Midwife and Military/Tricare

[Pirogi]

I am sorry this is long, but I would love a little perspective on this.  I am active duty military and have Tricare Prime (military insurance).  Prime is the Tricare option where there are no copays, deductibles, etc.  This is the mandatory insurance option for all active duty service members.  There is a network of providers under Tricare.  Prime enrollees must choose from this network, if there is/are provider(s) in network within a certain distance of your home who fulfill the required service (general practitioner, specialist, etc).  Like many insurance plans, Tricare negotiates the amount they will pay for claims of every covered service, and providers presumably agree to this payment when they become network providers.

I am seeing a midwife who, when I began the pregnancy, was practicing under an in-network obstetrician and attended in the hospital. She moved to autonomous homebirth practice a few months into the pregnancy, and lost her in-network status when she left the practice.  She is still listed in the Tricare system as a non-network Tricare provider, and I was able to change my referral to her, from the practice where she worked before, because there are no other in-network midwives within the required distance from my home.  There is one other hospital-based midwife in the area who accepts Tricare insurance, but she is under an obstetrical practice as well.  *She* isn't in the system, but Tricare patients can see her if they get a referral to the practice.

My midwife had another Tricare Prime patient (spouse of AD member) who was due before me, and she recently submitted a claim for the services she provided this woman.  Tricare paid only half of her usual fee and said that was all they would cover.  She told me today that I would have to pay the balance of the fee (nearly $1500).  I have never signed any sort of agreement with her listing a price that she would be paid, and I don't think legally she has any recourse if I don't pay.

So WWYD in this situation?  I am 35 weeks, and I feel like I have three options:  1. Agree and pay her $1500.  AD service members NEVER pay ANYTHING for healthcare generally.  That is how the system is set up to work, and that is the reality.  One of the benefits of military service.  2. Tell her now that I refuse to pay the balance and risk her firing me or using it as an excuse to risk me out.  3. Wait until after the birth and then refuse to pay.  If I refuse to pay, the midwife may decide not to accept Tricare patients anymore, which would land all military women in my area back in the hospital as their only option.  

I really feel like this midwife is holding my birth hostage over the payment situation, which she should have known about when she went into private practice.  I also feel like if I don't pay, I am dooming all the military women who may have wanted to use her in the future to a hospital birth.

[MarineWife]

You are saying that the TriCare allowable charge for a homebirth is $1500 and your MW charges $3000, correct? You did not discuss her full fee before agreeing to use her services? If she is out-of-network, she may be able to legally charge you up to 15% above the TC allowable charge plus any deductible and co-pay. I assume that since you got a referral you don't have a deductible or co-pay. I believe that means the most she can charge you is $225. I'm not 100% sure if she can charge the 15% above for Prime. That may only apply to Standard. I would call TriCare to verify this and then discuss it with the MW. Then she has the choice of accepting the $1500 from TC as full payment or not and you have the choice of paying more if she does not accept it. I think it would be wrong of you to lead her to believe you are going to pay her $1500 and then just refuse after you get what you want.

Personally, I would pay the extra if that's the normal going rate in your area. $1500 is a steal for a homebirth. You are choosing to see this provider because you want a different kind of care from what you would get with a doctor. That's worth paying for. If you don't want to pay, you can always go back to the MTF or an in-network provider who will accept the TC payment.

[mntnmom]

I know as AD, you're not accustomed to paying for your care, and didn't expect to when you started out. But if you want to maintain your integrity, you really only have 2 choices. Pay your midwife for the services she renders, or explain the situation and go with another provider (do you have access to an MTF?). She might even be able to work out a payment option or reduced fee, depending on your situation  If you really want a homebirth, $1500 isn't that bad. I'm an AD spouse, and we paid $3000 out of pocket because Tricare wouldn't cover our CPM. But it was worth it, and we had the next baby at home too!!   Congrats, and good luck working this out.

[MarineWife]

Yep, I'm an AD spouse. We paid $2800 for our homebirth and will pay more this time. I'm used to paying some, though, because I have Standard. I could switch to an OB and have minimal costs or even switch to Prime and see an OB and have no costs. It is so worth it to me to pay to get the care I want rather than just the minimal care that someone else thinks is adequate. KWIM?

I have been considering switching to Prime for this pregnancy in case there is a problem and I have to go to a hospital. I want to be able to go to the MTF without a hassle because the civilian hospital here is atrocious when it comes to L&D and newborn practices and the 2 OB practices are out of the 1950s or something. Problem is that a lot of Prime carriers get referred out to those civilian OBs so even having Prime won't guarantee that I could go to the MTF. Because I have Standard and they don't even have enough room for all the Prime people at the MTF, I can't get appointments at the MTF. I'd still pay the $3000 for my homebirth MW unless there was a serious medical condition that required doctor care and hospital birth.