, they should
have no excuse for not paying for nursing care. I subtract an hour
of the time I'm there from the G0154 to allow for he time that I
am doing the delivery part of the birth (which would be included with the
59400.
Licensed
Midwives Guidelines from Regence
Blue Shield [currently unavailable]
A
nice introduction or review about OB billing
Helpful
Hints for Filing Claims for respironics.com
Don Self's web
pages have lots of great forms related to dealing with insurance companies.
COLLECTION &
REIMBURSEMENT from The Professional
Association of Health Care Office Management
Coding Resources
- a collection of links to helpful sites.
Coding for Birth
Professionals from birthwithlove.com
Medscape articles about coding:
Getting Paid: Are
You Coding Accurately?
Correct Coding
Helps You Get Paid What You're Worth
Search
for other "Coding" articles
Pocket Guide to Clinical
Coding - used to be available for $14.95, now appears to be available
only in a large, expensive set?
Risk-Based Coding
from Tray Dunaway, MD
Here's ACOG's page on Coding
and Nomenclature
Codes Collected from the Midwife Lists
- a lot of these are old and are here primarily for backward compatibility.
You're advised to find more recent and reliable resources.
Completion of the
HCFA-1500 Claim Form - basic guidelines for completing the HCFA form
CIGNA's
Notice to Paper Claim Billers - more good tips for completing the HCFA
form. CIGNA also has a customer service line to answer questions
regarding the completion of the HCFA 1500 claim form - 615-251-8182.
Medicare Offers FREE
National Education and Training Program , including a
module on Women's Health
Healthcare Professional Publications, including the Medicare
Part B Reference Manual (in HTML) and Medicare
Part B Reference Manual (in PDF Acrobat format)
L)Medicare
Part B - Physician Fee Shedule
CIGNA HealthCare
Medicare Administration
Modifiers
for Medicare Billing
HCFA
Place of Service Codes (11- Office, 12 - Home, 21- Inpatient Hospital,
25 - Birthing Center) [NOTE - When you use Home as the Place of Service,
do not include facility address.]
A
table of which services should occur where.
California Law - Midwife Payment Through Preferred
Provider
Health Care Financing Administration
(HCFA), the federal agency that administers the Medicare, Medicaid
and Child Health Insurance Programs.
American Academy of Family
Physicians (AAFP) pages on Coding for Intrapartum Care and Other
Obstetrical Services
They have a terrific description of 59400 -Routine obstetric care including
antepartum care, vaginal delivery (with or without episiotomy, and/or forceps)
and postpartum care
"The word routine and the fact that these codes are for use only in
situations where one physician provides all three components of the global
service indicates the limits of these codes. Family physicians can best
understand these "global care codes" by understanding their three component
parts: (1) antepartum care; (2) delivery; and (3) postpartum care.
"According to CPT, routine antepartum care includes initial and subsequent
history, physical exams, recording of weight, blood pressure, fetal heart
tones, routine chemical (dipstick) urinalysis, monthly visits up to 28
weeks gestation, biweekly visits between 28 and 36 weeks, and weekly visits
until delivery. Under the CPT definition, a physician should not submit
more than seven maternity care visits in the first 28 weeks. Instead, the
physician should code any other visits (even routine maternity care visits
more frequent than once a month) separately. The same applies for biweekly
visits between 28 and 36 weeks.
"The CPT manual states that delivery services include admission to the
hospital, the admission history and physical exam, management of uncomplicated
labor, vaginal delivery (with or without episiotomy, with or without forceps),
or cesarean delivery. Please note that the manual specifically refers to
"uncomplicated" labor. If there are any complications, then one should
use additional codes." [Ed: Please note also that "labor management"
in this context is not the same as what a homebirth midwife means by "labor
management", i.e. personally being there to assess vitals and guide the
progress of labor, which is a task performed in the hospital by nursing
staff.]
