Billing- a year and three months later... (update #2)

[morningloria]

My midwife (CPM) just called to say she had an issue with our insurance. When I returned her call, she informed me that her biller had submitted the paperwork to my insurance company and they never responded.

I asked her why this was not resolved earlier, and she responded that it was submitted on time and really didn't have a very good answer as to why she hadn't called earlier- like say, before my kid started walking.

They did a pre-authorization during my pregnancy and she said the insurance company would reimburse at 80% of their out-of-network rate. My dh and I were expecting a bill from her, but I had also discussed her billing the insurance company enough so that she would get her full amount without us having to pay the co-pay- so I wasn't surprised to not have heard, I just assumed it was all set (since a year and 3 months had passed...) My dh even called the plan's administrator to make sure it would be covered.

We need to talk to the biller and our insurance company tomorrow, but this is eating away at me tonight.

So my question is- if her biller screwed up and failed to submit the information to the insurance company (which is what I assume happened, since we never rec'd any paperwork from the ins co stating a claim had been filed) do we pay out of pocket, or is it her problem?

I don't want to cheat her out of her money, but she assured me that we wouldn't be paying the entire amount out-of-pocket. And if her biller is the one who screwed up....? I don't know.

Input much appreciated.

[lorijds]

I don't know, but I wanted to address the time issue.

I used to work for a birthing center, and it wasn't unusual for paperwork for a birth to take months. With insurance companies that didn't routinely work with us, it could very well take over a year for them to figure out what to do with the bill. Sometimes it would take months and months for them to even respond to inquiries. It takes a huge amount of time and effort to slog through billing insurance companies.

We can bill federal and state insurance (Medicare, state assistance, etc) and they were over a year behind on their payments for quite some time.

So, while it totally may be on her end, I just wanted to caution you to not assume that it is an issue of her not submitting the paperwork or billing in a timely manner.

You need to call and discuss this more in depth with the midwife, and with her biller. From my personal experience--if *we* messed up, we covered the balance. So you would only be responsible for the 20% of the out of network costs. If it is an issue with your insurance, than you would be responsible for the entire amount.

I am not sure she can just bill a random amount, so that she would get her full amount and you wouldn't have to pay a co-pay. I seem to remember insurance companies would want paperwork from other companies, to see how much they reimbursed. They also would simply *tell* us how much they were going to reimburse, regardless of the costs to us. We would submit detailed paperwork showing the cost per birth for the facility fee as $1950 (really detailed, like down to what percentage goes to rent and utilities, staff salaries, what the individual items used at a birth cost, etc), and they would send back a little letter basically saying,"Well, sorry, but an average payout for a birth center is $1600. So that is what we are reimbursing you, regardless of your fees. You can accept that, or be dropped from us entirely." Blue Cross is notorious for this. So is state insurance.

[mwherbs]

it is a game played by some insurance companies they try to end up not paying, or make it cost you to get paid... and the thing is because where an insurance company is based may have different laws they can get away with things you may have thought not possible...
if she has a biller then I would guess it was sent in timely-
and this is why many mws offer a cash discount

[time4another]

I also want to address the insurance issue. I was still being "billed" for a PN test when my DD was 2&1/2 years old. This was for care with a CNM. Insurance cos are notorious for doing these things. Keep fighting. I'm sure your mw will too!!! I understand your frustration!!!

Heather

[nashvillemidwife]

Why is your midwife only now checking up on it?

[nashvillemidwife]

Originally Posted by morningloria

I asked her why this was not resolved earlier, and she responded that it was submitted on time and really didn't have a very good answer as to why she hadn't called earlier- like say, before my kid started walking.

I'm always the first to stand up for fellow midwife, but I think the issue here lies with her and why it took her so long to follow up on it. If an insurance company owed me money I wouldn't sit around for over a year without raising hell myself to find out where my paycheck was.

I had also discussed her billing the insurance company enough so that she would get her full amount without us having to pay the co-pay

That's insurance fraud!

