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Experience with gap exception versus just global billing?

post #1 of 37
Thread Starter 
I have UHC PPO, which I know is a pretty common plan. I tried to get a gap-exception last time around, which they completely and thoroughly botched, enough so that a competent employee that I spoke with after the fact (to find out if it had ever happened) was incensed, and was adamant that I file an appeal.

The time before that, I hadn't heard of it, but they didn't pay much, which is why I wanted the exception.

This time, I'm hearing it might be better NOT to have an exception - it might be best to leave well enough alone and not contact them unless absolutely necessary.

So, I'm curious... Has anyone done both and noticed a difference in payout? My main goal here is to get them to pay my MW what she's due. I don't really care how that's accomplished, as long as she gets paid!
post #2 of 37
We're switching to UHC in July, and I already have dh's HR folks lined up to deal with them for me

What they've explained is that if we pick HMO the gap coverage will cover at in-network rates (reasonable and customary?) for the midwife. Then she can balance bill the difference to us.

IF we pick PPO then she will be covered at their out-of-network rates, and can still balance bill us the difference.

Either way we can also dump $ into our HSA/MSA (forget which) to cover the difference.

What it really comes down to for me, is what will our OOP cost be for the insurance (HMO vs PPO) because either way my chiro is also not covered, so it might be worth it to go HMO for the cash in our pocket each check.

Her cash rate is $4k, and global billing is $4600. Reimbursement from UHC can be as low as $2200 (I'm going to get the ICD9 codes and call them for specifics once I have the plan details).

So max, with the HMO plus some supplies, I see our max OOP at $2500. With the PPO it could be higher, since out of network will reimburse at somewhere between 60-80% (still don't know the details of the plan).

If we went cash, we'd obviously pay the full $4k. I'm so sad, we're currently on BCBS PPO which covered my son's hb at 100%, we just rented a tub and got some basic supplies.

I'm hoping the PPO vs HMO difference is as large as it was with BCBS (it was over $100/mo) and that will really help to offset the OOP cost for the birth if we get the HMO. Either way, I'm sticking with the midwife we have and I'll really give HR a hard time if UHC screws it all up.
post #3 of 37
Thread Starter 
It's all so complicated, isn't it? We haven't switched insurance in many years now (not companies, anyway, though the policies have changed constantly), so we haven't had to do quite that amount of juggling.

Your reimbursement amount sounds alot like what we've gotten. We actually, though, just got notice of a class-action suit against UHC about out-of-network claims not being reimbursed properly. I'm hoping that our homebirths will be part of the settlement, as we got so very little out of UHC for them. They're also supposed to be changing how they evaluate the claims, so, again, I'm hoping it's in our favor!

As for gap versus simply global billing, I'm going with just global billing and not messing with anything more than necessary. I have a local friend using the same MW who has the gap exception (and due within 10 days of me), and we will be able to compare payments. They should be identical, but if they're not, we can appeal based on the other payment for whomever got short-changed. That seems like a good plan to me, anyway!
post #4 of 37
I'm clueless as to what gap extention and global billing mean but we had UHC PPO when we gave birth. They said upfront that they'd pay our midwives 60% of their fee. Our midwives did some creative biliing and billed for some prenatal care, home visits, and newborn exams and the amount that UHC paid them was closer to 92% of their fee.
post #5 of 37
Thread Starter 
That's fantastic, Belle! Do you happen to know what codes they used, or specifically what they billed for? I hear most people get better payments billing globally (same code an OB does), but perhaps separating some of the care can work out in one's favor.
post #6 of 37
i too have uhc ppo and we are working on getting hb covered. i think we are using the whole gap scenario.....nothing in writing yet from uhc, but when i have it i will let you all know how it turns out.

i *think* what will happen is that we are responsible for our in-network deductible and uhc will cover 65% (the out of network percentage) of our midwife's bill.
post #7 of 37
Originally Posted by HeatherB View Post
That's fantastic, Belle! Do you happen to know what codes they used, or specifically what they billed for? I hear most people get better payments billing globally (same code an OB does), but perhaps separating some of the care can work out in one's favor.
I don't know the specific codes. I just got a statement from the insurance company that prenatal care had been applied to our deductible before we met it. After the birth I got the statements that they paid 60% of the birth fee. Then later that they paid home visits and newborn exams. We had already paid the midwives' fee which included everything so we got reimbursement checks from our midwives for months after the birth. It was great.
post #8 of 37
Thread Starter 
My understanding is they should pay it ALL based on in-network rates. I hope it works out for you! They made it virtually impossible for me last time, and I hear that's not uncommon.

