Moral Dilema

[MrsShow]

I had my baby at home in November. I have High,ark BCBS insurance, and was told coverage would be out of network, but, I could appeal after the baby was born. My deductible was $4500, my midwives fee for services was $3600 for prenatal, birth and postpartum. I had to pay the entire amount prior to 36 weeks. She filed with my insurance.


To my surprise! My insurance covered InNetwork and sent the midwife payment for $1400! I had to really fight her to reimburse me that money. Well...in April, my insurance sent her more...amounting to $600 dollars! I gave her time to reimburse me, but it is September, and nothing.isent an email...but anticipate an argument.


Am I wrong thinking the reimbursement comes to me? We signed a contract that her complete fee is $3600 for insured clients. Slightly less for cash paying clients. I feel like she tried making $4700 on a service she charges $3600 for.

We took out a personal loan...against our strong debt free living beliefs...to do this. We make under 40 k...this is not chump change to us.


Btw...she didn't make the birth, only the assistants I'd bc I delivered too quickly....10 hours after I originally called her, and she lives an hour away.

[JamieCatheryn]

The independent midwives I've known aren't great at accounting. Most bigger medical professionals have people for that, but they don't. Keep after her, you agreed (by contract, yes?) to an amount, if she's been overpaid she reimburses you, absolutely. She should have an accurate record of your account and if it's wrong show your proof of payments and insist she get it sorted. If email doesn't work try phone and regular mail, if it gets serious keep records and have things delivery confirmed. I don't know what's going on with her end, whether she's not good at the record keeping or is having hardships of her own and can't afford to pay you back, or even is not so honest, but she owes you back any overpayment. The not making it to the birth thing shouldn't be a factor, they usually cover that in the financial contract that you pay anyway, that's more of a spread the word about the issue if you'd like than an ask for a refund thing.

[MrsShow]

She is wonderful on the clinical side.

We learned early on that she is NOT great on the administrative side, so we have attempted to show grace, and be patient. I'd love to continue to use her for my well woman health, just to support her practice, as I know she doesn't profit a ton of money. But, this'd ssue, as it goes on...is making me reconsider.

[Gryphonn]

I would insist upon the repayment like JamieCatheryn states through increasingly serious calls/certified mail ...  Insurance is not something that comes free to you, it is either paid for directly or indirectly through the earnings package of you / your husband, so this isn't "bonus" money that she's received, it's rightfully your money.  I am a bit analytical, so I'd just send a letter with the accounting on it and the newest payment, showing that your balance with her is (-xxx) which should be returned to you in 30 days or some date.  I wouldn't budge on it.  Don't worry, it's not a moral dilemma, as there's no argument for the money being hers to keep.  No matter you or the insurance company writes the check, she has been paid more than agreed upon for these services... 

[MrsShow]

Thanks for the thoughts. I feel better just being confirmed that I am right in my refund assessment.

I'll do a letter with the accounting, and send copies of my insurance payments as well.

[JudiAU]

The circumstances of the birth aren't really relevant.

But the fact that you paid in full dictates that you receive the reimbursement. Keep contacting her, escalating with certified mail if necessary. I would assume it is an accounting error.

[WildKingdom]

She is committing insurance fraud.

Give her one more chance.  Let her know that if she doesn't respond, you'll report her to your insurance company.  They will get your money back, no doubt about it. 

What she is doing is illegal- there's no moral dilemma involved.  She could go to jail over it (not likely) or be fined (very, very likely), or have her license suspended/sanctioned (also likely).

[chocolatechip]

Since you like her, and would like to continue using her services, you might explain that to her too. That you would really like to continue giving her your business, but in order to do so, you need to feel comfortable that her fees are set, and that she will reimburse you if the insurance company pays more than expected. Otherwise, you are inclined to find someone else to work with. :) Good luck!

[Katie8681]

Yeah... That's fraud. You are not the one who should be having doubts about your morals! The math ain't that complicated.

[fairydoula]

So, if I've read this right, you had your baby almost a year ago, and your midwife owes you $600, because you already paid in full, and your insurance sent the money to her?  What's the dilemma? Lay or CPM type midwives are notorious for being bad businesswomen. It sucks, but there is no or very little training for them on advertizing or record keeping, bookkeeping, billing, etc. I know. I used to be an apprentice.  You need your $600 and you need to let her know you expect it by such and such a date, or you will report her to your insurance. She is extremely unlikely to ever be able to bill them again, if you report her, because she will be on their "fraud" list.  If it's not fraud, it is at the least very unethical. I'm sorry this is happening to you!

[krst234]

OK - I'll tell you right now that this is not as straightforward as it seems.

This does *not* mean the homebirth parent is wrong - but just want to let you in on the reality of insurance billing so you all can understand what's going on. (Or what is probably going on - this is what I have seen with numerous midwifery practices).

The billing services that work with midwives will charge more than what the midwife charges the client. The amount charged to the client is sometimes called the 'deposit' on the birth fees. In this case it was $3600.