"The CPT manual states that postpartum care includes hospital and office
visits following vaginal or cesarean section delivery. Of course, this
includes not only the routine post-delivery hospital care offered by a
family physician, but also the postpartum visits in the office. However,
this code does not include any laboratory services provided at the postpartum
visit (e.g., PAP, blood work)."
Unusual Insurance Billing Codes extracted
from above.
For contact information, call CAM at 800-829-5791 or write P.O. Box
460606, San Francisco, CA 94146-0606
They are for sale -- 20 forms for $7.50 pp.
I'll also send a sample one filled out, the code numbers for prenatal
care, classes, labor support, delivery, lactation consulting, doula care,
gynecological care, as well as hints from the person who taught our workshop.
She's a former midwife, now insurance billing specialist in her husband's
chiropractic office.
MMA, 4220 E. Loop Road, Hesperia, MI 49421
Patrice Bobier, Treasurer of the Michigan Midwives Association
I order my forms from Medical Arts Press 1-800-328-2179. As low
as $26.95 for 100.
I call the insurance co. after the first visit and ask how they expect
to be billed. Most want global billing and almost all will pay only after
the delivery. Global billing is easier - one code v22.2, or The ICD-9 .(
I think that's 95400). I usually include both the diagnosis code and the
ICD-9, to cover all my bases. I like to send a bill of some kind early
on in the pregnancy, or do the midwife equivalent of the "pre-admit". It
gets them into the computer and should shorten the waiting period between
billing and collecting. Insurance companies seem to be very expert at the
run around, so I like to include everything possible with each bill- the
codes, my tax ID#, my social security #, and every piece of info I have
on my client's ID info. They will certainly use confusion on levels of
midwifery practice as an excuse to delay payment. It's a good idea to call
the office to pre-register. It will probably be obvious who knows what
they're talking about and who doesn't understand midwifery. Get names and
try to stick with one knowledgeable person. After you send the bill, follow
up to see how the processing is going.
Which, if any insurance companies, reimburse? What codes do you use?
If you are not licensed in your state, do you use SS#?
I have received reimbursement from some insurance companies - CIGNA
is one (I think they thought I was a CNM) but that was only once, the second
time claim was rejected; Transport Life, Guardian (submitted itemized bill).
CIGNA is the only insurance company I've had much trouble with --I can't
stand CIGNA! Very little problems with Blue cross Blue Shield, Globe, Aetna,
Prudential, Principal Mutual, Travelers. American Medical Securities is
very easy to deal with. I don't know if Brokerage services is a state HMO,
but they can be a pain. It takes a while, but you'll get paid.
A lot of them only reimburse CNMs. That hasn't been a problem for me
as I sometimes work with a CNM and she can supervise the care for those
guys. But I think that often, an insurance co. (like everyone else) is
poorly informed on midwifery. I do send a copy of my license, and a letter
of explanation to any insurance company who initially refuses to cover
my services. I include a cost comparison, and some info on my statistics.
I've never had an insurance company who covers OB costs refuse to cover
my services after getting the info.
Insurance reimbursement for me is iffy. Some companies do sometimes,
and some never do. We always have the client pay us, then we submit the
reimbursement form for her to get reimbursed. I make up a "bill" on the
computer. It has all the "numbers" that have ever been associated with
reimbursement in my experience. It includes my social security number ,
and a TIN taxpayer identification number which I can't remember how we
got but was required by one insurance company about five years ago. About
ten years ago, an out-of-state Blue Cross company reimbursed us (referring
to us as CNMs which we are not and never implied). They gave us an ID number.
It goes on all our bills now. We are licensed as lay midwives, and those
numbers go on the bill, too, in addition to the newly acquired CPM numbers.
Then we also list the codes. In a regular bill for full services, the code
is 59400.
