help! my homebirth is being held for ransom

[elus0814]

I'm 29 weeks and have been seeing a homebirth midwife since 8 weeks. She and her staff are very nice and it's been great so far. I'm now very excited for the homebirth of my fifth child after having not thought about homebirth before. I had first went to two separate ob/midwife practices (the only two in town who take our insurance) but was discharged from one then the other because I refused to consent to a c-section at the initial appointment, among other reasons.

Today I received a letter from the midwife saying they have found that some insurance companies are not paying their birth assistant fee so they are now requiring all patients pay the $500 fee by 36 weeks (just 7 weeks away for me!). There was no mention of this fee in financial contract that I signed. We're stretched thin as it is between preparing to move to another state (military move, no choice but to go), having been making payments every month on the $800 agreed upon cost, and having just purchased our homeschooling materials for the year for the older kids. Compounding it all is the page long supply list I was given at the last appointment which will amount to about $150 (not money we have on hand right now).

So now DH and I are at a loss for what to do. Our options, as we see them, are:
1. somehow try to come up with another $500 on top of all the other expenses, meaning using our emergency credit card or borrowing from family
2. try to find care elsewhere but there are no other homebirth midwives in the area and since both in town ob practices have turned me away I would have to go to another city. Also, since I had to change insurance to see this midwife I would have to pay 20% of a doctor's fee, which could amount to the same as what the midwife is asking. This would also mean walking away from the nearly $700 that I have already paid since it would be held as payment for the prenatal appointments I've already had.
3. try and explain that we just can't come up with that kind of money so fast but I'm concerned that if I tick her off or she thinks I'm not going to pay more after the birth she will refuse to see me
4. contact tricare (military insurance) and explain the situation. We tend to think they would frown on charges like this, to say the least, but again I don't want to annoy the midwife and I don't want her to get in trouble with tricare which could make it difficult for other military families to have a homebirth.

If she won't see me and I can't find care elsewhere I'll have to go to the emergency room in labor as a patient with no prenatal care at a hospital with a 40-something percent c-section rate and get stuck with all kinds of extra tests for both me and the baby. This hospital also called cps on a new mom who tried to refuse a bottle of formula for her breastfed baby. As I mentioned before, if she refuses to see me or if I look for care elsewhere I will be out everything that has already been paid.

I feel like my homebirth is being held for ransom! What would you do if your midwife upped the fee (by 62%) in your third trimester?

[WTHamI?]

Wow, that's a tough situation. I would start by talking to the midwife. It's one thing to require this fee of new patients, I do not think it's okay to ask for it from existing patients who have already signed a contract for payment. Really I don't see how she can even do that since I'm assuming you have some sort of signed agreement for payment that does NOT include that $500 fee in its terms, and I would (nicely) bring that up with her. That you would have made accommodations for it had it been part of your initial contract terms, but she can't ask for it out of the blue at 29 weeks when she has already agreed on payment terms with you that did not include that fee.

If she's not willing to budge it sounds like in your situation coming up with the money somehow is probably your best option, but I would not let her know that unless it really comes to that. I think you should try to get her to waive that requirement for you. Really she should only apply it to new patients anyway, I don't think that's fair even if you were only 10 weeks but had already signed an agreement. If you hired someone to rebuild your garage after a fire and had contracted for a certain price, no way could they come back months into the project and say sorry, but we're going to need an additional $500 deposit because we don't like your insurer. They are already under contract, it doesn't work that way. They can require that of new customers, but they can't legally stop construction on your garage until you pay them some arbitrary fee that was not part of the original contract. This scenario really isn't that different and I don't think she has a leg to stand on.

[*MamaJen*]

I would be so upset that they would try to pull something like that. You already have a signed contract with them, outlining the fees that you will pay for the services you will receive, right? So legally, they can't just announce that they're changing the terms of that contract. I think that's horribly unprofessional of them, and I would let them know that. Since I could see myself getting upset in a face to face conversation, I would probably write them a fairly strongly worded letter.

[HeatherB]

I would call the MW and say, "Gee, I got this letter, and I'm kind of confused about it. I haven't heard anything about this before, and as you know, with all that's going on, things are very tight as it is. Can you tell me what we can do about it?"

Really, when they bill the insurance, it should be one big, lump sum. I'm not quite sure what the extra fee is all about. And, I agree, they can't just add something to your bill when you haven't been told about it or agreed to it. But I think taking it to them and discussing it (with the assumption that it's some sort of an error and they'll take care of it) is the best way to go. Definitely don't just pay it. Be willing to work out arrangements if necessary, but also let them know what your real situation is and that while you've budgeted to cover the costs discussed, that coming up with a big sum at this point in time seems entirely overwhelming and downright impossible to you.

