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Need help with Tricare and homebirth - Page 18

post #341 of 366
Quote:
Originally Posted by spencerrn View Post
So is there anyway to get around the "certified" requirement? Tricare says they will not pay for my CNM unless she is certified by them but if she does that then she can only charge 15% above Tricares maximum allowable which I believe is about $2000.

She doesn't want to do this because her fee is $4000.

Any advice would be greatly appreciated.
As I understand it being "certified" does not mean that she agrees to accept Tricare's rate, it just means that Tricare acknowledges that she is a licensed provider. I got my son's ped certified a couple of years ago and we were still balance-billed. That was per the letter we received from Tricare that said because they were not an "in-network" or "non-network" provider they were not bound by the rules of Tricare and we could be balance-billed after Tricare paid their max allowable charge. There is a differentiation between "non-network" and "certified," apparently. Double-check this with Tricare, get it in writing if you can (easier said than done, I know) and talk to your midwife about it. I was in the North region.
post #342 of 366
http://www.tricare.mil/tma/Provider-Cert.aspx

According to this website if you are "certified" by Tricare and charge more then 15 % over TMA then you are committing fraud. So any midwife who balance bills more then 15 % is doing something illegal.

I am wondering though because from what I undersand most midwifes bill insurance closer to the neighborhood of $7000 but only expect cash only clients to pay the $4000 then anything inurance pays over $4000 is just extra. So if Tricare would pay my midwife anything it would be better then nothing.

I was just wondering if anyone had expereince dealing with a midwife who had never gotten a Tricare payment before. My midwife is realitively new to midwifery.

Thanks for all you great input.

When I asked the utilization review person at Great Lakes. "What would you do if I needed a super specialiast and there was no one "certified"? She said, "that would be unfortunate for the patient" that's nice huh?!!
post #343 of 366
If I understand correctly, you won't be using her as a tricare authorized/certified provider - you'll be seeing her out of pocket, then getting reimbursed by tricare.... You'll have an agreement that says as much. (Mine agreement says more or less that she expects payment in full upfront, but is willing to file a claim with insurance company, which will be returned to client up to but not above the amount charged)
post #344 of 366
Quote:
Originally Posted by spencerrn View Post
http://www.tricare.mil/tma/Provider-Cert.aspx

According to this website if you are "certified" by Tricare and charge more then 15 % over TMA then you are committing fraud. So any midwife who balance bills more then 15 % is doing something illegal.

I am wondering though because from what I undersand most midwifes bill insurance closer to the neighborhood of $7000 but only expect cash only clients to pay the $4000 then anything inurance pays over $4000 is just extra. So if Tricare would pay my midwife anything it would be better then nothing.

I was just wondering if anyone had expereince dealing with a midwife who had never gotten a Tricare payment before. My midwife is realitively new to midwifery.

Thanks for all you great input.

When I asked the utilization review person at Great Lakes. "What would you do if I needed a super specialiast and there was no one "certified"? She said, "that would be unfortunate for the patient" that's nice huh?!!
I am also in the Great Lakes area and had to had surgery at Northwestern (downtown) last year with a reproductive endocrinologist. He was not in-network but was credentialed and I receieved a letter from Tricare saying that because I had chosen this provider I could be balance-billed for whatever Tricare did not cover. I don't know whether this was right or wrong but it was what they said. I was active duty so I did not get balance-billed, but that was what their letter said.

I found the Tricare office at Great Lakes to be very helpful-- if you haven't been there already give them a shot- the supervisor is a lady named Christina who is very nice and always goes out of her way to get a good answer.