The problem I have is that I think that the insurance companies only
pay the midwife fee, such as what the ob/gyn bills, and doesn't pay for
the "birthing fee"...which I feel should also be billed and paid for since
in a hospital birth there are many charges for monitoring the baby and
mother, labor sitting, supplies (my client's buy a birth kit but I supply
things like O2, sutures, laboring herbs and remedies, etc.) and of course
all those many post-natal contacts and visits. For instance, on my last
billing to an insurance company I billed the standard 59400 for $2400 and
received $1300!!! This is pretty much the average I receive. This is even
less than my cash rate, and there is no way that I think that is a fair
fee for giving someone nearly a year of care until being paid!!!
I guess I have learned my lesson and I will start to bill using every
code and fee I can come up with! Anyone have a sample of one of their bills
that include all these other fees?? Marguerite...are you there...how does
your center bill????
This is my biggest gripe with insurers. We beg and scrape for every
cent we get when as midwives we provide: labor mngt/support, supplies,
delivery, postpartum, PP home visits, etc., etc. Spend many more
hours
than an OB that shows up at complete & pushing! The insurers don't
seem to bat an eye at the hospital costs and we have to explain every little
thing -- "What do you mean by supplies?" Like chux, gloves, cord clamps,
O2 ... !! Duh! Not to mention the birth assistant, who types the birth
cert and does the billing, etc.
I think it just irritates me the most when they give us such a hard
time when we are SAVING them money! Why doesn't this make sense to them?
One ins co told my client that they'd pay 80% if she delivered at the hospital
with an OB, but only 70% if she delivered OOH with a midwife! So they'd
rather pay more for her to go to the hospital? I just really don't see
how this makes sense.
There are a couple of ins co's, that I know of, now saying they'll pay
100% if the woman goes to a birth ctr (Great West, John Hancock). I hope
more of them will wise up, get smart.
What I do is bill or precertify as soon as the client starts prenatal
care. Then we know whether they honor LMs. If they don't, I send them a
form letter about my services, and I also suggest that the client challenge
her insurance company's policy. I've never had it fail in the end.
"...unbundling occurs when a single procedure with two or more explicitly
described components is broken into its component parts and reported with
several CPT codes instead of the single CPT code for the combined service.
A simple example of this type of unbundle can be illustrated with the procedure
for a combined abdominal hysterectomy with colpourethrocystopexy.
Because the two components of this procedure are frequently performed together,
a combined code 58152 has been assigned to describe this service.
However, it is also possible to perform each of the components separately
(abdominal hysterectomy 85150 and colpourethrocystopexy 51840 or 51841).
When the combined procedure is performed during a single surgical session,
it must be reported with the bundled CPT code 58152. If it is reported
with code 58150 in conjunction with 58140 or 58141, it is considered to
be unbundled.
Unbundling, whether intentional or not, is considered by payors to be
a form of fraudulent or reckless billing. The rationale is simple.
Unbundled services will frequently net more reimbursement than reporting
the single bundled CPT code.
HCFA has adopted Correct Coding Initiative unbundling guidelines, an
evolving list of codes that cannot be reported in combination with other
codes for Medicare claims. CPT does not have a specific guideline
for unbundling. Instead, payors and other interested parties have developed
guidelines for bundled procedures from information that is listed in CPT...Payors
interpret the rules and guidelines for separate procedures differently.
Payors may base payment guidelines on definitions established by outside
consultants or by their own internal sources. Some payors strictly
interpret CPT while others may be more lenient in how they interpret separate
procedure guidelines....The following may be considered unbundled:
59409 Vaginal delivery only (with or without episiotomy and/or
forceps);
Suppose the physician performed the delivery but did not plan on seeing
the patient for postpartum care. However, the patient came in for
postpartum care when the claim for the delivery had already been submitted
to the payor. The claim for the "postpartum care only" could be denied
by the payor. The payor may weigh the fee for 59430 against the difference
between the cost of 59409 and the fee for delivery including postpartum
care (59410). If the difference in the amount was not more, the payor
may reimburse for 59430. For accurate coding, the claim should have
a corrected billing sent, reported as:
59410 Vaginal delivery only (with or without episiotomy and/or
forceps); including postpartum care"
Whew! Sorry that was so long. Anyway, if you unbundle with
private payors, they may consider it fraud, but most likely they will either
reject the claim or bundle it back up for you. However, if you unbundle
with public payors such as Medicaid, and they feel it is a pattern, there
may be jail time in your future, because it's a criminal offense.
