"Reasonable and customary"

[thursday2]

Maybe this is a post for my tribe, but does anyone know or have experience with what insurance decides is "reasonable and customary" fees for HB? We met for an info session with a MW today, and while I know that our insurance treats HB as in-network since they do not have any MWs in network (which is GREAT because it means insurance will reimburse us), she did forewarn us that they reimburse based on what they consider "reasonable and customary," not on the actual costs.

IMO, "reasonable and customary" should be a hospital birth at 10 grand and they should pay me my measly $4400 in full , but her tone implied it was usually the other way around - they claim it should only cost $2000, for example, and only pay me back $1200 despite what I actually paid.

If you had a HB and got reimbursed, did you have to fight about the cost that was reimbursed or did they honor your MWs global codes?

[LiLStar]

i paid my mw her global fee before the birth, with a discount for paying by 32 weeks. My mw billed insurance the full fee AND billed them for every pp visit, doing the pku test, the oxygen ds needed, the foley i needed pp, the vit k, and.. i'm not sure what else, i couldn't translate many of the billing codes to what actually happened, but my mw found pleeenty of things to bill them for So even though they only reimbursed 1200/4000 of the global fee, there was enough extras that i got all my money back, plus the checks kept coming and I had $220 extra to give my mw!

[ShwarmaQueen]

For our UHC plan, it's $2340. Minus copayment and deductible, we got back about half of what we paid upfront. We were satisfied after that because it took us almost 2 months to be reimbursed (they had really dumb reasons everytime we called for status) and we were tired of dealing with it.

[xixstar]

mine was out of network so they covered only 80% of what they considered to be the proper amount... So they paid $1,700 total for the global billing and everything else she billed for, so I guess that works out to them thinking the reasonable fee was a little over $2,100 if my math is right -- which is ridiculously low of course considering how much my birth could have been in the hospital with 100% coverage.

[meesh933]

My insurance company told me that the reasonable and customary charge for my area was around $1300. They were only going to pay $993 of that. The CNM I met with (they only cover CNMs) charges $4800, but was willing to go down to $3200.

I ended up getting my prenatals through an in-network OB, and I am paying a CPM half her normal fee to just attend my home birth. That was the only way I could afford it.

[jorona]

My midwife said she typically only gets about $1400 of her $3400 fee covered by our insurance carrier (after our cash pay discount, leaves us about $1600 out of pocket).

[lastrid]

You'd think they'd be happy that women were doing something that's so much cheaper. It's so ridiculous.