Insurance Reimbursement Followup

First principles first:

The squeaky wheel gets the oil.  This is so true when it comes to insurance reimburesement.  Insurance companies are in the business of making and keeping money, and if they can get you to give up your claim to their money out of frustration, they're very happy with that.  Some insurance policies seem to lose half of their initial claims, and then deny the other half right off the bat, so don't be surprised that you need to hassle them to pay you.  But don't be discouraged, either.

An insurance policy is a contract saying that they will reimburse certain medical expenses according to whatever plan you have subscribed to, usually through an employer.  They are LEGALLY obligated to pay you for services covered by that contract.  You may have to argue about it, but they are LEGALLY OBLIGATED to pay you.  Remember that.

References in the Midwife Archives:

For Parents - How to Get the Best Care/Money and Insurance Issues

Money and Paperwork/Health Insurance Plans - Getting Payment

General Arguments

Cost effectiveness:
Summary of Critical Points from "Safety of Alternative Approaches to Childbirth" by Peter F. Schlenzka - A doctoral thesis comparing safety and costs of natural, out-of-hospital birth with in-hospital obstetric births.  He finds out-of-hospital births to be slightly safer and significantly superior in terms of economic costs ($13 billion annually) and social costs (reduced incidence of birth trauma and bonding disorders).

Homebirth Safety and Benefits

In the State of California:

General information about insurance for Consumers

Having Problems with Your Insurance?, including information about filing a Request for Assistance, which used to be called a filing a Complaint.

California now offers secured online Request for Assistance.

The two most common reasons for requests for assistance are:

  1. Improper denial of a claim or an offer of an amount less than that indicated by the policy.
  2. Delay in settlement of a claim.
The Type of insurance involved is probably Group Accident & Health but could be Individual Accident & Health

You can copy the information about the health insurance policy from the Explanation of Benefits in which they delayed, denied or underpaid the claim.

The Date loss occurred or began is the earliest date involved in any of the disputed claims.  For the mother's care, this could be the date of the first prenatal appointment, the date of birth, or any other date on which care was provided.  For the baby's care, this date would most likely be the baby's date of birth.

The answer to Have you contacted the company or agent?: should be Yes.  Even if you haven't contacted them, if I'm asking you to file a Request for Assistance, it's because they've not responded appropriately to inquiries from my billing service, Marnie Cabezas Skorupa, Midwife's Billing Service, Inc. (MBSI), 59 Bullard Pasture Rd., Wendell, MA 01379, 978-544-3551 [fax 978-544-3560]

The answer to Have you contacted another government agency?: is probably No.

The answer to  Have you contacted the Department of Insurance before regarding this issue?: is probably No.

The answer to  Is there attorney representation in this matter?:  is probably No.

The answer to Is a lawsuit currently ongoing or pending?: is probably No.

In the section: Briefly describe your insurance problem: you can fill in the problem description I have e-mailed you.

What would you consider to be a fair resolution?:  Prompt attention to the claims, allowance of the amount of the claim, and payment of the contract amount.  Thank you.

Scope of practice for Licensed Midwives, as defined in the Licensed Midwifery Practice Act of 1993

The license to practice midwifery authorizes the holder . . .  to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn.


SEC. 4. The Legislature finds and declares that:

          (a) Childbirth is a normal process of the human body and not a disease.
          (b) Every woman has a right to choose her birth setting from the full range of safe options available in
          her community.
          (c) The midwifery model of care emphasizes a commitment to informed choice, continuity of
          individualized care, and sensitivity to the emotional and spiritual aspects of childbearing, and includes
          monitoring the physical, psychological, and social well-being of the mother throughout the
          childbearing cycle; providing the mother with individualized education, counseling, prenatal care,
          continuous hands-on assistance during labor and delivery, and postpartum support; minimizing
          technological interventions; and identifying and referring women who require obstetrical attention.
          (d) Numerous studies have associated professional midwifery care with safety, good outcomes, and
          cost-effectiveness in the United States and in other countries. California studies suggest that low-risk
          women who choose a natural childbirth approach in an out-of-hospital setting will experience as low a
          perinatal mortality as low-risk women who choose a hospital birth under management of an
          obstetrician, including unfavorable results for transfer from the home to the hospital.
          (e) The midwifery model of care is an important option within comprehensive health care for women
          and their families and should be a choice made available to all women who are appropriate for and
          interested in home birth.