So my question is- if her biller screwed up and failed to submit the information to the insurance company

But the midwife said the biller did submit it on time?

(which is what I assume happened, since we never rec'd any paperwork from the ins co stating a claim had been filed)

The biller very well could have submitted it and the insurance company did not respond, which seems to be what you have been told.

do we pay out of pocket, or is it her problem?

I really think the midwife dropped the ball here. She's gone this long without being paid for her work? Or did you pay out of pocket already and are waiting for a refund?

I don't want to cheat her out of her money, but she assured me that we wouldn't be paying the entire amount out-of-pocket.

I wouldn't consider holding her accountable for failure to follow-up to be cheating her out of anything.

[mwherbs]

the biller may have submitted and resubmitted and did all the things that they say to do you know ok you need to fill out this form then they lost the first info sent to them-- it may be only now that the biller has requested something that they have asked for that needs more input from the client I am not sure the mw has dropped the ball on it... I have seen this happen at the local birth center and in out of network doc's offices not just midwives --

[nashvillemidwife]

Yeah, I didn't mean to come down so hard. I've just been wrapped up in so many insurance billing issues myself lately that I just can't imagine going so long without following up. Perhaps the midwife did not thoroughly explain the situation and hopefully the OP will post again when she knows more.

[morningloria]

My dh is calling to speak with the biller today.

I will update when I know more.

My main concern is that it's just been too long. I mean, it's been so long that when I heard her voice on my machine, I assumed she was calling to remind me to have my next Pap (which she does at 3 months pp).

[Dov'sMom]

I don't know if I'd be too upset.

My DS was hospitalized in December 2006, and toward the end of January, we got an EOB from our insurance company saying that the hospital could bill us c. $500.


LAST WEEK we got a bill from the hospital. Yes, 12 months AFTER insurance processed it. I was upset, but DH says, "hey, at least we got to earn interest on the money until now!" and if you think about it, 4% on $500 is $20... and then he paid the balance by credit card on the last possible day so we won't actually pay until March -- another two months...

[morningloria]

My dh spoke with the biller and our insurance company. The biller submitted a bill to an insurance company (but not OUR insurance company) in Sept 07 (Enzo was born Oct 31 06). After the claim was denied, she resubmitted it, but only in Nov 07 (after the year was up).

When my dh called our insurance company, they said they never rec'd a bill from the midwife, and looking at the info the biller faxed over, they are right. The biller sent a bill to a general Blue Cross Boston company, but not ours.

So now over a year has gone by. I don't know why the biller didn't submit a bill before 11 months had passed, and I don't know why the midwife didn't call us when the entire claim was denied.

So I'm kind of in a quandary. Dh is going to talk to his boss and see if he can get the insurance company to accept a late billing. If they don't, is it reasonable to offer my midwife the difference of what they would have paid to an out-of-network provider?

This is a very small birth community and I am a birth professional myself (doula and L&D nurse). I don't want to step on any toes, but I don't feel that we are at fault. My husband pointed out that if this was a hospital, I wouldn't be so concerned if they billed the wrong insurance company and missed out on payment.

[homewithtwinsmama]

It is not at all unusual to have it take that long. My first birth of twins in a hospital it was 14 months before my OB was paid. My homebirth I paid out of pocket after the billing efforts were unsuccessful and my midwife told me it wasn't going to happen. I paid a couple hundred a month or less until I was done. Services were rendered. Insurance coverage is never guaranteed -I can't figure out why I am being billed an extra 5K for one daughters surgery right now and am fighting for reimbursement and you are responsible for you bill. I can't believe anyone would stiff a midwife or advise someone to do so when when she helped you have a good birth because you think it took too long to find out there was a billing error. I hope you don't plan to have other kids. Midwives do talk and word can get around and you might have trouble finding someone to take care of you in the future.

I just read that you also work in the birth community. I really wouldn't try to cheat a midwife out of her pay in that case because her biller screwed up and sent it to the wrong address. You might find your own referrals dry up. And honestly, wouldn't that just be karma righting things? I still don't understand the argument for her not deserving to be paid. Obviously if you are going to have to pay out of pocket a long easy payment plan is in order given the error, but I don't see how you justify giving her any less than she is due.

