insurance denial of home birth

[acp]

So, 15 months after my home birth, I finally got official denial by my (PPO) insurance to cover any of the $4,000 midwife fee (which covered all prenatal and postnatal care in addition to the birth). The hold-up was the midwife's fault (it took her almost a year to file the claim), but I'm now in the process of trying to appeal the decision and wondering if anyone has advice on the best things to emphasize in my appeal.
I've made an initial appeal by phone, and was notified that I can submit any additional information for them to consider in the next few days before i hear the result.

Insurance is Tufts Health Plan (which is based in Massachusetts, where my employer is based, but I'm in Illinois, and consequently use their national PPO network, which is Private Healthcare Systems). Apparently they have a clause that excludes home births. I have a hard time understanding how that is possible to do, given that birth is something they obviously cover, and this was done by a legal, certified midwife (CNM) in a state that allows home births (at least, those attended by CNMs). At the minimum, I feel they should be covering the prenatal and postnatal care, though I realize it's problematic since my midwife didn't break it out for them (just submitted the global fee).

Any suggestions? People who have dealt with this before? Additional information you think I should submit or emphasize to them?

Thanks!

[2ID_Wife]

Insurance can exclude legal things. I would see if she could submit the care bill then the birth bill and see if they would cover at lest the care.

[skyblufig]

I used to have PHCS PPO when I worked at a hospital in Chicago. Is your CNM in-network for them? If she is, they have to cover her services. Although, if I remember correctly, I had to let them know I was pregnant and get pre-authorized for global pregnancy coverage. If that's the underlying issue, she could try billing for individual appointments/tests/etc if she hasn't gone beyond the time limit for billing. If she's not in-network, and they won't cover the homebirth, she should still be able to bill them at the out-of-network rate for everything except the birth itself.

As far as the appeal, have they shown you in writing the no-home-birth clause, or have you checked your detailed policy? I'd emphasize that what you're asking for is the services rendered be covered per their contract with your CNM (if she's in-network), and try to not even mention the "home" aspect.

Sorry and good luck; unraveling insurance stuff stinks!

[nashvillemidwife]

She needs to re-bill them for prenatal and postpartum care only. That's going to be your best chance of getting any money back.

[AlexisT]

Originally Posted by skyblufig

I used to have PHCS PPO when I worked at a hospital in Chicago. Is your CNM in-network for them? If she is, they have to cover her services.

No, they have to pay for any covered services for an in-network provider. They can legally (in most states) exclude homebirth as a covered service, even though they'll pay for the exact same birth in a facility.

Similarly, my RE is a network provider with my insurer. However, my insurer won't pay a penny for IVF, because it's not a covered service.

The prenatal and postatal care are covered services, however, and can be submitted separately and paid for--just like I could get the ovulation induction for IVF paid for if my RE submitted it piecemeal.

[skyblufig]

Yes, you worded it better than I did. Plus I'm going by my policy back in '05, which did cover CNMs for homebirth. The OP would have to check her current policy. But yes definitely all the pre-and-post-natal stuff should be covered, either at the in or out of network percentage.

Also, if you're planning on appealing, check into Illinois insurance laws. I have no idea, but maybe since CNMs can legally attend homebirth here you can base it on that? Best of luck.

[acp]

Ugh. Sounds like I'm not likely to have a lot of recourse. Still hoping I can at least get a portion (prenatal/postnatal) covered. It's crazy to me that they're able to deny coverage of such a basic thing (a birth) done in a legal way with a licensed provider.
Thanks everyone!