IntroductionAfter more than six months and over 20 hours on the phone with insurance (regarding home birth coverage and a prescription coverage related to the pregnancy), I have succeeded in getting our insurance to cover our home birth. Well, they still owe us $87.89, and I’m working on that, but I’ll still count this as a hard-fought win.
I say hard-fought, because at every step of the way, either through incompetence, a lack of familiarity with the process, or intentional obstruction, our insurance repeatedly failed to fulfill their contractual obligation. They failed in a multitude of ways. I was promised multiple call backs that didn’t happen. I was told several times that things would be taken care of when they weren’t. I was given misinformation. Even when I did take a couple steps forward to get another step approved, insurance would usually make mistakes in the reprocessing of claims. Only through sheer persistence was I able to get anywhere. As a dentist, I see many of these same issues with dental claims. The more that an insurance can obstruct either willfully, or by having poorly trained employees, the less insurance has to pay out for claims.
I’m writing this post because I feel that these tactics are an unethical way to treat members and providers and because I feel that members shouldn’t have to spend over 20 hours on the phone over six months to get insurance to pay for a covered service. If it took me, as a healthcare provider with a decent working knowledge of billing, coding, and insurance terminology, this much work to get our home birth covered, I know there are many who have been bulldozed by insurance and given up.
I’ll first go over some terminology important to understand in our situation and with insurance in general, then explain the background for our case, then go through a detailed account of how we got insurance to cover our home birth, and then finally cover general recommendations on getting insurance to cover a home birth.
GlossaryBefore I start, it’s important to understand some terminology so that you understand what insurance representatives or providers are telling you, and also so you know what to ask for.
NPI – National Provider Identifier. A number that identifies medical providers.
CPT code – The medical billing code that defines what procedure was done.
ICD 10 diagnosis code – A medical code that defines a medical condition.
Gap exception – Some online sites, and the NY attorney general’s office, refer to a gap exception, although Excellus never used this term. Basically it refers to when an insurance company does not have a participating provider for a covered service and an exception is made to cover an out-of-network provider. This doesn’t insure that they full charged amount will be covered, or whether they will just cover the allowed amount.
Allowed amount – Each insurance has what they call a Usual and Customary Rate (UCR), although these rates are neither usual or customary. Basically, the insurance says that $X is the amount they think should be paid for a procedure. If you see an out-of-network provider, they will only process the claim based on that amount. You would be responsible or “balance billed” for the remainder. In-network providers agree to accept the allowed amount as payment in full, whether from you, your insurance, or a combination. They agree not to “balance bill” you for the difference between the allowed amount and their fee schedule. They agree to this tradeoff so that they get the increased number of patients from insurance.
Up-to-charge – Excellus (and maybe other insurances) used this term to refer to covering something up to the amount charged by the provider. This is in contrast to the allowed amount.
Balance billing – When a provider bills you for the difference between what insurance pays or the allowed amount, and what the provider’s charged amount is. Most or all insurance contracts do not allow in-network providers to balance bill.
Adjust a claim – Reprocess a claim with new information (corrected amounts, as in-network versus out-of-network, etc.).
Insurance adjustment – In-network providers will write off or adjust off the difference between their full fee and the allowed amount since they are contractually required to accept the allowed amount as payment in full. So, on your bill it will often say “Excellus adjustment” on a line and will show how much the office is writing off, or not collecting.
Authorization/Preauthorization/Preauth/Predetermination/PreD/Prior Approval – A request to insurance to approve a procedure, made before the procedure is performed. In this case, requesting an out-of-network provider be covered at an in-network rate was referred to by Excellus as an authorization, or “Pre Service Review for Out of Network Service.”
Member contract/subscriber contract – The terms of your insurance. The contract has important information about the process to get out-of-network providers covered, about deductibles, etc.
Deductible – The amount the insured has to pay before insurance starts paying. Even when you haven’t met your deductible, you get significant savings if you go to an in-network provider because you are only paying the allowed amount instead of the fee schedule amount. Insurances often have a separate in-network and out-of-network deductible. So even if you have met your in-network deductible, if you go to an out-of-network provider, you will be paying out of pocket, and be paying the full fee schedule amount.
Coinsurance – The percentage the insured pays. So if insurance pays 80% after the deductible is met, the insured patient’s coinsurance is 20%.
BackgroundNow, some background so that you can understand our situation and how it may apply to yours. We had a high deductible plan through Excellus BlueCross BlueShield based out of Rochester, NY, with a $2,600 in-network deductible and a $2,600 out-of-network deductible. After meeting the deductible for in-network providers, our plan covered 85% of remaining costs. After meeting the out-of-network deductible, insurance covered 70% of remaining costs of the allowed amount. Our insurance contract specifically stated that home birth and midwives were covered.