Belle, that is awesome!
post #9 of 37
My midwife said that the problem isn't so much that they will pay at their in-network rate, but that their in-network rate sucks compared to other companies. She said that last she checked, their "usual and customary" for a vaginal birth (regardless of location, hospital or home) was reimbursed at $2200. That doesn't cover her costs, so she'd lose money on a birth.

So we're going to hope they pay their max, and that it's higher than $2200, and we'll pay the difference OOP.
post #10 of 37
whew!! sorry it has taken so long to get you guys actual concrete information about what my particular case is, but here goes:

my mw's billing person applied for a gap exception. this process was started on her end on 5/13, for some reason UHC doesn't have entered until 6/1.

so I have called several times per day to check on the status. make sure you get a reference number. there are 2 800 numbers you can call: 800-638-3323 or 800-638-7204 (option 2, then option 1)

long story short, they approved our homebirth to be covered in network!!!!!

and for those who want the codes, apparently 59400 is the delivery code.

good luck....it's been a long frustrating wait for us but we are obviously thrilled with the results!
post #11 of 37
I found out yesterday that if you are w/in 3 months of your EDD you can apply for a transfer/continuance of care (it might be law?) within 30 days of UHC becoming your insurance, and they will pay your care provider at in-network rates even if they aren't.

We are doing this... we switch to UHC July 1, and my EDD is 9/28. Literally hours from the 3 month period ending. I'm positive I'll go into October before baby is born, but the coverage is based on your EDD via LMP, so I qualify.

post #12 of 37
This thread is kinda old but my billing issues were just finalized, so I came here to share what worked for me.

I believe it is best to get the exception. The insurance company might have the right to deny out of network claims or reimburse at lower rates if you do not obtain prior approval. Plus, it is just fun to think that someone from your insurance company is calling every single OB and midwife in their network within whatever radius to verify that they don't attend homebirths.

I have a BCBS of Illinois PPO plan. My individual deductible is $1k in-network and after that they pay 80%. For out of network providers the deductible is also $1k but thereafter bcbs will only reimburse 50%. Naturally my CNM, who runs her own business specializing in homebirths, is out-of-network for all insurances. But since bcbs does not have any in-network providers who will attend a homebirth, I applied for and was granted a PPO Waiver. They sent me a letter stating that they would reimburse the homebirth charges at in-network rates and my in-network deductible would apply. The waiver was good for 60 or 90 days after I applied, and could be extended if I needed it to be. I applied for the waiver in mid-February and was due early-April so the original waiver worked out fine.

Prior to 36 weeks I was too pay my midwife $1500 of her total $4200 fee regardless of the way insurance turned out. After my homebirth, my midwife billed BCBS her global fee. BCBS initially "overlooked" my waiver and tried to apply my out-of-network deductible and paid only 50% of what was left, approving $3700 as "reasonable and customary". As soon as I received my explanation of benefits, I called them and reminded them of my waiver. They sent the rest of the appropriate payment the next day. I was planning on paying the remaining few hundred dollars that BCBS considered unreasonable (whatever!) but my midwife's assistant had already billed separately for my Rhogam shot (the EOB read "injections") and some newborn procedures (EOB read "Physical exam), and possibly also my pap at the 6 week postpartum appointment? BCBS ended up paying small portions of those, which made up the difference.
post #13 of 37
Thread Starter 
Glad you had such a good experience, frenchkissed! I wonder if the differences I'm hearing are due to UHC's policies. I am very curious what will happen between my friend and I when we have our births billed - one with the gap exception and one without. I'm very grateful that we can appeal to have the lower coverage adjusted to the higher level for whomever that ends up being, as I hate to lose anything or have my MW lose out!
post #14 of 37
Any updates Heather (or anyone else) on the best way to deal with UHC?
post #15 of 37
It's so funny that this thread got bumped up! I'm with UHC under a PPO plan. I got a gap exception approved for my midwife: my out of network deductible is $2,000 whereas my in network deductible is $1,000 so I figure the difference was worth it. Since the major of my prenatal care will be in this year but the delivery in next year, it's very likely they'll want me to cover the deductible for both years. UHC wasn't too bad about the gap exception but getting my primary care physician's office to call it in was like pulling teeth.