[Banana731]

I don't think I would call tricare. They are more likely to pay everything if you submit it all at once.

If the MW does expect you to pay it, maybe you could explain to her that you budgeted for the amount in the contract only, and see if you can pay later, or a little at a time at least.

you could try the navy/marine core relief society too. medical bills are definitely one of the things that they are willing to help with. Even if you can't get a grant from them, you will most likely be able to get an interest-free loan. That's better than your cc, probably.

OT: $800 Wow! That's incredible.

[*MamaJen*]

How can she be expected to pay a higher amount than what she contractually agreed to? That's just flat-out not legal. I'm really surprised that people are saying she should pay it. The midwife has a legal and contractual obligation to render services for the amount initially agreed to by both parties. She can't just decide to up her rates in the middle of it.

[MidwifeErika]

If you have a signed contract, then stick to what the contract states. I would approach the midwife from that angle. You should not be expected to come up with more money if the contract does not say anything about it.

[Ola_]

Originally Posted by HeatherB

I would call the MW and say, "Gee, I got this letter, and I'm kind of confused about it. I haven't heard anything about this before, and as you know, with all that's going on, things are very tight as it is. Can you tell me what we can do about it?"

Really, when they bill the insurance, it should be one big, lump sum. I'm not quite sure what the extra fee is all about. And, I agree, they can't just add something to your bill when you haven't been told about it or agreed to it. But I think taking it to them and discussing it (with the assumption that it's some sort of an error and they'll take care of it) is the best way to go. Definitely don't just pay it. Be willing to work out arrangements if necessary, but also let them know what your real situation is and that while you've budgeted to cover the costs discussed, that coming up with a big sum at this point in time seems entirely overwhelming and downright impossible to you.

This is the approach I would go with. Make sure you don't go into the conversation defensive, just ask about it and let her explain or whatever. It could be that this letter wasn't even meant to go to you, only new patients, and you received it in error because someone else was mailing them for her.

I'm a bit confused though, is the plan that you pay $800 and they bill the insurance for the rest? And now they suspect your insurance won't pay their share? If that's the case then after your conversation with her (depending on how it goes and what she suggests) I'd give the option that IF the insurance company doesn't pay up, you will pay at that time. You can sign something to that effect if needed and it would at least give you time to save/budget.

But if this $500 fee is totally new (i.e. you were told that the $800 would cover the entire cost, with nothing else from you or insurance) then I don't see how they can ask for more. However $800 for a homebirth seems a bit low, so I'm guessing it's like the situation I described above?

Re: homebirth supplies. Normally this is something that you would be expected to get and pay for, so there's not really too much to do about that. It's just part of the cost. Now around here some homebirth practices say upfront that if you cannot afford the supplies, let them know, they may have some that have been donated that they could pass on to you. That's definitely something to ask about.

[SoulCakes]

What's the point of legal contracts if you can change them anytime?

What I would personally do is act confused, call them and say that you're sure you weren't supposed to receive this because the contract says x, y, z and of course you know that *they* know that they can't change it now. Haha, so silly... yes, you understand, it was all a mistake. Seriously. Maybe I'm just overly cynical but I'm not getting a good vibe from someone who would do this, so if you approach the subject timidly I have a feeling they'll try to railroad you. You have to pretend that this was obviously a mistake. It's the only attitude to have.

[elus0814]

Originally Posted by Ola_

This is the approach I would go with. Make sure you don't go into the conversation defensive, just ask about it and let her explain or whatever. It could be that this letter wasn't even meant to go to you, only new patients, and you received it in error because someone else was mailing them for her.

I'm a bit confused though, is the plan that you pay $800 and they bill the insurance for the rest? And now they suspect your insurance won't pay their share? If that's the case then after your conversation with her (depending on how it goes and what she suggests) I'd give the option that IF the insurance company doesn't pay up, you will pay at that time. You can sign something to that effect if needed and it would at least give you time to save/budget.

But if this $500 fee is totally new (i.e. you were told that the $800 would cover the entire cost, with nothing else from you or insurance) then I don't see how they can ask for more. However $800 for a homebirth seems a bit low, so I'm guessing it's like the situation I described above?

Re: homebirth supplies. Normally this is something that you would be expected to get and pay for, so there's not really too much to do about that. It's just part of the cost. Now around here some homebirth practices say upfront that if you cannot afford the supplies, let them know, they may have some that have been donated that they could pass on to you. That's definitely something to ask about.

