TriCare does cover homebirth for Prime and Extra/Standard with a TriCare Authorized Provider - Mothering Forums

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Old 06-16-2009, 06:12 PM - Thread Starter
 
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I just got confirmation that TC does cover homebirths with a TC authorized provider. To find out if your provider is authorized by TC, you can go to the TC website and look them up or you can call your TC office and give them your provider's name.

I called the TriCare (TC) North Region office today, Tuesday, June 16, 2009, to ask about homebirth coverage. I spoke to a woman in the management department, not just a phone rep. I was told that TC will cover a homebirth as long as it is with a TC authorized provider. As far as I know, any licensed hpc who can legally practice in your state is authorized unless there is a specific exclusion for that individual. That's where you get back to the issue of whether or not it's legal in your state for licensed CNMs and/or CPMs to attend to homebirths. If CPMs are not licensed in your state, TC will not cover a homebirth with a CPM. This applies to Prime (even ADMs) as well as Extra/Standard beneficiaries. The difference is that, if you have Prime or are an ADM and don't get pre-authorization, you will have higher out of pocket expenses, $300/individual or $600/family + 50% of the doc's fees. There is an annual catastrophic cap for each fiscal year, above which the beneficiary does not have to pay any more out of pocket. That's set at $3000, I believe. If your total medical expenses for any fiscal year, whether ADM, Prime or Extra/Standard, go over $3000, you will not have to pay for any medical care for the remainder of the fiscal year.

There are basically 3 types of TC authorized providers.

1) In-network participating providers

2) Out-of-network participating providers

These two types providers will file claims for you and charge you only your deductibles, copays/cost shares and possibly up to 15% above the TC allowable charge.

3) Non-participating providers

These providers will require you to pay their entire fee up front and you will have to file claims for reimbursement with TC. You will then get a reimbursement check directly from TC. They still cannot charge more than 115% total of the TC allowable charge once they accept you, a TC beneficiary, as a client/patient.

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Old 06-16-2009, 09:27 PM - Thread Starter
 
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I talked to my neighbor who is a retired Navy Corpsman who now works at the local naval hospital as a beneficiary/patient rep. His job is to help patients get the info and care they need. He is going to have his boss call me tomorrow to see if she can answer my questions about authorized providers and CPMs. I'll post any new news I get.

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Old 06-16-2009, 10:23 PM
 
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I have one Tricare Standard Handbook that says:

Quote:
While certified nurse midwives can be authorized TRICARE Standard providers of care, “lay” midwives (midwives who are not registered nurses) are not authorized under TRICARE Standard.
Even though that wording is not in the newest edition, I don't think that policy has changed. It doesn't have to be explicitly spelled out in the handbook to be excluded. Instead, the current handbook says:

Quote:
TRICAREauthorized providers are those who meet TRICARE’s licensing and certification requirements and have been certified by TRICARE to provide care to TRICARE beneficiaries. These include doctors, hospitals, ancillary providers (such as laboratories and radiology centers) and pharmacies. If you see a provider who is not TRICARE authorized or can never be certified, you are responsible for the full cost of care.
Unless something has changed very, very recently, midwives who are not CNMs (even if they are licensed) fall into the category of "can never be certified".

There is a group of CPMs who have dedicated hours and hours of their time and energy working to change Tricare's policy. They have talked to Tricare, have studied their policies, and sent formal petitions. They have gotten MANA involved, who has resolved to take on the mantle also. If it were already possible for us to become authorized, I think they would have run into that truth early on and not still be wasting their time flogging a dead horse.
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Old 06-16-2009, 10:25 PM - Thread Starter
 
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The quote from the current handbook didn't show up. The handbook does state that the list of exclusions is not inclusive. In other words, there may be other things not listed that are excluded.

I've been thinking about this more and I think you probably have to have a medical license in order to be an authorized provider. That really sucks. If so, I'm ready to start filing grievances.

I thought of another thing that needs to be looked into further, whether or not state law supersedes federal regulations for TC.

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Old 06-17-2009, 01:22 AM
 
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Doubtful. Tricare is not an insurance company, it is a government benefit. Insurance laws do not apply.