Our home birth fees were $4,640 billed for my wife which covered all prenatal and postpartum care with the exception of Rhogam injections, ultrasounds, and labs, and $660 billed for our newborn which included delivery and two subsequent home visits. Our midwives did not participate with our insurance, and I think they only participate with Medicaid. Despite it being listed as a covered service, there were no in-network midwives that performed home births in the area, or likely anywhere with Excellus. However, I have seen forum posts stating that there are a couple home birth midwives that do participate with insurances in some metropolitan areas like New York City.
Our ExperienceWhat follows is a very detailed and lengthy account of what we went through to get our home birth covered. You can skip ahead to the next section where I explain how I recommend proceeding to get insurance to cover a home birth, but most of those recommendations stem from my experience. Reading through this account, though long, will likely help you understand what you will likely be up against, and will probably save you time in the long run.
We didn’t seek out a home birth, but ended up with a home birth because the providers my wife felt most confident would provide the care she wanted, ended up being home birth midwives. Were there a birthing center nearby, we would have seriously considered that option. In the end, the home birth went extremely well and we have no regrets.
Our midwives gave us some direction on how to start the process to get insurance to cover them as in-network because there are no in-network home birth midwives. They also let us know that it was a difficult process, that insurance typically fights paying, and that often when they pay, it is a small amount. We were given receipts for the care that we could submit to insurance listing the CPT billing codes, the diagnosis, and the amount we paid. Our midwives submitted the requested information to insurance to process the authorization for the birth. However, as a small midwifery practice without a billing person, we were on our own. Given that each insurance is different, that they midwives don’t participate with most insurances, and that insurance is notoriously difficult to deal with, the midwives were understandably not obligated or equipped to help us further through the process. The more time a healthcare provider has to commit to fighting with insurance and the more compromises they make in terms of reimbursement rates, the less they are able to practice the way they feel best.
So, the first step I took was to follow the midwives' instructions to call Excellus’ Medical Authorization Intake team (1-800-363-4658) a month or so before the birth and request a “Level 1 Pre Service Review for Out of Network Service,” specifically a home birth with a certified nurse midwife. I had the NPI (identification number for healthcare providers) and the practice name, but my instructions didn’t tell me what ICD (diagnosis) or CPT (billing) codes were going to be used. The representative wanted those codes, so I had to get those codes from the midwives and call back.
The midwives gave us the ICD code Z34.00 (which is specific for normal first pregnancies) and the CPT code 59400 (global maternity care for a vaginal birth). CPT 59400 is one code that covers all prenatal care (outside of injections, labs, ultrasounds), the delivery, and postpartum care. They also gave us the ICD codes Z38.1 (single liveborn infant born outside of hospital) and Z13.228 (encounter for screening for metabolic disorders) along with CPT codes 99345, 99348, 99349 (home medical visits). Now, I don’t remember exactly what happened here, but I think all the representative wanted was the ICD (Z34.00) and CPT codes (59400) that applied to my wife. After all, this was an authorization that was being submitted to get Excellus to consider covering treatment for my wife by an out-of-network provider. I didn’t end up giving her the ICD and CPT codes that would be billed for our newborn, and this ended up being a problem that I will describe later. Once I gave her this information, she said she would reach out to request information from the midwives. Basically insurance needed to verify the midwives’ credentials, that they have an OB they work with, and that they have liability insurance. The representative was a little surprised that I was initiating the authorization request rather than the provider, which also comes into play later. Anyway, from my understanding this process was both to 1) preauthorize the maternity care by an out-of-network provider (basic medial preauthorization for a major medical procedure), and also to 2) evaluate an out-of-network for coverage at in-network rates since there was no in-network participating provider. At one point a representative told me that those two processes were separate and that after authorization, I would then need to request consideration for the in-network coverage, but other representatives told me it was one process.
Weeks passed and the authorization still showed as pending. So, we called Excellus and a representative stated they were waiting to hear back for more information from the midwives. We then called the midwives who didn’t seem to be aware insurance was waiting for further information. There may have been some miscommunication, but eventually things got rolling again. Insurance apparently wanted to verify one of my wife’s allergic reactions to a medication that was on her medical history, although irrelevant to an un-medicated childbirth, and would not approve it until that happened. Eventually the authorization got approved a couple weeks after the birth. This timing was also significant later.
