received letter that tricare denied part of my homebirth

[elus0814]

I received a letter today saying that my midwife's appeal of a denial of reimbursement for 'unusual travel' expenses had been reviewed and denied again. She asked for $1600. Her fees were $5000 and since tricare standard pays 80% I paid $1000 out of pocket while pregnant. I thought it was all set. I'm wondering if there anything I can do to help her get this money. $1600 seems like a lot for travel - she came to the house once for a prenatal visit, once for the pre birth home check, once when my water broke, once the day after for the birth, then once for a post birth check. $320 for each seems high but maybe that's just how she has to bill it to be reimbursed. If they continue to deny the claim can she ask me to pay it out of pocket? With four kids and one income the $1000 was a big expense and I'm not sure how we would come up with more.

[Momsteader]

Of course she can ask you to pay out of pocket! You received the services. There should be something in your contract with her.  The midwife I am looking at says 'federal reimbursement rate for mileage outside the xxxx city limits' which for me would be 110 miles per trip to my house (roundtrip) which would be about $55/trip. (Fed rate is right about $.50 a mile). Your midwife might be including a fee for travel time?  You would have to discuss it with her, and probably should have prior to delivery. She might negotiate and let you pay less if you paid all at once, but she certainly doesn't have to.

[elus0814]

I guess what I was asking is: can she MAKE me pay it out of pocket? We simply don't have that kind of money, even $1000 was a struggle to pay and took the entire pregnancy of payments. I was concerned when I first went to see her that tricare wouldn't pay it. She showed me a tricare form for someone who lives right near me and has exactly the same form of tricare (she blacked out the name but I later me the woman who's bill it was). This showed that they paid her $4000 exactly. I only went with her because this gave me the confidence I wouldn't have to pay more than $1000.

[gemasita]

I think she would have had to let you know about that fee up-front.  She can't just spring it on you afterwards.  My guess is that she is billing the insurance company a different amount than she would or would have charged you.  She may have anticipated only getting partial reimbursement from the insurance company.  So if it were me, I wouldn't be too concerned.

[Momsteader]

Can she 'make' you? Of course. You received the services, and you are responsible if your insurance company does not pay. Did you have a contract? Refer back to that. Call her. Talk to her about the bill.

How would she 'make' you pay? She could turn you into collections, take you to court, get a garnishment, get an order to seize money from your bank account, etc.

But, what you should do first of all, is pull out your contract and call her. Let her know you received the denial (she should have as well) ask her what to do now? What does she expect? Is she willing to write off any of it? What kind of payments does she expect?

[Snowmama2011]

Does she happen to be in NW Florida and is 'covered' by Tricare Standard? Her total fees are around $5000 and your only payment is $1000? You can be vague if you want.

[elus0814]

Originally Posted by Snowmama2011 

Does she happen to be in NW Florida and is 'covered' by Tricare Standard? Her total fees are around $5000 and your only payment is $1000? You can be vague if you want.

I'm kind of confused by this. Could you restate it?

[Snowmama2011]

Sent you a PM. If you did not get it just let me know.