I don't know why you can't see my quote above. I had to redo that post twice because it kept losing the second half, but I can see it now.
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Old 06-17-2009, 10:29 AM - Thread Starter
 
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Originally Posted by nashvillemidwife View Post
Doubtful. Tricare is not an insurance company, it is a government benefit. Insurance laws do not apply.

I don't know why you can't see my quote above. I had to redo that post twice because it kept losing the second half, but I can see it now.
I can see the 2nd quote now. That confirms that they require a medical license, which CPMs do not have, to be authorized providers.

I know TC is not a private insurance company like BCBS, but they are privatized. If you have Prime and use a MTF, everything is run by the military/government. However, if you use the Prime POS or Extra/Standard it kicks to a private insurance company that is contracted to run the program. For example, Humana is the insurance company that runs the TC North Region. So, while you may not be able to get the MTFs to provide CPMs on staff, there might be a way with enough pushing to get the POS plans to cover their services. Also, I think the military, government and TC are much more likely to listen to people inside the program rather than outside. If enough ADMs and their families complain about the lack of service, they might eventually start authorizing CPMs. Of course, that may take years and we could very well be dead and gone by then.

You never did give me a link to the manual that you downloaded. Do you have one?

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Old 06-17-2009, 11:50 AM
 
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google "Tricare standard manual"
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Old 06-17-2009, 01:12 PM - Thread Starter
 
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Easy enough. Is this where you got it? TriCare Manual If so, are you looking at the operations, policy, reimbursements or systems manual?

I found that the other day but wasn't sure about it. It seems to be a manual for providers. I was looking for a manual for beneficiaries. I guess it doesn't really matter because they should both say the same thing. I found where you quoted it saying a LM can not be an authorized provider. My neighbor just called me. He said someone should be calling me in a few minutes. I'll still ask them about homebirths and CPMs and the insurance company/state law question to see if they know the answers.

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Old 06-17-2009, 03:34 PM
 
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Sorry, I searched for "Tricare Standard Handbook", not manual. I found the current edition at www.tricare.mil.

The definition of "Tricare Authorized Provider" can be found on pages 7 and 40.
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Old 06-17-2009, 06:14 PM - Thread Starter
 
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Thanks. That is exactly what I was looking for. I didn't see the statement about only covering CNMs or NPs (that's what it was, right?), but since it was in the other manual it doesn't matter. No one has called me back yet today. Maybe tomorrow.

It still remains that TC will cover a homebirth as long as it is with an authorized provider. Too bad that most authorized providers do not attend homebirths.

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Old 06-18-2009, 07:50 PM
 
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I am planning a homebirth with two CNMs (I'm in the state of Maryland). They were willing to become a non network provider or a non participating provider so that I could use the Point of Service option. They even went so far as to fill out the forms and talk to Tricare.

Then they found out about the 115% rule. They charge around $3500 for a birth, and Tricare will only authorize $1600 in this area. So obviously they are way over the 115%. Understandably, they can't accept $1600 (it wouldn't even cover their insurance fees, never mind make them a living).

Is there anyway to get around the 115% rule?

Thanks so much!
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Old 06-18-2009, 09:20 PM - Thread Starter
 
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Shannon ~ You can just give them the difference. Call it a tip for great service or something. That would still save some money. If they want, to cover themselves from you changing your mind later, you can all sign an agreement that states that you understand that they charge X amount above the 115% TC allowable charge and that you are willing to pay that. You don't have to submit that to TC. It would just be between you and your CNMs. There is a little blurb about that in the TC Manual or Handbook somewhere. I can't remember exactly where I read it now. Anyway, TC would never know unless someone told them and I would assume you have no intention of doing that.

I talked to the boss lady at my neighbor's work today. She said it sounded like I knew more than she did. She didn't even know there were different kinds of MWs. She did say she has a co-worker who has all of her children at home. She searched the database to see if there were any CPMs listed as providers, which there weren't. Duh. She said I could always file a claim and just see what happened. I can't do that, of course, because CPMs aren't licensed in this state.

After that, I talked to my neighbor again and he said he'd ask the charge nurse he seemed to know a lot more about home births in general to call me. She might know a CNM or two who would attend one. I doubt I'd switch if there was one, though. I really love my MW. She's a dear friend as well as my birthing assistant.