Somewhere around this time, I had submitted a claim for a Rhogam injection the midwives gave my wife. I was confused to see that even though the midwives charged $122 for the injection, insurance only considered $93 of the charge as the “Allowed Amount.” At this point I realized that this was going to be an entirely separate battle. Even if insurance decided to cover the midwives as in-network, they would likely just consider the allowed amount, which has no relation to the actual charge. Participating providers agree not to bill patients for the difference between their actual charge and the lesser allowed amount that insurance covers. It’s a trade off for providers, but they get the benefit that participating in insurance gives, namely that patients are driven to their practice. Since the midwives are not participating providers, they are not bound by the same rules that a participating provider is, nor should they be, since they derive none of the benefits that the participating provider does.
I spent several phone calls trying to find out what the allowed amount would be for the CPT 59400 code. A couple representatives tried to obstruct saying that they couldn’t get that information (someone has to have it, because Excellus uses it every time the process a claim for that code), that we couldn’t be sure that that was the code that would be billed if the birth had complications and needed to be transferred to a hospital (sure, but I still wanted the allowed amount for that code), and that the reimbursement rates change monthly (fine, but they aren’t going to change that drastically). Eventually I reached someone who was able to do some research and told me that the allowed amount for CPT 59400 was around $1,700. Specifically, she left me a voicemail saying that the estimated amount I would have to pay was $1,700, which couldn’t be further from the case. What she didn’t understand was that because that allowed amount is so low, Excellus would likely only try to pay 85% of $1,700 after the deductible was met, leaving them paying little to nothing. We, on the other hand, would be paying out of pocket for the balance of the CPT 59400 charge ($4,640 - $1,700).
Once I found out how low the allowed amount was, I called Excellus to discuss the matter. I explained to them that it was not our fault that Excellus does not have any in-network providers to perform a covered service, which is largely a result of their low reimbursement rate. As such, we should not be the ones to bear the financial responsibility of Excellus’ inadequate network. The representative at first claimed that the midwives had requested consideration to be covered as in-network providers and therefore would have to accept the allowed amount. I explained that I had been the one to request the midwives to be covered at the in-network rate, not the midwives, and that they had no obligation to accept anything less than payment in full, which we had already paid. Another representative suggested that the midwives could bill more charges to us so that we could submit them to insurance to maximize our reimbursement. When I explained that this was being coded as a global maternity charge that shouldn’t be unbundled, she clarified she was referring to other charges like lactation counseling, etc. I explained that given how low the allowed amount for the global maternity charge was, I was doubtful that additional codes would significantly change the reimbursement. Additionally, the midwives would have to charge for these procedures, which would either have increased our bill from the midwives, or required them to restructure their fee schedule to keep the total amount the same but accommodate these additional charges. I wasn’t able to get a satisfactory resolution at this point, and it sounded like I just had to wait until the claim was processed to fight the low allowed amount.
Meanwhile, the birth had happened on October 20th. At the birth, the midwives gave us two receipts. One was for $4,640 covering CPT code 59400 for my wife and the other for $660 covering CPT codes 99345, 99348, and 99349 for our newborn for the birth and two subsequent home visits for a follow up exam and the genetic screening visit. The $660 receipt had the date of service for the first code, but not for the other two codes because they hadn’t happened yet. These missing dates also became significant later on.
A couple days after the birth, I manually submitted claims for the birth to my insurance using their claim forms. I accidentally submitted our newborn’s claim under my wife’s name, as I overlooked the fact that some of the charges were for my wife, and some were for our newborn. This mistaken submission ended up causing some problems later, even though I resubmitted it correctly a few days later when I realized my error.
At this point, the procedure was done, insurance had the submitted receipts, the authorization was in process, and the procedure should have been covered at an in-network rate, with insurance covering 85% after our deductible was met. Unfortunately, the process was far from over.
A couple days after submission, insurance processed the claim. Since the authorization had not been approved yet, it was processed as an out-of-network provider. Out of the full $4640 for CPT 59400, $1723.47 was the allowed amount. The full $1723.47 was applied to the out-of-network deductible, which is completely separate from the in-network deductible, and insurance paid nothing. Out-of-network providers are not contractually obligated to accept an allowed amount, yet the claim was incorrectly processed to indicate that the provider could only bill us $1723.47.
The newborn charges, which were three home visit codes totaling $660, processed out-of-network with an allowed amount of $178.16. Insurance paid nothing as this was again applied to our out-of-network deductible. The claim also incorrectly stated that the provider could only bill us $178.16 out of the $660. As mentioned earlier, I submitted the receipt which did not have the dates of the second and third home visit since the receipt was given before those happened. So, the claim was actually processed with all three visits on the same date of service, and the second and third home visits had a $0 allowed amount, without an explanation on the claim as to why. It was only on a later call to a representative where I was explained that they were denied because all three were processed on same date of service, so only one was considered. I was told to resubmit with the dates of the second and third visit and the claim would be reprocessed. I resubmitted the claim on November 8th but for some reason that resubmitted claim was not processed until three months later. Several representatives in the meantime were able to see the resubmitted claim and told me that it would be reprocessed, only to have it stay unprocessed.