2007 ICD-9-CM
Volume 1 Diagnosis Codes from icd9data.com - This has great descriptions
Complications
Of Pregnancy, Childbirth, And The Puerperium 630-677
ICD-9
Code List from tdrdata.com, Timely Data Resources, Inc., a gateway
to our integrated, on-line epidemiological databases. This includes
a great searchable
database.
ICD-9
searchable database from chrisendres.com. This has the Tabular
Index to Diseases, with the relevant sections for
Official ICD-9-CM
Offical Guidelines for Coding and Reporting effective April 1, 2005.
ICD-9
Provider & Diagnostic Codes
Arnold M. Epstein, M.D., Thomas H. Lee, M.D., and Mary Beth Hamel,
M.D.
NEJM, Volume 350:406-410, January 22, 2004, Number 4
Why Money Is Important
What Midwives Say About Themselves
I barely scrape by from month to month supporting <educational
birth associations> and now putting together a conference.
Comparison Pricing for Maternity Services
Birth Center $3500 - $8300
Hospital $4300 - $16,000
Cesarean $9300 - $26,000
Consumer Activism in Negotiating Coverage for Alternative
Healthcare/Homebirth/Midwifery
HIPAA Protections
What is a preexisting condition? A preexisting condition is a
medical condition present before your enrollment date in any new group
health plan.
Setting Fees
Fee Policies
Leigh Ann Backer
Fam Pract Manag 11(7):43-47, 2004
Credit Options
Benchmark Fees
Geographic Multiplier
Getting Payment from Clients
Health Insurance Plans - Getting Payment
Homebirth Coverage as an Employee Benefit
If your health insurance coverage is through an employer, that employer
is intending that the insurance coverage be a benefit to you. Often,
the people in your employer's Human Resources Dept. or Personnel Dept.
can help you negotiate with the insurance company to get the coverage your
employer intends for you to get.
Your Insurance May Pay for Midwives Anyway
Insurance Coverage - Equitable - Their Name Says It All
I am in California. For my 3rd baby and current pg, I have different insurance
that will cover homebirth. In both cases there was/is a need to pay the
midwife upfront and be reimbursed by the insurance co after the birth.
For my 3rd baby, my insurance was to pay 80%, but ultimately they paid
100% because
they were righteous and saw how much money they saved
and waived my deductible! (Equitable) Currently, I have Blue Cross and
they have agreed to pay 80% of the "usual and customary fees". Hummmmm
Insurance Coverage - Humana
Humana has paid me twice for attending a homebirth, and they paid very
nicely.
Insurance Coverage - Blue Shield
Blue Shield does allow homebirth, but since there are no homebirth providers
on their PPO, they only cover 70% of allowed costs.
Ontario Health Care Covers Homebirth
Midwifery legislation passed in January 1994 in Ontario. Since then, midwifery
services (including home births) are funded by the government so that anyone
who can find a midwife has access to one. The down side is that the demand
is overwhelming so midwives get booked quickly and is someone doesn't call
early in their pregnancy they may not be able to get one. There are also
many communities that do not yet have a midwife to serve them. Since a
new batch of registered midwives should graduate each year, we hope to
slowly remedy that problem.
Mandated Homebirth or Midwifery Coverage
The Office of General Counsel issued the following opinion on April
13, 2005 representing the position of the New York State Insurance Department.
Conclusions:
1) The services of a nurse midwife must be covered by a health insurer,
including a Health Maintenance Organization.
