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Need help with Tricare and homebirth - Page 11

post #201 of 366
Quote:
Originally Posted by Abbysmom1 View Post
I spoke with my CNM's billing office and was told that Tricare Standard usually only pays $1,500 to $2,000 for a homebirth. She said that since my midwife is not contracted with Tricare, that I would have to pay the rest of the fees, which would amount to approximately $1,500. out of pocket for me. She also said that Prime doesn't pay much better, and since the midwife is not contracted, I would still have to pay out of pocket.

Has anyone else heard this? I was told somewhere else that as long as I have an "out of network waiver" that I would not have to pay, if I'm on Prime.

Right now I need to decide if this is worth fighting the battle with Tricare to get my auth on Prime, switch to Standard or have a hospital birth fully covered.

:

I think you are being told incorrectly by your MW's billing dept. I don't believe they can charge you the "difference" either on Standard or Prime. It's against the law. You need to clear that up with your Tricare supervisor ASAP.

Yes, there are several mamas here who have had their HB's covered under Prime Remote like you. CNM's are typically te only ones covered, but there have been a few people who have gotten Tricare to pay a non-CNM.
post #202 of 366
Quote:
Originally Posted by UlrikeDG View Post
As far as we can tell, we are in DEERS. She was able to see us, etc, Hubby's orders are there (she gave me the dates). Hubby is trying to talk to the lady in charge of DEERS for our base, but he wasn't able to talk to her yesterday or today. The day before yesterday, he did talk to her about something else, but we didn't realize our eligibility status was still an issue, because I hadn't talked to Tricare yet.

Further complicating things... The letter we got saying the "family members" were not eligible for Tricare due to DEERS was dated Sept 27. Today, we received letters dated Oct 24 saying that we had been covered Aug 16 - Sept 30, but that the coverage ended then. Now, this actually almost makes sense, because there *was* an issue with his orders that had to be corrected (we didn't get paid at all in October until today!), except that they told us we weren't covered at all. Both can't be true.
If you are in DEERS, then you are eligible.
post #203 of 366
Quote:
Originally Posted by StacyL View Post
I think you are being told incorrectly by your MW's billing dept. I don't believe they can charge you the "difference" either on Standard or Prime. It's against the law. You need to clear that up with your Tricare supervisor ASAP.
According to the Fact Sheet posted earlier in this thread (page 1), "Non-participating providers may bill the beneficiary up to an additional 15% of TRICARE allowable charges." (That's for STANDARD; Prime doesn't mention a cap.) That could be "the difference", but if the cap is as low as is being quoted on this thread, most midwives charge a lot more than 15% more than Tricare allows, and I doubt most of them can afford to simply accept 50% (or less!) than their usual fees.

Quote:
Originally Posted by StacyL View Post
If you are in DEERS, then you are eligible.
: Maybe everything will be straightened out when I call on Monday. :
post #204 of 366
Quote:
Originally Posted by UlrikeDG View Post
According to the Fact Sheet posted earlier in this thread (page 1), "Non-participating providers may bill the beneficiary up to an additional 15% of TRICARE allowable charges." (That's for STANDARD; Prime doesn't mention a cap.) That could be "the difference", but if the cap is as low as is being quoted on this thread, most midwives charge a lot more than 15% more than Tricare allows, and I doubt most of them can afford to simply accept 50% (or less!) than their usual fees.



: Maybe everything will be straightened out when I call on Monday. :

First of all, as far as I am aware the law is the law, and you CANNOT be charged more than 15% above the allowable reimbursement rate. Whether or not you are on Standard or Prime has no bearing, but you can verify that with a supervisor. Secondly, I highly doubt that the rate of reimbursement is very much higher at all for Prime vs. Standard - probably only a few hundred dollars at most. Generally, the Tricare rate of reimbursement runs about $1,400 - $2,000. The govt. insurance plans reimbursements are the lowest in the country, and MW's know this.

P.S. Yes, most MW's accept Tricare's rate. Obviously, the retail rate is much higher, but I don't think MW's get a lot of military business in the first place, which may be why they are willing to accept the rate.. My HB didn't cost me a dime.
post #205 of 366
This is not at all how I understand it. My midwife charges a flat rate no matter what kind of insurence you have as she is not in any network. She does bill after the birth for us but that money comes to us as she must be paid in full by week 36.
post #206 of 366
Same here. I have to have my MW paid in full by 36 weeks (this week!), as well. She'll then file the paperwork with the insurance company to have us reimbursed after the birth.
post #207 of 366
I'm glad that I found this thread. I'm new to the military and new to this board and just found I was pregnant.