At this point, the next step was to wait until the authorization was approved and then have the claims reprocessed as in-network claims. When I inquired at this time about the allowed amount versus the charged amount, I was told that the authorization determination would also decide whether the claims were processed at the allowed amount or “up to charge” which meant using the provider’s charged amount as the allowed amount. A couple weeks after the birth, the authorization was approved. I was told on a call November 8th that it was approved to cover the midwives in-network and that claims would be processed up to charge. Given what representatives had told me about the allowed amount, I’m pretty sure that had I not brought up this concern before the authorization was approved, the authorization would be approved using Excellus’ allowed amount. I was told that adjusting the claims and receiving a check from Excellus would take up to 30 days, but no further action was needed on my end.
I was also told that the authorization was only for my wife’s care and not for any of the newborn charges. So, the $660 that was billed for our son for the home visits (including the delivery and stabilization) would not be considered for in-network coverage. I explained that when I originally requested the authorization, the representative processing it said she was familiar with this process and had performed these before, so she should have told me at that time that I not only needed to request an authorization for my wife, but also for our son. I also explained that at the time the authorization was requested, my son was neither born nor had insurance coverage, so I technically was unable to request an authorization for someone who didn’t exist. I explained that I wasn’t positive, but I thought that I had tried to give the original representative more than the global maternity CPT code, but was told that that was the only one needed. Finally, I explained that it would make no sense for Excellus to approve an out-of-network midwife to be covered as in-network to provide care for my wife since there was none participating, but to deny an out-of-network midwife to be covered as in-network to provide care for the resulting newborn. She told me there was nothing she could do, that they would have somehow noted the authorization had I requested the newborn charges to be covered, and that all I could do now was file a grievance for reconsideration.
On November 16th I called in and was told by another representative that the claim for my wife needed to be sent for adjustment, despite being told earlier that it was being processed and nothing was needed on my end.
Finally the claim for my wife got reprocessed about a month later, only to be denied with some error about the authorization. I called that day or a day later on December 12th and talked to a supervisor who said that they had made a mistake and that she was adjusting the claim while I was on the phone, that the full $4640 was the allowed amount, and that I would be receiving a check in a few days for 85% of the balance after the in-network deductible was met. I had her look at the newborn charges, and she said that I should hold off submitting a grievance, but that she would try to escalate things internally to get the newborn charges added to the authorization to be covered in-network. I also explained the issue with the dates missing for two out of the three visits. She was able to pull up my resubmitted claim, which had not been processed despite being submitted over a month ago, and said she would send it to be reprocessed. Finally, I let her know my concern about these charges being covered up to charge and not with Excellus’ allowed amount. She said she’d get back to me. A few days later I received the check covering the proper amount of the CPT 59400 code for my wife. At this point the charges for my wife had finally been processed correctly, two and a half months after being submitted.
Two weeks passed without word from the supervisor regarding the newborn charges. I called on December 27th and was told by her that the resubmitted claim with the dates had still not been processed, and that that had to be done before she requested it to be covered on the authorization. She asked me to call back early to mid January. I called back at that time and the claim had still not been reprocessed. Eventually on January 30th I called in and was told that the supervisor had submitted a grievance that was approved, and that the newborn charges would be covered in-network. The representative wasn’t sure if it was to be covered up to charge or the allowed amount. She assured me that the charges to be considered were the three separate dates of home visits totaling $660, and not all three visits on the same date of service. However, on my end, I had not still not seen any indication that the claim was reprocessed with the correct dates. She told me she would have the supervisor call me back regarding whether the claim would be covered up to charge.
After receiving no call from the supervisor, I saw online that the claim for the newborn charges had been adjusted as in-network. However, Excellus was still using an allowed amount instead of the charged amount, and all three visits were still showing the same date of service and the second and third codes were therefore denied. I called in February 2nd and spoke to a representative who did some research and later called me back assuring me that things had been resolved. She told me that I would be receiving the check for the first home visit up to charge, but then later I would receive a check later for the second and third home visits up to charge also. Additionally, she informed me that the supervisor had reprocessed the newborn charges that I incorrectly submitted under my wife’s name, and that claim was being paid out in an $87 check to me. She told me that I should send that check back to Excellus. I was told that nothing else needed to be done on my end.