Getting Coverage for Homebirth from Insurance Companies
that Don't Cover Homebirth
HMO Coverage for Homebirth
probably tell her that there is none in network, but they have plenty
of other options. She will have to stipulate to them that she has
researched
the treatment plan and decided that the midwifery model is her preferred
treatment plan. Then she will need to say since there are no "in-network,"
providers I want a "transfer of care (TOC) exception number, or waiver
for the services." (different terms for the same thing.) Many
company insurance specialists will have the form. If they refuse
to consider a TOC you can file for a review for the denial at that point,
then appeal, and finally arbitration or State Insurance Board.
Medical Necessity of Care for "False Labor"
Medical Necessity of Care in the Immediate Postpartum
Medical Necessity of In-Home Maternal Followup
and Continuity of Care
Ekstrom A, Widstrom AM, Nissen E.
Birth. 2006 Jun;33(2):123-30.
Anette Ekström, PhD, RNM and Eva Nissen, PhD, RNMTD
PEDIATRICS Vol. 118 No. 2 August 2006, pp. e309-e314 (doi:10.1542/peds.2005-2064)
Grullon KE, Grimes DA.
Obstet Gynecol. 1997 Nov;90(5):860-5.
Medical Necessity of In-Home Newborn Followup
Moritz ML, Manole MD, Bogen DL, Ayus JC.
Pediatrics. 2005 Sep;116(3):e343-7.
Galbraith AA, Egerter SA, Marchi KS, Chavez G, Braveman PA.
Pediatrics 2003 Feb;111(2):364-71
Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon
N, Schelstraete C, Vittoz JP, Francois P, Pons JC.
Pediatrics. 2005 Feb;115(2):e139-46.
Medicare/Medicaid
New Mexico Business Weekly - May 19, 2006
by Haley Wachdorf
Homebirth Midwives as Contracted Providers, aka
Preferred Providers
Verification of Benefits
Insurance Billing - General
Sample
Superbill
He's also got a great links
page.
Medicare and HCFA links
An Online version
of HCFA-1500 form, the universal health billing form, or you can buy
them through the Staples catalog for about $22.00 for 500.
California Association of Midwives - Insurance Research Committee
The committee is collecting information about insurance providers and whether
or not they are currently reimbursing midwives for services. Please list
the insurance carriers who have paid your fees, indicating whether they
did so through your client or directly to you. If possible, please send
a copy of the "Explanation of Benefits" which accompanies all reimbursements.
Also state whether you are a LM, a CNM, etc.
Insurance Claim Forms for Sale
The Michigan Midwives Association purchased a box of HCFA-1500 insurance
forms
(have to buy 1000 at a time) for resale. These are the standard forms used
to file claims with all insurance companies. We are trying to all file
with these forms the same way (same code #s) in hopes that being more consistent
with forms will help with more consistency with payment.
Unbundling
"Unbundling" is defined, according to my "Code it Right" book, as "breaking
a single service into its multiple components to increase total billing
charges." It goes on to describe:
59430 Postpartum care only (separate procedure)
Diagnosis Codes - ICD-9 Codes
Certain
Conditions Originating In The Perinatal Period 760-779
2006-2007 ICD-9 Changes
AAFP
Summary
Official documents:
New
2007 ICD-9-CM Codes Applicable to Pediatrics
ICD-9 Notes - These were notes I took while
going through the Official ICD-9-CM
guidelines from the National Center for Health Statistics (NCHS) Web
site.
THE CODING EDGE® ARCHIVES from 10/15/00 have a great article on
"
Faye Brown has some good college level books on coding and advanced
coding. A great book that explains what you will need to know to
do you own billing is Insurance Handbook for the medical office.
Obstetric
and Newborn Coding Guidelines Reviewed for ICD-9-CM Coding Issues from
ADVANCE for Health Information Professionals
NOTE - This piece claims that "Codes from category V27 should not be
assigned if the delivery occurred outside the hospital."
Blue Cross has just informed me that V27.0 is a discontinued code for
"live newborn." I have used it successfully until now. Is anyone
else having this problem? Are you using V30.2?