[Peppamint]

Originally Posted by morningloria

My dh spoke with the biller and our insurance company. The biller submitted a bill to an insurance company (but not OUR insurance company) in Sept 07 (Enzo was born Oct 31 06). After the claim was denied, she resubmitted it, but only in Nov 07 (after the year was up).

When my dh called our insurance company, they said they never rec'd a bill from the midwife, and looking at the info the biller faxed over, they are right. The biller sent a bill to a general Blue Cross Boston company, but not ours.

So now over a year has gone by. I don't know why the biller didn't submit a bill before 11 months had passed, and I don't know why the midwife didn't call us when the entire claim was denied.

So I'm kind of in a quandary. Dh is going to talk to his boss and see if he can get the insurance company to accept a late billing. If they don't, is it reasonable to offer my midwife the difference of what they would have paid to an out-of-network provider?

This is a very small birth community and I am a birth professional myself (doula and L&D nurse). I don't want to step on any toes, but I don't feel that we are at fault. My husband pointed out that if this was a hospital, I wouldn't be so concerned if they billed the wrong insurance company and missed out on payment.

Oh ouch... that's awkward. I had a similar instance with pg issues when I was hospitalized a week before dd1's birth and some things were not properly billed. I ended up with a $5k bill out of the blue when dd was over a year old. I didn't even know any of the bills were unpaid but suddenly started receiving stuff from a collection agency (and we've always had good credit so this was a new experience for us!).

Long story short, NO ONE would answer my questions or help and I ended up just mailing a Registered Letter to the collection agency explaining that I had dual insurance policies, 100% coverage and that I was never informed of any unpaid charges until it went to collection. I never heard anything else and it never went on our credit record.

But, like you said, this is more awkward because it's a more personal relationship than just say, the hospital. I would say at this point, what seems fair is to have you pay her the portion you expected to have to pay (deductible/copays/etc) and the rest can be worked out between her and her biller.

It just doesn't seem fair that a person who pays insurance premiums should get stuck paying for something that should have been covered by their insurance. KWIM?

[morningloria]

Originally Posted by homewithtwinsmama

I hope you don't plan to have other kids.

so very out of line. really. i didn't ask you if i should have more kids or if i should deal with this midwife again. but thanks for the judgment.

[Ginene]

If she participates with your insurance company and they deny it for timely filing then she has to write it off.

First call your insurance company with the claim information

They will need your insurance id #
Providers Name
DOS
and Charge Amount

Tell her they sent you a bill and you are calling to check the status of it. If the insurance company tells you it was denied for timely filing, tell them the provider sent you the bill. If they tell you there is no claim on file, document the person's name, time and phone number and call your dr back and tell them to submit the claim. Inform them that if your insurance company didn't state you are responsible, then they are breaking the law and you will report them.

[Dov'sMom]

Originally Posted by homewithtwinsmama

It is not at all unusual to have it take that long. My first birth of twins in a hospital it was 14 months before my OB was paid. My homebirth I paid out of pocket after the billing efforts were unsuccessful and my midwife told me it wasn't going to happen. I paid a couple hundred a month or less until I was done. Services were rendered. Insurance coverage is never guaranteed -I can't figure out why I am being billed an extra 5K for one daughters surgery right now and am fighting for reimbursement and you are responsible for you bill. I can't believe anyone would stiff a midwife or advise someone to do so when when she helped you have a good birth because you think it took too long to find out there was a billing error. I hope you don't plan to have other kids. Midwives do talk and word can get around and you might have trouble finding someone to take care of you in the future.

I just read that you also work in the birth community. I really wouldn't try to cheat a midwife out of her pay in that case because her biller screwed up and sent it to the wrong address. You might find your own referrals dry up. And honestly, wouldn't that just be karma righting things? I still don't understand the argument for her not deserving to be paid. Obviously if you are going to have to pay out of pocket a long easy payment plan is in order given the error, but I don't see how you justify giving her any less than she is due.