I called in February 6th and talked to a representative who routinely would cut me off and explain that he knew exactly how the process worked and that he could resolve any issues for me. I asked him to confirm that I would be receiving a check for the second and third home visit. He told me that those were denied because those charges did not meet clinical guidelines, and that they had to be sent to a different department to be reviewed. I explained that I was told everything was resolved with those charges, but he insisted they were being denied. Eventually I realized that the clinical guidelines he was talking about were that the charges were still all showing the same date of service. He was finally able to manually look up the updated submission from November 8th that had still not been processed three months later. He told me that the updated claim had not been sent to be adjusted as in-network and up to charge (despite being told less than a week earlier that it was all taken care of), and that he would submit it. I asked him about the $87 sent in error, and whether I really needed to send this back or if I could destroy the check. He said I could shred the check. I asked how long it would take for the second and third home visit checks to be processed. He told me it would take 30 days. I advised him that I was not interested in waiting 30 days after waiting for over three months to get this far, and that I would give them some time but would be considering filing a complaint with the Department of Financial Services. At the end of the call he tried to explain to me that when I call in to Excellus, there is no reason to give a long explanation of the problem, because they know how to resolve issues and are able to look up in the documentation to see everything that has happened with the case. I let him know that after three months and almost 20 hours on the phone with Excellus resolving this and a pregnancy prescription issue, I wasn’t confident that was true.
A day later I received a check for 85% of the allowed amount of the first home visit (the date of delivery).
The next day, on February 8th, I called and spoke to the original supervisor who had submitted the internal grievance. She thought that she had resolved the issue. I explained to her that the second and third home visits were never entered in with the correct date despite my resubmission, and that the first home visit was only adjusted to the allowed amount. She adjusted the claims while I was on the phone and told me I would be getting a check for 85% of the charged amount of all three home visits, minus what I had already received.
Finally, it was resolved.
Or not. I received the check a few days later with all that she had told me I would receive, minus the $87.89 that Excellus had mistakenly sent me and then told me I could shred. It was deducted as an “Overpayment Recovery Amount.” I called and spoke to different supervisor on February 15th, explained the situation, and he said that he would send this to the finance department to correct. On February 25th I emailed him to let him know that I still have received no word on a resolution. On February 28th, he emailed back saying he was reviewing my issue. On March 6th I submitted a grievance regarding this outstanding amount. As of March 22nd the issue has still not been resolved, and I’ve had no follow-up from Excellus.
Overall, it took around six months from start to mostly finished. I spent over 20 hours on the phone with Excellus resolving this issue and a prescription drug issue that was related to the pregnancy. Let me share what I’ve learned.
Recommended Steps (roughly in order)
- Know your insurance contract
- As you can see from my story, the more prepared you are, the better able you are to anticipate pitfalls and avoid mistakes. Any mistakes that you may make could extend the process significantly.
- The first part of this involves knowing your insurance contract. Request it from your insurance, or you are likely able to download it from your insurance website after logging in. Find out the following:
- Is home birth specifically listed as a covered service? Are midwives specifically listed as covered providers? If not, this does not mean you are out of luck, but it certainly makes it easier if they are. Some states may have legislation dictating that home births or midwives are covered, making it a moot point as to whether it is spelled out in your contract. More on that below.
- What is your deductible? Is there a separate in-network and out-of-network deductible?
- What is your coinsurance for maternity/prenatal care for in-network and out-of-network providers?
- What stipulations does your contract have regarding situations when there is not an in-network provider for a covered service. My contract with Excellus had the following under “Access to Care and Transitional Care”:
- “Authorization to a Non-Participating Provider. If We determine that We do not have a Participating Provider that has the appropriate training and experience to treat Your condition, We will approve an authorization to an appropriate Non-Participating Provider. Your Participating Provider or You must request prior approval of the authorization to a specific Non-Participating Provider. Approvals of authorizations to Non-Participating Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Non-Participating Provider You requested. If We approve the authorization, all services performed by the Non-Participating Provider are subject to a treatment plan approved by Us in consultation with Your PCP, the Non-Participating Provider and You. Covered Services rendered by the Non-Participating Provider will be paid as if they were provided by a Participating Provider. You will be responsible only for any applicable in-network Cost-Sharing. In the event an authorization is not approved, any services rendered by a Non-Participating Provider will be Covered as an out-of-network benefit if available.”
- This is an important paragraph to become familiar with. It says that if there is no in-network provider, insurance will approve an authorization to an out-of-network provider. If your insurance benefits specifically list home birth and midwives, you can make the argument that there is no in-network midwife for home births (as long as there isn’t) and that the contract requires they cover an out-of-network midwife for you. If it doesn’t specifically list those benefits, you may need to research if there are laws in your state that require midwives or home births to be covered. New York has such a law, and I’ll cover it below.