I have not heard anything about the V27.0 code being for hospital use
only. It is for the mom’s record only. Most all of the V27, V28,
V29, and V30 categories of codes must have a 4th digit for more specificity,
but I have not had any returned or delayed claims with this problem.
I did have a claim returned the other day because I coded 650(.)
Because I put the . behind the 650 the computer scanner forced a zero,
and it produced an error stating that the code was not specific or was
discontinued. This may be the same problem.
Newborn ICD # is V30.2 single liveborn , born out of hospital,
Use this on claims for the baby's care.
As for the idea of using a code for the "outcome" of the birth, you
don't need to give a code for outcome of the birth to
A
Primer on ICD-9-CM Coding (search for "Coding Primer")
Index to
the most comprehensive descriptions of diagnosis codes I've found online,
from The Philadelphia Medical Mall.
Flashcode has a free 30 day trial.
Just go to www.icd9coding.com and read about it. You can do basic icd9
coding online for free also.
ICD
(International Classification of Disease) Finder from CDC
WONDER
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
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.
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]
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.
I have used it and gotten as high as $45.00 for this code.
Insurance Coverage for Cord Blood
Collection
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
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"
You could also use modifier -21, "Prolonged Evaluation and Management
Services," when an E/M service takes more time than is usually
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
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;
From The
Mississippi Workers' Compensation Commission:
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
-21 Prolonged Evaluation and Management Service
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
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.
Alpha-Numeric
HCPCS from cms.hhs.gov
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
See also: Waterbirth/Tub Insurance Coverage
and Reimbursement
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.
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)
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 99211 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.
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
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!
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
Here is the url to the AAFP website where they show a
sample letter describing care and the need for a c/s.
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?
Prolonged codes 99354 1st hour $175.00
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.
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.
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?
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:
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.
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
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.
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.
Aetna is offering web-based
claims submission through their provider web pages.
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 "
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
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.
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!
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?
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)
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.
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"
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.
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
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.
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
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 Letter To Clients About Reimbursement
Postpartum Doula Reimbursement
A printable form
used by many doulas
Physician's "Prescription" for Doula Care
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."
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
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:
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!
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
If I do private instruction, I also use:
Home Medical Service - Private Class
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).
See also: How To Get Insurance Reimbursement
for Homebirth
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 Insurance Claims for Homebirth
Maternity Care
Appeals Letter - this great letter
is simple, but it got an extra $7000 reimbursement.
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
Here's an Alta
Vista search for "Medical Claims Resolution" or "Medical Claims Recovery"
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
Judge’s
Ruling Slows Cigna’s Attempt to Sidestep Global Class Action Suit
Self-funded plans are covered under ERISA and are not subject to state
insurance laws.
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:
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.
and someone else concurs with:
and here's a testimony as to why CIGNA is so great!
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.
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
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.
Codes
relevant to antepartum, intrapartum and postpartum
Episode of Care
If you look at the box (if you have Ingenix books) above code 650 Normal
Delivery you’ll see immediately the concept:
They’re saying: this is the diagnosis:
1. not known if at the delivery, or pre- or post-partum
2. at the delivery, and the mom might or might not have had this
condition in her prenatal care
3. at the delivery, and the mom will definitely have this condition
during her postnatal care
4. anytime, not necessarily at the delivery only, its just a
condition mom has during prenatal care
5. anytime, not necessarily at the delivery only, its just a
condition mom has during postnatal care
Global Routine OB Care
Procedure Codes - CPT-4 Codes
Before choosing 99213 for routine visits, consider whether your work
qualifies for a 99214.
Billing for Medications
When needing to charge for supplies or MEDICATIONs like Vitk Rhogam, Pitocin,
Methergine , ..... and such, this is what you do:
On your HCFA form- after you've listed your service, on the next line,
put your date, then your place of service home 12 office
11 (I have more) and your type of service F is for maternity. Then
you place your HCPC number for the medication, then your DX code -( if
anyone wants I'll talk them through some of this) and then your price
of the medication-.