Oh my, you are upset about this. The argument for her not deserving to get paid? It's not that she doesn't "deserve" to get paid, it's that she's not getting paid because of her own negligence and that OP shouldn't be responsible for making up the payment the midwife/her biller was too incompetent to file for in a timely fashion. Of course, if insurance didn't work out b/c of some clause OP hadn't read properly in the contract, or because OP's DH left his job suddenly and didn't have COBRA, or any other such reason, then OP would be fully obligated to "make her whole." But when the claim is denied because the midwife, who presumably accepted responsibility for billing, just didn't bother doing it properly, then that's the midwife's fault and she bears responsibility.

Of course the OP is responsible for paying that portion that would not have been covered anyway, and if the OP feels like paying anything else she should be applauded. But to say that because this woman "helped her have a good birth" she is entitled to be paid out of pocket when because of her own fault the insurance won't cover it is going too far.

Now, you should check your records, OP -- you might well have signed something making you responsible for anything not covered by insurance. My guess is that a court wouldn't uphold that if you can demonstrate fault on the part of the midwife, but I don't really know. That's why I check doctors' contracts before I sign at my first visit and write in "unless the failure of insurance to pay is due to the provider's negligence."

[AmieV]

homewithtwins....you're way out of line. I personally think you should edit your post and apologize. You might disagree but there's absolutely NO reason to say "I hope you don't plan on having more kids." Uncalled for.

In a logical sequence, the "blame" here should go to the biller. If anyone should have to make up the difference it is her. The reason midwives pay these people is to deal with these headaches. I know from experience that claims have to be dealt with in a year, I am certain any biller worth her salt knows that as well. Yes, mistakes were made, the midwife deserves to be paid for her services, but I don't see how it is the OP's responsibility. If you want to offer to pay half or some portion of it in good faith, that is probably the most I would do.

If word got around that you didn't want to pay for the mistakes of her biller, I think there's worse rumors that could be started. As a mother and a professional, I would be FAR more appalled at a midwife spreading talk of that or telling people you didn't pay her than I would be at what actually went down. That would be really, really lame of her to do.

[Defenestrator]

I write into my financial contracts that if I'm not paid by 6 months after the bill is submitted, then the family needs to make a payment plan and pay me cash. Partly this is because I'm in a state where homebirth midwives don't have a lot of bargaining power with insurance companies.

That said, if a bill was submitted too late to be paid by me or my biller, I would never go back to the family and ask for money. I might fire the biller if I had provided info to her in a timely manner and she took a whole year to file a claim -- after all, that's my money that will take even longer to come in.

I don't think it is reasonable for you to have to pay the whole fee. Perhaps making an offering of the difference between the in-network and out-of-network rate would be a nice peace offering, but I don't think that you have to do this.

[nashvillemidwife]

To me, the fault here lies with the biller and the midwife. Yes, the biller messed up, but ultimately it is the midwife's responsibility to make sure she gets paid. I'm not suggesting the midwife get "stiffed" because insurance didn't pay, but she shouldn't make the client pay because insurance was never billed. The midwife had an agreement with the client that insurance would be billed and that didn't happen. She's the one who has reneged.

Legally, the provider is responsible for everything that is billed to insurance even when a third party is contracted to do the billing, i.e., if the biller commits insurance fraud the provider is going to be the one to suffer the consequences. I just don't understand why the midwife wasn't more on the ball with this. If insurance wasn't going to pay the claim because of a policy restriction on midwives or home birth then the client should be responsible, but in this case the client would be penalized thousands? of dollars for someone's simple negligence.

[laoxinat]

Ot

Originally Posted by Dov'sMom

DH says, "hey, at least we got to earn interest on the money until now!" and if you think about it, 4% on $500 is $20... and then he paid the balance by credit card on the last possible day so we won't actually pay until March -- another two months...

THIS is why I love nerds!!!