- Note that this paragraph is somewhat ambiguous. Insurance could and will likely interpret covering an out-of-network provider as an in-network provider differently than you will. They will likely try to pay the in-network percentage of the allowed amount for that service. In my case, this would have been 80% of $1723 for the global maternity fee (after the deductible was met), leaving me on the hook not only for the 20% but also anything above the allowed amount, i.e. $4640-$1723. You need to make the argument that the lack of a participating provider in their network is not any fault of you, the subscriber (it is likely due to their low allowed amount), and therefore you should not bear the resulting financial burden. They should treat the entire billed amount as the allowed amount and cover it at the in-network percentage after applying it to the in-network deductible.
- Does your insurance cover house calls? Our midwives billed the newborn charges as home visits, and our Excellus insurance contract stated:
- “Office Visits. We cover office visits for the diagnosis and treatment of injury, disease and medical conditions. Office visits may include house calls."
- Know your laws
- I heard our midwives and our doula state that New York state has a law stating that insurance cannot dictate where you give birth, but I wasn’t able to find out where that was stated. After doing a bit of research on my own, I found the following related paragraph in New York Insurance Law § 4303(c)(1) which I believe applies to managed care organizations, including HMOs and PPOs, but may not apply to employer funded insurances, and may not apply if the insurance is managed outside of New York or covers people in multiple states, but I’m not sure of the specifics (underlining is my own):
- "(A) Every contract issued by a corporation subject to the provisions of this article which provides hospital service, medical expense indemnity or both shall provide coverage for maternity care including hospital, surgical or medical care to the same extent that hospital service, medical expense indemnity or both are provided for illness or disease under the contract. Such maternity care coverage, other than coverage for perinatal complications, shall include inpatient hospital coverage for mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean section, and for at least ninety-six hours following a caesarean section. Such coverage for maternity care shall include the services of a midwife licensed pursuant to article one hundred forty of the education law, practicing consistent with a written agreement pursuant to section sixty-nine hundred fifty-one of the education law and affiliated or practicing in conjunction with a facility licensed pursuant to article twenty-eight of the public health law, but no insurer shall be required to pay for duplicative routine services actually provided by both a licensed midwife and a physician."
- I also found that the Department of Financial Services website has a page with an opinion issued April 13, 2005 by the Office of General Counsel at http://www.dfs.ny.gov/insurance/ogco2005/rg050409.htm. Granted, this is a legal opinion or interpretation of the previous law, but is not itself law. One section reads:
- "While home births are not specifically mentioned in New York Insurance Law § 4303(c)(1), if supervision of a home birth is within the scope of practice of a midwife, the HMO would have to provide coverage for such services."
- The rest of the opinion deals with Healthy New York, which is a program to provide affordable health insurance, and may not apply to you.
- Other states may have laws that work in your favor. New York also may have additional laws, but I was unable to find any beyond what is quoted above. During this process, I reached out to the New York State Association of Licensed Midwives and also to the Health Care Bureau (under the New York Attorney General’s office), but didn’t find that either of them had much more information than I was able to find myself. Had I hit a dead end, I would have worked more with the Health Care Bureau, because I think I would have eventually been directed to someone more familiar with the laws on maternity coverage.
- Know your area's providers
- At one point during this process, an Excellus representative mentioned that they had midwives that participated. I asked if any of them performed home births, because if they did, Excellus would not need to cover our midwives. The representative did not know. Unfortunately, while insurance will have a list of participating midwives, they will likely not know if they perform home births. Most won’t, but the onus may be on you to prove that none of them do. I never got much pushback on this, because I think Excellus knew that there were no home birth midwives that participated. Your home birth midwives will probably know the other midwives in the area that perform home births, and should know if any participate with insurance. But to cover my bases, I looked up all the participating midwives on the Excellus website within a reasonable 50 miles or so and called. It took a couple hours, and I got a bunch of No’s as expected, but at least I had done my due diligence and verified that their were no home birth midwives in-network. You may be fine going off of your midwife’s word that none participate, and if insurance gives you pushback, try putting the ball in their court to find you an in-network home birth midwife.
- Know your midwife
- See what recommendations your midwife has in regards to your insurance. Some midwives have a billing person that can handle a lot of this work, many will not. Some midwives may be familiar with insurance and what hoops to jump through, but often providers are as much in the dark with insurance as you are, and many times you as a subscriber can get more done, having more time and motivation, dealing insurance than a provider.