The cost of the entire 'package' (prenatals plus the birth) is $5000, insurance pays $4200 and we agreed to pay the other $800 in payments with the final payment no later than 36 weeks. That part I'm totally ok with, I agreed to it. This new fee is for the birth assistant (a doula). The midwife (a cnm) will not work without an assistant. I don't remember anything being said about an extra fee for the assistant, it seems like something I would sure have taken note of since the cost was a big discussion point on deciding if we would do a homebirth or not.

The supplies aren't really a big issue, it was just unexpected. After four hospital births I can't believe I'm being asked to purchase my own box of gloves. I guess I understood 'birth supplies' to be personal things like a birth pool, candles, snacks, etc. but I never really researched it.

We've been looking over the initial contract more and I think I'm going to call someone else who also has tricare to see if they paid the birth assistant fee. If they did there is no way we will pay it upfront since the financial agreement states that they do not refund overpayments.

Thank you everyone for your input. I'm still stressed out over the whole situation but I feel better knowing that I'm not being unreasonable to object to a new fee being presented so late in the game.

[MidwifeErika]

I see a bit more clearly now. It isn't really a new fee as the entire package fee is $5000. If the insurance has now suddenly decided that they will only pay for $3700, then you really may need to cover the rest. It does not matter if the contract states specifically that there is a fee for the assistant, what matters is if it states what the full fee is and what the insurance coverage ends up being. Discuss it with her and see if she can work with you on it or take payments on it.

[elus0814]

Originally Posted by MidwifeErika

I see a bit more clearly now. It isn't really a new fee as the entire package fee is $5000. If the insurance has now suddenly decided that they will only pay for $3700, then you really may need to cover the rest. It does not matter if the contract states specifically that there is a fee for the assistant, what matters is if it states what the full fee is and what the insurance coverage ends up being. Discuss it with her and see if she can work with you on it or take payments on it.

Yes, it is a new fee. The 'package' costs $5000. Insurance pays $4200. We agreed to pay the remaining $800. This fee would make the total cost for the package + fee $5500. They are concerned that insurance will not pay this extra $500 assistant fee so they are now asking for prepayment of it. The understanding before (and what is in the contract) is that if the insurance will not pay as much as they estimate the remainder would be billed after the birth but they are trying to change their policy and ask for more money up front.

We have also found out in the past few days that our insurance has a $1000 yearly 'catastrophic cap', this fee would put us several hundred dollars over this cap and with their no refunds for overpayment policy I doubt we could ever recover the money if we end up prepaying and insurance picks up the bill.

[MidwifeErika]

So, before were they including the assistant in the global fee and now they are not? Or before did they get $4200 from tricare plus and additional $500 for the assistant for a total of $4900? It all is a bit confusing, so I think talking with the midwife is the only thing to do at this point to figure it all out. Good luck!!

[elus0814]

Originally Posted by MidwifeErika

So, before were they including the assistant in the global fee and now they are not? Or before did they get $4200 from tricare plus and additional $500 for the assistant for a total of $4900? It all is a bit confusing, so I think talking with the midwife is the only thing to do at this point to figure it all out. Good luck!!

They are not including the assistant fee in the package rate. They will be receiving $4200 from tricare plus whatever tricare will pay towards the $500 fee plus our $800 in cash. It's really not confusing, they have decided they don't want to wait and see how much insurance will pay towards the extra $500 so now they are asking patients to come up with all that cash up front (and, for me, at the last minute).

[*MamaJen*]

I hate to say this, but that would give me a really bad feeling about the midwife in general. I would feel like they were trying to scam me, or like it was a betrayal of trust. At the very least, I believe that it's incredibly unprofessional to just announce that you're changing a legally binding contract. Especially in this situation -- there are dynamics of trust and power in a doctor-patient or midwife-patient relationship.
Say I had a written, signed contract with my lawnmower guy, saying he would mow my lawn for a year for $100 per month. If he suddenly came in three quarters of the way through and said he had to tack on an extra $40 per month for an assistant's fee, I'd be mad, and I'd be like, nice try, buddy, but no cigar. But I wouldn't feel distressed or betrayed, because it's not a relationship with a doctor or midwife, where they are in a position that carries authority and we are supposed to feel trust in them.

[nashvillemidwife]

I'm really disheartened that so many of you are making the midwife out to the be villain. The problem here is TriCare. It's no more unfair for the client to be asked to pay more than she was expecting than it is for the midwife to be expected to be paid less than she was expecting. They're both getting screwed by TriCare.

I am curious about what your financial agreement actually says. Mine explicitly says that out-of-pocket amounts and payment plan is subject to change based on communication or behavior from the insurance company, and in such case the agreement will be modified. So it sounds like her policy is similar in expecting you to make up the difference, the issue is about when she expects that difference to be paid? It is legal for her to change your out-of-pocket amount if the agreement allows for a change to be made. If your agreement does not state that, she can't make you pay it up front.