Then you can do the same thing for giving an injection, IV, charge
for that also. Many Dr's offices charge between 10.00 to 25.00.
Billing for E-mail Correspondence
Procedure: 0074T - Online evaluation and management service, per encounter,
provided by a physician, using the Internet or similar electronic communications
network, in response to a patient’s request, established patient.
Modifiers and NDC Codes
CPT Modifiers
Many midwives wear multiple hats and provide a variety of different services
to the same client on the same day. For example, a routine postpartum
appointment may often include a portion focused on the mother's well-being
(services typically provided by an obstetrician), a portion focused on
the baby's well-being (services typically provided by a pediatrician),
and a portion focused on the breastfeeding dyad (services typically provided
by lactation consultants). It's easy to tease apart the services
provided separately to the mother and the newborn since they are two separate
"patients", but the breastfeeding consultation is typically billed to the
mother's insurance.
Feeding problem, newborn 779.3
Feeding problem, infant 783.3
required for the highest level of service
within a given E/M category.
"Modifier 32
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.
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.
-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
-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)
NDC Codes
Each drug has a unique 11-number code specific to the manufacturer, med,
and dose. That means that Rhogam manufacturered by
various companies will have completely different numbers. I knew from
my Rhogam dose forms (the little carbon copies that you fill in and keep)
in the chart that the Rhogam was made by Bayer and I followed through on
Bayer sites until I found one that listed their BayRho-D. Like I
said, I was lucky to find it and doubt that most meds have NDC codes listed
on the internet. That's why you might want to write it down
off the packaging of any med you dispense, esp expensive stuff like Rhogam.
HCPCS - Medications and Supplies
DME - Durable Medical Equipment
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.
Educating Clients
Billing for Assistants
prolonged codes) as for the main midwives OR have the other bill come
directly from that midwife's office.
Ultrasound Procedure Codes
Transports
Hospital Transfer from Planned Homebirth
I know this has been posted before, but can anyone help with codes for
home labor support, and hospital labor support? billing is tricky
when it involves a hospital transfer after failed home birth.
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 coodes: 99201-99205, 99212-99215,
99241-99245, 99341-99345, 99347-99350
HIPAA - Health Insurance Portability and Accountability
Act
Billing Services
--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?
(435) 752-9414, Email:, Christine84321@aol.com
Can communicate via phone or fax or email or whatever - willing to
do pre-authorizations and lost-causes.
Web-Based Medical Billing
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!
Billing Software
Where to Purchase HCFA Forms
Billing Labs
Military Births and Reimbursement
Flexible Spending Statement
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
Waterbirth/Tub Insurance Coverage and Reimbursement
In Box 19, put "Four-week rental of AquaDoula portable warm water immersion
tub"
Lactation Consultant Reimbursement
Sample
Superbill
Doula Reimbursement
805 Washington Ave.
PO Box 336
Lowden, IA 52255
<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]
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:
Doula CPT Codes
Professional Labor Support/Doula Services 99499
New Patient - Intermediate Visit 99342
Appeals/Arbitration/Small Claims Court
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.
Legal Recourse
Statement of Bohn D. Allen, MD, President-Elect, Texas Medical Association
700,000 Doctors Win Critical Decision Against HMO
Request for Refund
What to Do When They Have Legitimately Overpaid
In the rare situation where the insurance company truly does overpay you,
here's what Don Self recommends:
"I NEVER recommend sending it without a reference request from the
carrier. I also do not just hold it and hope they eventually realize it
either as that is deceitful and unethical in my opinion. I notify the carrier
of why they need to request a refund and tell them by letter that I'll
be glad to send the money upon receiving an official request for the refund."
"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. "
"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
WASHINGTON (Reuter) - The National Association of Women Business Owners
Wednesday announced a partnership with Wells Fargo and Co. that calls for
the California bank to set up a $1 billion fund to aid women business owners.
Asset Protection
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