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Old 06-19-2009, 11:39 AM
 
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We discussed that above. You are not obligated by law to pay more than 115%, but if you want to choose a provider who will not abide by that it is your choice to pay the difference.
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Old 06-20-2009, 08:54 AM - Thread Starter
 
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I don't know if I made it clear that you can always file a claim and see what happens. Even if you hear stories from people saying that TC let CPMs through by accident before but aren't anymore, still try. The lady I spoke to didn't even seem to know there were different kind of CPMs so you could still get your claim approved. A friend of mine got her birthing center birth with CPMs in Florida reimbursed and my MW said she knows of at least one person in Texas who got her CPM care reimbursed so it does happen.

Maybe if more people submit claims and file appeals and grievances and call and let the TC people know this is something we want, they'll look into again. (My MW seems to think the "TC authorized provider" thing is contingent on liability insurance rather than whether or not you have a nursing or medical license. She said at least one civilian CNM at the naval hospital here is not licensed to practice in this state all. She got some sort of federal waiver for being a federal emloyee.)

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Old 06-21-2009, 12:02 AM
 
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I know two people who got the same Texas CPM covered about 4 years ago. Since then, Tricare has realized their mistake and no longer covers that midwife.
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Old 06-21-2009, 09:37 AM - Thread Starter
 
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Originally Posted by Plummeting View Post
I know two people who got the same Texas CPM covered about 4 years ago. Since then, Tricare has realized their mistake and no longer covers that midwife.
My friend in Florida got her birth with CPMs covered maybe a year ago. That's why I think it's worth it to at least file a claim and see what happens. Maybe they aren't supposed to allow it but if some reps still let them go through then let's take advantage of that.

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Old 06-21-2009, 12:11 PM
 
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Originally Posted by MarineWife View Post
My friend in Florida got her birth with CPMs covered maybe a year ago. That's why I think it's worth it to at least file a claim and see what happens. Maybe they aren't supposed to allow it but if some reps still let them go through then let's take advantage of that.
I know of a few ladies that got reimbursed for their CPM homebirth. I knew TC wouldn't cover the homebirth we were planning with DS because my midwife wasn't licensed in the state of NC. I will submit a claim this time, though.

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Old 06-21-2009, 01:08 PM - Thread Starter
 
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I knew TC wouldn't cover the homebirth we were planning with DS because my midwife wasn't licensed in the state of NC. I will submit a claim this time, though.
Yea, that's my issue now. I can't file a claim because my state won't license CPMs. Everyone I talk to seems shocked that I pay her entire fee myself. First, it's not that much in the big scheme of things. Secondly, it's more important for me to have the birth I want than to save a few bucks. I know I'm lucky that I can afford it but she is always willing to work with people who can't afford her entire fee.

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Old 06-21-2009, 01:48 PM
 
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My friend in Florida got her birth with CPMs covered maybe a year ago. That's why I think it's worth it to at least file a claim and see what happens. Maybe they aren't supposed to allow it but if some reps still let them go through then let's take advantage of that.
Oh, I agree with you. I was just saying that if they covered someone before and now they don't, it's because they noticed what was happening. This midwife NEVER gets covered anymore. I think when they make these kinds of mistakes, maybe they keep a list or something, so they at least know not to cover those particular midwives anymore. Maybe???
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Old 06-21-2009, 01:59 PM - Thread Starter
 
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Each TC office is regional and there are at least 3 regions. I don't think the different regions necessarily share info since they are run by different insurance companies when it comes to the POS and Extra/Standard options. What one or two TC reps do in their office in Galveston, TX, for example, is not necessarily practiced by all TC reps even in the same region, much less different states or parts of the country. If they are targeted one particular MW, maybe they had some specific/personal issue with that provider. I don't know. It would be nice to get an answer to that but I think that's the type of thing that the TC reps either don't know or are told not to divulge. :

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Old 06-21-2009, 03:47 PM
 
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Originally Posted by shannon_na_gig View Post
Then they found out about the 115% rule. They charge around $3500 for a birth, and Tricare will only authorize $1600 in this area. So obviously they are way over the 115%. Understandably, they can't accept $1600 (it wouldn't even cover their insurance fees, never mind make them a living).