I will be PCS'ing in Dec/Jan and need to start looking at my options.
post #208 of 366
I just went to my PCM's office today to ask them to resubmit my referral as "Global Maternity", so that Prime would cover it. They said they would, but were really snotty about it. The office manager acted as if putting another referral thru was a huge inconvience for her. I've been waiting for almost 4 weeks for this to go thru, so I'm getting really stressed out about it.

I don't understand why this has to be so difficult. If this referral does not work, my dh says I have to give up and see a regular ob for my care

Anyways, I just needed to vent this. Hopefully it will all work out, and I won't have to see an ob.
post #209 of 366
I called Tricare back today and was told that we *are* now enrolled in Tricare Prime Remote. I looked at the website first, which was unclear. It said we were "eligible" as of Oct 1, but not that we were "enrolled", but that we *had* been "enrolled" until Sept 30. :

It will be 10 days until we get our insurance cards. In the mean time, we are supposed to use my military ID if we need to see our PCM. That's great, except that I don't actually have a current military ID, and I'd really like to get my referral in this week, on the off chance that I actually manage to have this baby *before* my husband leaves.
post #210 of 366
Quote:
Originally Posted by StacyL View Post
I think you are being told incorrectly by your MW's billing dept. I don't believe they can charge you the "difference" either on Standard or Prime. It's against the law. You need to clear that up with your Tricare supervisor ASAP.

Yes, there are several mamas here who have had their HB's covered under Prime Remote like you. CNM's are typically te only ones covered, but there have been a few people who have gotten Tricare to pay a non-CNM.
They most certainly CAN bill you the difference, if you sign a contract. IME midwives have you sign a contract for treatment and payment, including the fees they charge with the understanding that they do not contract with the insurance company and do not accept their rates. It is perfectly legal if you agree and sign this paper. If you don't agree, and don't sign, however, they have the right to just not accept you as a patient.

Even with Global billing, Tricare pays approx. $1700 to the midwife...even here in NYC, where the fees are $5-7k for a homebirth. It's truly horrifying that they pay less than half what Medicaid reimburses the midwives.
post #211 of 366
Quote:
Originally Posted by Abbysmom1 View Post
I just went to my PCM's office today to ask them to resubmit my referral as "Global Maternity", so that Prime would cover it. They said they would, but were really snotty about it. The office manager acted as if putting another referral thru was a huge inconvience for her. I've been waiting for almost 4 weeks for this to go thru, so I'm getting really stressed out about it.

I don't understand why this has to be so difficult. If this referral does not work, my dh says I have to give up and see a regular ob for my care

Anyways, I just needed to vent this. Hopefully it will all work out, and I won't have to see an ob.

Why would you have to see an OB? Why wouldn't you just switch to Standard for your birth, if for some reason you can't get it thru Prime Remote? It still doesn't cost you anything.
post #212 of 366
Piping in about how much an out-of-network provider can charge under the law. It's not a TriCare law. It's a federal law and all care providers must abide by it. I believe, though, that what it states is that the provider can charge up to 15% above what is reasonable and customary for the service, which is not necessarily the same as what TriCare will pay. For example, say TriCare pays $1500 for homebirth with a CNM. CNMs in the area normally charge $2500, customary and reasonable. (Making up figures.) The provider can charge you the difference between what TriCare pays and 15% above the reasonable and customary charge, which would be $1375. Remember, though, that 15% is in addition to any copay or cost share that you may have. With Standard it's usually a 20/80 split. So, of the $70 that Tricare allows, they will pay 80%, or $1200. Your copay or cost share is 20%, or $300. The total that you pay for the homebrith is the $300 copay + the $1375 reasonable and customary charge, so $1675. I think the only difference between Standard and Prime in this instance might be that you don't have the copay with Prime if you get a referral, so your total cost would be $1375, but I'm not totally sure on that because I have never used Prime. That's why it's important to find out how much TriCare allows for a given service and how much the particular out-of-network provider you want to see charges. Then you can figure out exactly how much you will have to pay. You can always try to negotiate with the provider to see if they will accept the TriCare allowable charge as full payment or at least charge you a reduced fee.

I successfully fought a doctor who was charging me more than the 15% above what's reasonable and customary. TriCare actually handled it for me and got the doctor to cancel my bill.