I am leery of their policy that they don't refund over-payments. It does not seem legal or ethical to me to require payment in advance without refunding you what insurance reimburses. Are you sure that policy applies to patients, and not insurance companies?

My biggest question: how on earth is your midwife getting $4200 out of TriCare? That's the most suspicious thing to me. Our practice gave up working with TriCare because their reimbursement rate was around 1/2 of our $3500 fee.

[Ola_]

Originally Posted by elus0814

Yes, it is a new fee. The 'package' costs $5000. Insurance pays $4200. We agreed to pay the remaining $800. This fee would make the total cost for the package + fee $5500. They are concerned that insurance will not pay this extra $500 assistant fee so they are now asking for prepayment of it. The understanding before (and what is in the contract) is that if the insurance will not pay as much as they estimate the remainder would be billed after the birth but they are trying to change their policy and ask for more money up front.

I would have thought that the $500 fee was included in the $5000 package (not a cheap package, yikes). So the total cost stays the same but they are asking you to pay upfront an extra $500 because they don't think the insurance will (i.e. they will get $3700 from insurance instead of $4200). Even if that is the case they can't IMO ask you to give them the whole $500. Ask them to be flexible due to the circumstances and late notice to you.

Also, if you are going to pay the $500 I would expect that an additional contract would be signed regarding this. Something to document that you are agreeing to pay it and it's meant to go towards any costs not covered by insurance. That way THEY have proof that you said you'd pay it, in case you try to back out and YOU have proof that they owe you that money in case insurance does in fact reimburse for the full cost.

It wasn't clear from your post if you've talked to your midwife yet, but if you haven't I definitely would do that asap. It can really help to "clear the air", either that or solidify in your mind that you really don't want them attending your birth.

[elus0814]

Originally Posted by nashvillemidwife

I'm really disheartened that so many of you are making the midwife out to the be villain. The problem here is TriCare. It's no more unfair for the client to be asked to pay more than she was expecting than it is for the midwife to be expected to be paid less than she was expecting. They're both getting screwed by TriCare.

I am curious about what your financial agreement actually says. Mine explicitly says that out-of-pocket amounts and payment plan is subject to change based on communication or behavior from the insurance company, and in such case the agreement will be modified. So it sounds like her policy is similar in expecting you to make up the difference, the issue is about when she expects that difference to be paid? It is legal for her to change your out-of-pocket amount if the agreement allows for a change to be made. If your agreement does not state that, she can't make you pay it up front.

I am leery of their policy that they don't refund over-payments. It does not seem legal or ethical to me to require payment in advance without refunding you what insurance reimburses. Are you sure that policy applies to patients, and not insurance companies?

My biggest question: how on earth is your midwife getting $4200 out of TriCare? That's the most suspicious thing to me. Our practice gave up working with TriCare because their reimbursement rate was around 1/2 of our $3500 fee.

We combed over the financial agreement and there wasn't anything about amounts being subject to change. She even showed me a tricare billing statement (I was apprehensive that they wouldn't pay and we would be stuck paying the full amount) with the name blacked out so I could see they would pay most of it. I wish I could remember if it showed an assistant fee.

I wonder if your patients with tricare were on prime. Prime will only pay 50% but if they switch to standard tricare will pay 80% but it means the patient is responsible for 20%, up to $1000 per year.

Do you know if she is able to refuse to see me anymore if she decides she doesn't like me questioning this or if I don't pay it up front? Is that even legal, especially at nearly 30 weeks? My biggest concern with this situation is that she will refuse to see me or attend the birth, leaving me without prenatal care and having to birth as an er walk-in patient.

[nashvillemidwife]

Originally Posted by elus0814

I wonder if your patients with tricare were on prime. Prime will only pay 50% but if they switch to standard tricare will pay 80% but it means the patient is responsible for 20%, up to $1000 per year.

They were on standard. The problem was that their allowable amount was too low, it was something like $1800, so they were only paying 80% of $1800 instead of 80% of $3500. It sounds like your midwife is billing them for more than the global fee (initial exam, birth tray, newborn care, etc.). I do that too, but I make it clear that those charges are extra and separate from the global fee of $3500.

Do you know if she is able to refuse to see me anymore if she decides she doesn't like me questioning this or if I don't pay it up front? Is that even legal, especially at nearly 30 weeks? My biggest concern with this situation is that she will refuse to see me or attend the birth, leaving me without prenatal care and having to birth as an er walk-in patient.

In this situation, she only has the right to terminate your care if you violate the contract and do not pay as agreed. She cannot refuse you because she wanted to change the terms of the contract and you did not agree.