Notes on Health Insurance Reimbursement

Specific laws about Private duty nursing agency

Some ideas:

To get better reimbursement for labor management and postpartum nursing care, consider establishing yourself as a "Private duty nursing agency"

Dear CAM Readers,

I was recently asked to write a form letter for CAM that could be sent to insurance companies expressing the desire to have homebirth offered as a covered service.  As a midwife, I am the primary care provider, front office clerk, back office clerk, etc.  I have many other important duties to spend my time and energy on rather than worrying about insurance billing.  I have served as Insurance Contact for CAM, however, I wish to resign from this position.  I find it to draining to deal with insurance anymore.  For my personal practice, I use a billing service for all of my insurance needs.  Writing individual letters for each claim is a part of the service that is provided for me.  I would like to nominate Susan Weckter, owner of S & W Medical Billing, to take over my position as Insurance Contact with CAM.  She has been providing my billing service for over 2 years.  As an insurance biller, she understands the insurance field with all of its problems.

As for writing a form letter, I can only give basic suggestions:
? Have the insurance policy holder call the company themselves to state they want their homebirth to be covered
? Have the insurance policy holder contact their human resources department if the insurance is through their employer
? Have the insurance policy holder write a letter stating that they pay the insurance premium and would like their homebirth covered

I recommend writing letters based on each individual claim.  Unfortunately, there is no form letter that will work so always be diligent in your billing (or get a service that can help you).  Currently most insurance companies do cover homebirth, but only in some types of policies (mostly PPO type policies).  Another important step in the billing process is to call when first providing care to find out what the insurance company covers.  Many times a pre-authorization is needed for any birth to be covered.  This will help you know if the company will pay or deny your claim (they won’t tell you for sure until you submit a claim).  My billing clerk does all of this for me so I don’t have to deal with it at all.

HMO’s, Medi-Cal, and Champus (Military insurance) are the main reason claims are not paid.  I feel that until we can change these types of policies, there will be problems in getting claims paid.  To help make this change, bill every claim and insurance policy (even if you know they will deny the claim).  Claims that are billed need to be regularly followed up on - calls to the insurance companies (at least once a week), faxing letters of explanation for the services, etc.  Eventually, insurance companies will see that there is a demand for homebirth; it is not going away!  Once you receive a denied claim a letter and appeal should be submitted.  Having a billing service will provide all this for you.  My billing clerk only charges me a fee for paid/approved claims, that means I don’t have to pay for billing services on denied claims to HMO’s.

The main reason HMO’s don’t pay is that they only pay providers in their group (they have a list of providers).  There is usually a group of medical doctors and nurses who decide on paying or denying claims for HMO’s.  In general, if a provider is not part of their group they don’t pay.  Becoming part of their group for LM’s usually involves having malpractice insurance (amounts are around 1 million/3 million that most require) and having a “supervising” physician.  This is one policy that must change for homebirth to be covered with most HMO’s.  HMO’s need to start offering coverage for more midwives.

Medi-Cal and Champus need to have a policy change as well.  This will take some time to accomplish (they are government controlled).  We must all be diligent in our current billing and appealing processes to bring about changes in the insurance industry.  Susan recently wrote the following as part of a  letter to an HMO: “The current health care trend is that more people are becoming involved with natural health care.  As this happens more homebirths are being performed.  In my business, I have seen that more women want homebirth (with a provider of their choice, licensed midwife) to be offered as part of the covered insurance choices.  Many insurance companies have already started to offer other natural health care choices such as chiropractic, physical therapy, and acupuncture.”  Homebirth with midwives is the next area in the list of allied health care to be added as covered service with insurance companies.  With persistence change will happen.