BTW, this whole situation came about because Tricare has ZERO reproductive endocrinologists who are in network or non-network in the Chicago area and they were trying to make me drive 95 miles to see one in Milwaukee. So that was why I was allowed the exception.
post #345 of 366

transported

I know there was something similar in this post somewhere but cant find it...
ok so we are having a LM vs a CNM (had a CNM but she is closing her practice and leaving us before we deliver ) and we are paying 2200 out of pocket. I am so sick of dealing with insurance I dont even care anymore, but my worry is...if we get transported will we have to pay the hospital fees?

ps we are in california if that makes a difference
post #346 of 366
Tricare should pay the hospital fees just as if you had planned to go to the hospital. You may need to pre-register.
post #347 of 366
Yes, Tricare pays if you transfer.
post #348 of 366
Quote:
Originally Posted by StacyL View Post
Yes, Tricare pays if you transfer.
I called tricare and asked them about transferring. (we are also paying out of pocket) If you transfer, it is considered an "emergency" so even if you are on prime it will be covered. You can always try to transfer to your military hospital in the even of a transfer. if we go by ambulance, we transfer to civilian. if we can drive ourselves with our LMW we can go to naval
post #349 of 366

why switch to standard?

I am wondering why everyone is talking about switching to standard? Why does someone want to switch to standard when they are pregnant and want to have a midwife covered for a home birth? I realize this was probably stated somewhere else in the thread but I cant figure it out. Why standard over prime? I live on Little Rock Air Force Base and we are having a midwife. I strongly doubt we can get covered since shes a CPM and not a CNM, but I would rather go without than give birth at a hospital! One other question.. Is it seriously illegal for me to give birth with a CPM on base??? Am I honestly going to have to MOVE to have my baby? This is getting so frustrating.
post #350 of 366
Lets see if I can state this consicely. In my area, the total "allowable charge" was approx $2250.

So, had I been able to stay on prime, when I filed for reimbursement, I would have gotten a check(s) for a grand total of $2250, if I would have been able to get a referral.

Without a referral on prime, you have to use the point of service option, which I believe has a $300 deductible and 50% cost share, so going this route, my reimbursement would have been ~$975.

By switching to standard, you don't have to get a referral, and there's only a $50 deductible (if I remember correctly) and 15% (in network) to 20% co-pay, resulting in a check for ~$1800.

So, if you CAN'T get a referral, it's best to switch to standard. BUT only if you've got a CNM, because with a CPM the chances of you getting ANY reimbursement are very very slim, so there's no reason to switch.

Clear as mud, right?
post #351 of 366
Quote:
Originally Posted by mariekitt24 View Post
I am wondering why everyone is talking about switching to standard? Why does someone want to switch to standard when they are pregnant and want to have a midwife covered for a home birth? I realize this was probably stated somewhere else in the thread but I cant figure it out. Why standard over prime? I live on Little Rock Air Force Base and we are having a midwife. I strongly doubt we can get covered since shes a CPM and not a CNM, but I would rather go without than give birth at a hospital! One other question.. Is it seriously illegal for me to give birth with a CPM on base??? Am I honestly going to have to MOVE to have my baby? This is getting so frustrating.

On standard you don't need to seek a referral from your primary care physician on base for approval to deliver with a midwife or on base. You can deliver at home or in a birthing center w/o needing a bunch of referrals. If it is a CNM, Tricare will cover them in network and your copay will be $25 just like a hospital birth on standard as I understand. As far as I know, it is not in any way illegal to give birth in your home on base (unless your state has made CPM practice illegal). Overall, you have a lot more freedom on Standard than on Prime, though your cost share will depend on what services you seek during that time. If you have a MTF, you can still seek care there on an available basis (at Wright Patt, that was pretty slim for PCP, but fine for the ER, Labs, etc) and it will be covered 100% like under Prime for those services.
An additional note, those enlisted spouses can reenroll at any time in Prime, Officers spouses are locked out of prime for a full year from the date of disenrollment.
post #352 of 366
Quote:
Originally Posted by LinzluvsGJ View Post
If it is a CNM, Tricare will cover them in network and your copay will be $25 just like a hospital birth on standard as I understand.
If the CNM is in-network. I don't think that most home birth midwives are; reimbursement is too low to sustain a home birth practice with network agreements. It's my understanding that you can only go out-of-network if you are on Standard?
post #353 of 366
I think that you could do point of service on Prime, but it would cost a much larger amount of copays for all those services and higher deductible.