By the way, check your manual about using civilian or out of network doctors with Prime and no referral. I read in a TriCare Prime newsletter that it can be done at any time. Your costs are just higher. A $300 deductible per person and then a copay, not sure if it's an 80/20 split.
post #213 of 366
Thanks, MarineWife! That's very helpful. It still sucks that Tricare says it pays "100%" when they really mean, "Less than half the going rate, which is ridiculously low if you compare it to a hospital birth." :

Anyway, I got my referral yesterday. I called my PCM's office fairly late yesterday morning, expecting to get an appointment Friday at the earliest, and she apologized because the earliest available appointment was yesterday at 5:15. I'd already told her I wasn't sick, I just needed a referral for my new insurance!
post #214 of 366
If they say they pay 100%, maybe you don't have to worry about the deductible and copay and just have to worry about the difference between what TriCare allows and what the provider charges plus a possible 15%.

As far as I know, all insurance companies are like that. That's why they have in-network providers. They've gotten those providers to accept whatever the insurance company will pay as the full fee even if it's less than what they would normally charge. At least with TriCare we don't have to pay monthly premiums and we can get totally free care if we choose to use the MTFs. One way to save money if you see a civilian provider is to continue to use the military labs, radiology and pharmacy.

Here's a link to the info about getting services outside the Prime network without a referral: TriCare Point of Service Option for Prime
post #215 of 366
Me again. Here's what I found in the Tricare handbook on the 15% charge. "The law says they may charge up to 15 percent more than the TRICARE Standard allowable charge." So, I was wrong. The provider cannot legally charge you more than 15% above the Tricare allowable charge, unless, maybe, you sign something that says you agree to pay more. If you discuss this with your provider, she always has the option to not accept you as a client.

Maternity Care Fact Sheet
post #216 of 366
Exactly MarineWife. With our first baby, we didn't even realize we were signing a contract that made us liable for anything Tricare did not pay; I thought it was one of those standard you-responsible-for-the-bill kind of things you sign at every Dr. Tricare tried their best to help us out of it, their lawyers pored the contract and stuff for us, but in the end they said we would have to pay her. We felt screwed by our midwife. It was a nasty situation.

With DD, we didn't have CNM options so it was clear from the start we'd be paying the whole amount ouf of pocket.

With #3 now, our midwife would not take us on if we couldn't pay more than Tricare. Luckily, there is a Tricare option here in NYC called US Family Health Plan. We thought they'd cover the full amount, but it turns out they'll pay $3059...double what Tricare will pay at least. If we couldn't pay another $2k out of pocket, I don't think she would take us at all, and she has that right.
post #217 of 366
I was just about to post that you were wrong yesterday, but I was too sick to type - morning sickness! blah

Anyway, no you absolutely cannot be charged the difference (over 15 %) unless you were dumb enough to sign a contract without reading it! But, who does that?

I also wanted to comment that the POS option is the most expensive way to go. Any supervisor will tell you that. When I switched to Standard for my HB, there was no co-pay at all for Global Maternity (now there is a $150 co-pay.) I think $150 is pretty cheap to have your HB and all prenatal care covered!
post #218 of 366
Yes, POS is the most expensive way to go. I just wanted to point that out as an option for any medical service because very few people know about it.

I don't know what Global Maternity is. I couldn't get my HB covered at all because I couldn't use a CNM so I didn't look much further into the HB coverage. I have always had TriCare Standard and always had to pay a copay after paying my $150 deductible, even for maternity. How did you not have to pay anything else?

That $150 deductible is for officers. The enlisted deductible is less, right?
post #219 of 366
Hmmm - that's a good question. I'm not sure if there's a distinction between an officer's dependents and enlisted.

Global maternity is the term for all your maternity care: prenatal visits, L&D services, and postpartum care.

I switched from Prime to Standard for my HB, and there were NO co-pays related to my maternity care. If I had made an ER visit for any reason OTHER than maternity care, there would have been a co-pay for that ($150) but even that is only a one-time co-pay. All other co-pays for any medical care UNRELATED to the maternity care would have ended when I reached the $1,000 cap, but I never had a single visit.
post #220 of 366
Ok, I'm a dingbat. Now that you mentioned that I realize that I didn't pay for visits to my ob. Total brainfart. I'm so used to paying when I go to the doc that I didn't even think about it.

So, that would mean that with TriCare Standard, you'd only pay the $150 deductible plus, possibly, 15% above the TriCare allowable charge for a homebirth or with Prime and a NAS you'd pay nothing or could you still end up having to pay the 15% above the allowable charge?

Sorry if I confused the issue even more with my original post.
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