Now I'm running into a speed bump where I assumed that a home visit would be covered the same as an office visit. Instead of a copay, it is subject to coinsurance (so I need to fulfill the deductible and then they will cover 80%). My midwife doesn't plan to bill them again until the baby's birth. So I'm trying to figure out how to procede. My midwife has the option of office visits but it's a good distance to her office. She works with a biller but she hasn't been helpful and told me to call UHC to ask about coverage. Of course I worry I'm not asking the correct questions.

That was probably longer than it needed to be but when I talk to my hubby his eyes just glaze over.
post #16 of 37
Does anyone else's midwife use a biller who doesn't seem to know what's going on? I emailed the biller and she claims she billed the insurance for an office visit while the explanation of benefits very clearly states "home visit".
post #17 of 37
Allison, tell her the icd9 code is wrong, and that it's showing as a home visit, and you need her to resubmit. Though every time I call UHC they tell me that "location doesn't matter" and provider does.

And talk to your midwife, she might be able to come up with some other things to add on the bill, hydrotherapy for pain relief, or something else, that will give you "more" to bill so she gets reimbursed a little more.

My opinion at this point is that UHC sucks.

I switched to the UHC HMO July 1, and did a ton of paperwork to get them to do a "continuance of care" form (they told me to do it) and then rejected it because continuance of care isn't covered by the HMO, only by the PPO. I can't get a gap coverage because there is ONE hospital midwife (1.5 hrs away) who is within the 30 miles of coverage. So I'm now appealing the continuance of care. I should qualify for that because my edd is 3 days before the 3 month window the continuance covers.

My midwife won't even ask her biller to bill UHC, I'm going to have to submit it myself, because it's a pita for them to do. They only bill BCBS PPO.

BUT more importantly, I've talked to several women who have gone into a homebirth KNOWING that UHC wouldn't cover their provider/homebirth. They've paid their midwives up front, and then sent a really nice letter to UHC explaining that their homebirth (at 4k or so) actually saved the insurance company a ton of money (vs the cost of a hospital vaginal birth, vbac, or c/s) given the actual cost plus 2-5 days stay at the hospital, etc. etc. and UHC has quietly issued them a check for a big chunk if not all of their homebirth costs.

SO... once this is all said and done, and we have a balance to pay the midwife (we will, because I already know UHC reimbursement rate is lower than what my midwife will accept, so I will pay her out of pocket for the difference), I plan on sending a letter to UHC to ask them to reimburse me the difference that I pay OOP because the $1000 I pay OOP will obviously still be far less than what they paid her vs. the cost of a hospital birth.

I figure the worst thing is they say no.
post #18 of 37
Lisa - When I talked to UHC, they did seem to see the difference between home and office visits. I'm not sure what you mean by code. Is icd9 the code she should use or the code she should not use?
But when I emailed her back about the claim and said it was definitely showing as a home visit as she could see on the EOB I sent to her and she replied with something along the lines of "oh yeah first visits are often office visits but yours wasn't".

I did send an email to my midwife (since the biller isn't being particularly helpful) and asked if it would be possible for visits to be billed as office visits to get the maximum reimbursed amount. I'm hoping she will be just fine with that ethically.

It sucks that insurance make such an issue over covering homebirths when the cost is way less than a hospital birth.
post #19 of 37
icd9 is just the name of medical billing codes. So she needs to find the right icd9 code to use.

Like the ones I know off the top of my head are:

vag birth 59400
nst 59025
nb exam 99461
postpartum visit mom 99350
hydrotherapy for pain mgt 97036

And those get sent in with a dollar value attached, and reimbursed. They also need a diagnosis code with them (pregnancy, vaginal birth, labor services, etc.) or the insurance company won't pay for a service is there was no diagnosis to warrant the service.
post #20 of 37
Lisa - UHC is willing to cover the claim once I reach my deductible. It's not that she's billing it incorrectly; it's that UHC is treating home visits different from office visits.
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