If the midwife uses a billing service, the billing service itemizes the midwife's fees and this is usually more than the 'deposit'. Sometimes it is double the 'deposit.' Let's say it was $5400. (Because that is not an unusual amount for the insurance to be billed.)

To the parents' knowledge - the midwife is billing their insurance company the same amount as they were charged, ($3600), and all payments from the insurance company should be refunded to the parents. There is no reason why parents should not assume this!

But in actuality, the insurance was billed more than what the parents paid.

Anyway - the process of refunding the parents gets confusing when the midwife billed insurance $5400 (this is what she is telling the insurance company it cost her to provide services), and 'charged' the parents $3600.

Insurance sometimes pays a percentage of the total fees charged - 60% or 80% - and the insurance company assumes that the policy holder (the parents) are paying the 20%-40% out of pocket.

If the insurance company agreed to pay 60% of the fees ($3240 is 60% of $5400), the parents are responsible for the other 40% = $2160. The insurance company in this case would 'refund'  the midwife $3240, but the parents are expected to pay $2160. Or, at least, that is what the insurance company believes... because it agreed to pay 60% of the total fees charged.

The parents expect that $3240 is coming back to them. But in order to keep it kosher with the insurance company - the parent's refund is only $1440. ($3600-2160 = $1440)

It just gets confusing - and I saw very few midwives actually come clean with their clients and actually inform them of how much their insurance was billed. So parents believe that the midwife is holding on to their money (again, a rightful assumption!). And the midwife has to figure out a way to not commit insurance fraud by refunding too much money to the parents because if the insurance company pays a percentage of the total fees -the client is accountable for the difference.

Yeah - I don't know how this is legal - or ethical - I just know that this is how I've seen it done. And I'm not saying it's right!

I don't believe parents should be left in the dark about these practices. Unfortunately, they too often are.

If the midwife had charged insurance $3600 - this situation would be much more straightforward. My educated hunch is that much more was actually charged to your insurance company.

Sorry. This is a headache.

[IdentityCrisisMama]

Like Krst - I would have guessed that it was probably more complicated than what the OP first thought. First, some MW's have sliding scales and/or offer a discount to clients who do not have insurance (or who are not able to bill insurance). That is probably the base price you were given, which could be looked at as a "discount" for uninsured/underinsured clients, yk? When it came time to bill, your MW could have billed insurance her full price - at least that's how I understand it. 

Yours is a different situation because you're not uninsured but you do have a super high deductible. So you're saying you paid the MW $3,600, which you thought would only meet part of your deductible. Then they billed in-network and things changed. 

I think this is a tricky situation and not one that is all that clear as to exactly who gets that money. For all I know the insurance company could get it. I think I would approach the MW and just tell her you don't understand the billing and insurance thing and ask for an itemized bill. Tell her you need to keep track of your deductible and need to have good accounting of what has been paid and etc. 

Good luck! 

[MarleneCPM]

I rarely get a client wealthy enough to have insurance, so I don't deal with it often. I Expect clients to be responsible for paying my fee directly, then I give them a receipt for services, complete w all those confusing codes. Each line of the bill itemizes services & amt paid. The last line usually says balance -0- I then add a line that says "paid in full, please reimburse client at your earliest convenience." And they usually get reimbursed. I have never sent any bill to  an ins. co. for more than what I actually billed the client! I thought that was insurance fraud. Personally. I'd just as soon barter for all my births, than fool w ins companies! "Thank God I'm a country Girl!"
 

[fayebond]

I doubt that going to the insurance company for fraud is going to help the OP.  If anything, they might end up having to return part of the money that they were already refunded.  Communicate with the midwife, and try to understand what happened with the billing, but don't expect to get any extra money.  You already got alot back all things considered, so while yes it would be great for you to get all the money that the MW was refunded, don't hold your breath, its not likely to be legal for her to do so.   My MW doesn't do this, but I would rather that she did, and get paid a little more, since our bill is 3600 too. Its perfectly legal, just not commonly known.  And we'll get back from insurance the same $1400 that the OP got the first time.  Although she should have paid you right away, it took us three months to pay our $65 class fee to the MW because no one at the office could work the credit card machine except this one person who was only in once a week and it took forever to catch them in.  Its not like these are number crunchers, ladies: the CPM degree doesn't really emphasize finance.

ditto what krst234 said.  As an accountant, I see this alot.  The hospitals do it too, only slightly backwards in that the parents aren't told the discounted price up front, they only learn about that # if the insurance doesn't cover them and IF they then fight the bill and IF they then are able to negotiate with billing.  Hospitals, though, have an accounting department: MWs might have a billing service, or just wing it.   Its just like using loopholes to avoid paying higher taxes: not fraud, but it feels underhanded to alot of people.  I see it as the way the system (of insurance, of taxes, whatever) works these days, so whatever you can do to make it work better for you, do it.  Billing services excell at loophole finding, and that's probably what is going on.