- Contact your insurance to request home birth coverage in-network
- Get the CPT and ICD codes that your midwife will be using for both the pregnant mother and the newborn, along with the midwife’s office address, fax number, and NPI. Approximately two months before the due date, contact your insurance and let them know you are planning on having a home birth, that there are no in-network providers (if that is the case), and that you would like to request an out-of-network provider to be covered in-network. This may be called a gap exception, depending on the terminology used by your insurance. Some midwives may start this process for you, but we initiated this request, and because we did, I was able to counter an insurance representative who at one point argued that since the midwives were requesting to be covered in-network, they were agreeing to accept the allowed amount. Since I had requested the authorization, I explained this wasn’t the case, and the midwives had no obligation to accept less than their fee schedule. I’m not even sure if what the representative said would be true if the midwives initiated the request.
- Make sure that you are requesting the CPT codes for both the pregnant mother AND the baby. This may be difficult, because the baby doesn’t legally exist yet and is not covered by insurance. Be clear with insurance that you are requesting both the charges for the mother and newborn to be covered in-network. If you know there will be any other procedures outside of the birth, for instance a Rhogam injection, you might as well include the CPT code for this.
- When you are making this request, specify that you are requesting the charges to be covered at the provider’s fee schedule rates, not at the insurance’s allowed amount. Excellus called referred to this as being covered “up to charge.” The person you are initiating this request with may not know anything about this, or how this is handled. They may give you pushback as they did me. You may also have to wait until the approval is granted to find out whether insurance has decided to cover at the allowed amount or the fee schedule amount. If they tell you they are using an allowed amount, explain that you should not bear the financial responsibility for the fact that the insurance does not have a robust enough network to have an in-network home birth midwife. It is not your fault, therefore you should not have to pay the difference between the allowed amount and the billed amount. The strength of your argument will depend on your state laws, if home birth is listed in the contract as a covered service, and the wording of your contract’s stipulation on what happens when there is not an in-network provider. You want to get this issue of allowed amount versus billed amount sorted out before you submit the claim.
- With Excellus, this authorization step consisted of calling the Medical Authorization Intake Resource Team at 1-800-363-4658 and requesting a “Level 1 Pre Service Review for Out of Network Service.” You will need the CPT codes and ICD diagnosis codes for mother and child, as well as the midwife’s name, office address, fax number, and NPI number.
- Get insurance coverage for the newborn
- Once the birth happens, contact your HR department at work or contact insurance to get your newborn active on your insurance. Submit the paperwork that work or insurance requires to get your newborn covered added to your plan. You have 30 days to enroll your baby under your insurance, but once he is active it gets backdated to when he was born. Make sure he is covered before submitting your claim, or it will be denied and will need to be reprocessed/adjusted later.
- Submit your claims
- Download or obtain the form to manually submit your claims to insurance. The form should tell you what is required on the receipt, including ICD and CPT codes, dates of service, name, address, NPI, etc. Make sure everything is in order before you submit:
- Are the ICD diagnosis codes and CPT codes on the receipt?
- Is the midwife’s name, address, NPI on the receipt?
- Is there a date of service on the receipt? Are all dates of service filled in? Our midwives gave us a receipt at birth for the newborn that had the dates of service blank for the 2nd and 3rd home visit, because they hadn’t yet happened. I submitted this to insurance without catching this, and three CPT codes were all incorrectly processed on the same date of service, leading two of the three to be denied. Make sure these are all filled in. Preferably, ask the midwives for the receipt after the home visits are completed so that the date of the receipt is after all the dates of service. One representative I talked to said that it may be a problem that my receipt had the date of the bill as being before the dates of the 2nd and 3rd home visit. She told me providers are not able to bill before a procedure is performed. This didn’t end up being a problem, and I didn’t need to request a new receipt, but it could be for you.
- Is the newborn active under the insurance?
- Are you submitting two separate claims, one under the mother and one under the newborn? I accidentally submitted both under my wife, and it resulted in denials and other unforeseen problems.
- Is your gap exception or authorization approved? I submitted while ours was still pending, so the claim got processed as out-of-network and had to be adjusted when the authorization was approved.
- Have you confirmed that insurance is going to be covering up to the billed amount and not using an allowed amount? Otherwise the claim will get processed and you may have a harder time fighting once you’ve been paid. It is better to have this issue squared away before the claim is submitted.
- The goal is to submit the claims once, and have them processed once.
- Excellus’ claim form is on the website under Claims > Submit a Claim, and can be uploaded electronically.
- It may take days to a whole month for the claim to get processed after submitting online. When the claim is processed, make sure it is processed correctly:
- Did the claim get processed up to charge, or to an allowed amount?
- Did the claim get processed in-network with the correct coinsurance (i.e. 15% coinsurance rather than the 30% that an out-of-network charge would be, or whatever your specific plan’s numbers are) and did the correct amount get applied to the correct deductible (in-network, not out-of-network)?