Here is what is typically covered under Prime: https://www.hnfs.net/bene/benefits/T...rnity+Care.htm

This is the breakdown of costs between the two coverages for maternity services: http://www.tricare.mil/FACTSHEETS/vi...eet.cfm?id=261

For participating providers:
On Standard, Non-participating provider may bill the beneficiary up to an additional 15% of TRICARE allowable charges.
Under the Point of Service Option, there is a 50% cost-share and an outpatient deductible of $300/individual and $600/family.
http://www.military.com/benefits/tri...care-options#5

Reimbursement for deliveries is approx $2,000 if I understand correctly. Some CNMs who do home deliveries accept Tricare as an insurance. The one who practices here in Albuquerque does. Others will agree to accept Tricare if you the patient pays the balance of their typical bill.

Does that help any?
post #354 of 366
Thanks everyone for your detailed inputs, you're great! Im sorry but Im still confused. Im on prime right now and when I went to the referrals office to get placed with an OB they told me I could still have the birth at home if I wanted to and just not get covered for it. From what you are saying, Im not allowed to PERIOD, covered or not, unless Im on standard? Or were you just meaning if I want to be COVERED for the home birth that I should switch? Since my midwife is NOT a CNM she shouldn't be covered anyway, as far as I know, even I did switch to standard, correct?

I dont want to go to the docter and somehow be told that Im not allowed to have the birth any place but the hospital. What do you mean by this:

"On standard you don't need to seek a referral from your primary care physician on base for approval to deliver with a midwife or on base. You can deliver at home or in a birthing center w/o needing a bunch of referrals."

Since my CPM wont be covered any way, do I still need to switch to standard so I can simply get this "approval"? Thanks!

Im adding that I did find out CPMS are legal in Arkansas, still not 100 percent sure that just because they are legal in this state that they will be legal on base.
post #355 of 366
Yes, you can still have your home birth with a CPM even though it's not covered at all. It doesn't matter if you're Standard or Prime, you won't be dealing with Tricare at all.

As far as whether you "can" have a CPM home birth, as someone mentioned, if it's illegal in your state then you're in the same boat as anyone else who wants to hire a midwife in an illegal state.
post #356 of 366
If tricare is not paying for the service, it does not concern them at all. They can't tell you what to do with your money. The only time you need to worry about referrals, prime, standard is if you are looking for them to cover it.
post #357 of 366
you can have a home birth on base. you cannot be kicked out of housing for this. i know several people who have had a home birth on base. it is just a matter of getting your mw on base to catch.
post #358 of 366
Quote:
Originally Posted by cruncydoulamama View Post
you can have a home birth on base. you cannot be kicked out of housing for this. i know several people who have had a home birth on base. it is just a matter of getting your mw on base to catch.
I think it depends on where you are because the local commander can make it against policy and I believe that some have. If it were me I would not ask permission and would not say anything- there's very little chance that they will find out.
post #359 of 366
Quote:
Originally Posted by CEG View Post
I think it depends on where you are because the local commander can make it against policy and I believe that some have. If it were me I would not ask permission and would not say anything- there's very little chance that they will find out.
true- i guess the CO could say no, but is he really going to know. besides they cant tell you not to have a friend over who happens to be a mw. lets say you go into labor while she is there...perfect timing
post #360 of 366
Goodness, I just spent the better part of the last 3 hours reading through this entire thread. Ironically enough, my specific question was not one I saw up here! I'm new to this, so be gentle with me,

Dh and I just found out we're pg (3 days ago, or I guess 4, as it's after midnight). I'm 4weeks today, which I know is HELLA early, but I've heard TriCare horror stories, and I know the fact that I am in OH wanting a home birth only adds to my challenge. So I'm giving myself a head start

I am TriCare Prime. When I transferred my enrollment to OH from CA, I was informed that all the PCMS at the MTF were full, and was referred out to a civilian. I have a civilian PCM.

Now, I DO live near (within 45 miles) of an AFB and hospital, and I'm sure it has an L&D ward, but I'm wondering, since my PCM is a civilian, if they can and are more likely to refer me for home birth? Can I bypass that whole nasty MTF battle?

Now i just need to track down a CNM in Dayton area who will do a HB AND accept TriHell.

Thanks for any input!
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