- Call to resolve problems
- If, or rather when your insurance gives you pushback or incorrectly processes something, call. You can try to be nice and give the 1st tier representative a chance to resolve your issue, but often times they don’t deal with cases this complicated and don’t have the authority to get things done. So, it may be better off just asking to speak to a supervisor.
- With Excellus, I had to walk them through every step of this process. More often than not, when something happened to the claim, it happened incorrectly. So I needed to stay on top of what was happening. I did not get callbacks, nor did things get resolved when I was told that everything was resolved. When representatives told me that no further action was needed on my part, I often found that further action was needed on my part. I found that supervisors (I believe they call them lead representatives with) were able to process claims while you were on the phone, whereas the 1st tier representatives could not, and usually told you things would take up to 30 days. So, if you don’t need to use a supervisor, great, but you probably will.
- Document every call to insurance. Ask for the representative’s name and the call reference number. Excellus representatives will only give you their first name and first initial of their last name. Keep a log of when you called, who you talked to, and the call reference number. You will likely have to refer to these in future calls. These are also helpful if you need to file a grievance. If you forget to get a call reference number, you can call back and ask for the call reference number of a previous call.
- If you need to, file a grievance with your insurance. With Excellus, you can even file a pre-service grievance before the birth takes place (but wait until the authorization is approved or denied), which may be helpful if you get stonewalled about the allowed amount versus billed amount issue. The grievance process is outlined in your contract. There are specific timeframes depending on what type of grievance or plan, but with Excellus they make a decision within 15 days of receipt of your grievance for pre-service grievances, and within 30 days for post-service grievances. You’ll want to confirm the address if you have Excellus, but for me the process was to send a letter to:
- Customer Advocate Unit
PO Box 4717
Syracuse NY 13221
- Make sure you include documentation of representative names, call reference numbers, dates, specifics of your contract, and applicable laws, etc. If your grievance gets denied, you can file a grievance appeal to take it one step higher within your insurance. If that gets denied, you can file for an external appeal.
- If needed, enlist help. This issue falls under a couple different governmental departments. You will likely have to have had something denied or processed unfavorably to get someone external to help. I tried contacting some of these numbers before the birth and before the authorization was approved because I was getting a lot of pushback from Excellus, but was told that I needed to have the claim filed and processed before anything could be done. Here are some contacts for New York. There is also a whole page of contacts for New York state residents at https://www.health.ny.gov/health_care/managed_care/complaints/:
- Health Care Bureau under the New York Attorney General’s office
- New York State Department of Health’s Bureau of Managed Care Certification and Surveillance
- New York State Department of Financial Services’ Customer Assistance Unit
- You may also contact your employer’s benefits department and ask them to advocate for you with their representative from the insurance company. Your company pays insurance to cover its employees, and wants to know they are getting their money’s worth.
- You may also tweet at your insurance company. Many companies have dedicated social media teams that can escalate issues if you contact them. Towards the end, I sent a tweet at Excellus, and they responded back asking me to send them an email. However, I ended getting things to move forward again over the phone, so I didn’t end up emailing them.
ConclusionAs both a healthcare provider and a healthcare consumer, I’ve unfortunately seen a fair amount of obstruction from insurance companies as a measure of cost control. I’ve also seen a lot of human error, and poorly trained representatives.
On the one hand, our home birth was expensive for insurance to cover at the fee schedule amount of $5,300 when compared to the roughly $2,000 that would have been considered for a participating provider. So it’s logical that insurance would not be thrilled covering this amount. However, their low reimbursement rate for participating providers is one of the main reasons there are little to no home birth midwives that participate. The financial burden of the tradeoffs that stem from their low reimbursement rate should not be shifted to the member, particularly when home birth is listed as a covered service. Insurance cannot have their cake and eat it too.
On the other hand, given the significantly higher percentage of births performed by Cesarean when you compare hospital deliveries to home births and control for risk levels, combined with the substantially higher cost of such deliveries, and considering that a home birth requires no facility fees, homebirths likely save insurance companies money. When you consider this, you could say insurance companies want to 1) reimburse participating providers at a very low rate, 2) have members who decide to pursue home births cover any additional cost beyond their low reimbursement rate, and 3) benefit from the cost savings of less expensive vaginal deliveries and non-existent facility charges. Basically, they want to have their cake, and then eat it twice.
Hopefully this lengthy account of our experience and my recommendations is helpful to others pursuing a home birth, whether you are in upstate New York and covered by Excellus, or across the country with another insurance provider. Feel free to comment or ask questions.