Is there anyway to get around the 115% rule?
They will pay $1600 for the actual birth. You can ask your MWs to bill for each visit as well, and tricare will pay them the standard fee for that. My CNM in NY got $1400 for the actual birth and $300ish for each visit.
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Old 07-14-2009, 10:48 AM
 
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I think my case was pretty unusual, but in Kansas (the CGSC school), Tricare had an authorized CNM to do homebirths; they had no MTF, so all births were turfed, and she was amazingly a Prime provider. Her prenatal visits were paid in full, I think about $240 per visit, and even though we had to transfer at the last hour for mec and a vacuum extract (double nucal and a true knot getting squeezed at the end), she billed for and got paid by Tricare about $1800. The midwife and I were happily surprised by this; we had expected me to have to compensate her as she didn't think they'd allow it since we transferred. If she'd have delivered me at home, I think she said they'd pay her $2400, which is less than she charges out in town, but she was military rooted, so she liked to care for military.

The hospital asked for something outrageous, like $6500 for my hour of monitoring/delivery/recovery and 17 hrs of waiting to be discharged. They got about $1200 if I remember correctly, maybe less. Out of pocket expenses were $0 for me.

This time around, it looks like there is no way I can get a homebirth paid for since I'm now in Norfolk with an MTF and no CNMs to deliver. I'm almost depressed enough by it to consider not trying to get pregnant, but I've talked to a great doula, so I'm looking at my birth center/hospital options via Tricare Standard.
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Old 07-14-2009, 11:20 AM - Thread Starter
 
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I think the only unusual thing about your situation is that you found a CNM who attended homebirths. CNMs are authorized TriCare providers so you can have one as a Prime provider and your PCP whether you are having a homebirth or not. Kansas must be one of the states that allows CNMs to work autonomously.

In Norfolk, VA, it is legal for a CPM to attend a homebirth. So, the issue then would be whether or not TriCare will cover it. It seems from I've been reading most recently on these threads that TriCare is becoming more strict about that, not paying or reimbursing for a CPM. However, it's certainly worth a try to file a claim and see what happens as long as you can afford a CPMs full fee if you don't get reimbursed. One of the wonderful things about CPMs who attend homebirths is that they usually have payment plans and some even have sliding fee scales and/or are willing to work with families who can't afford their full fee.

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Old 07-15-2009, 06:17 AM
 
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Does anyone have any experience with the "authorized provider" part of the equation?

Tricare doesn't cover any midwives (homebirth or hospital-based) in our area. But we've found a CNM we love who does homebirths- my new-military-wife understanding is that to get her covered at out-of-network rates, I'll need to get her authorized by Tricare. Is this an involved process? Do providers get turned down a lot?

I feel so clueless!

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Old 07-15-2009, 09:41 AM - Thread Starter
 
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If she is a licensed CNM, she is an authorize provider unless TriCare has something in particular against her. There is a difference between an authorized provider, an in-network provider and a preferred provider. You will save money by using in-network and preferred providers because they have agreed to accept the TriCare allowable charge as their full payment and won't charge you an extra 15%. An authorized provider does not have to be in-network or a preferred provider and my charge you up to 15% above the TC allowable fee.

Whether or not you have Prime or Standard could affect how the situation is treated. If you have Prime and can't get a Nonavailability Statement (NAS), you can use the point-of-service (POS) option without a referral but it will cost you more. I think the deductible is $300 and then there's a 50% cost share plus the possible 15% above the TC allowable charge if the provider has not agreed to accept the TC allowable charge as his/her full fee.

With Standard, you can go to any licensed health care provider type that is authorized by TC without a referral. As long as the treatments and/or procedures are covered, TC will cover it. There is a $150 deductible and then a copay, which is usually an 80/20 split. Again, if you go to an out-of-network provider, you may be charged up to 15% above the TC allowable charge in addition to your deductible and copay. So, that will cost you, too, but not as much as using the POS option with Prime.

Some out-of-network docs will still file claims for you but some won't. If they don't, you will most likely have to pay their full fee up front and then file a claim with TC and wait to get reimbursed. That's when you have to pay close attention to how much you have paid to make sure you don't get charged more than 15% above the TC allowable charge. It's probably a good idea to discuss that with the health care provider before receiving any services to make sure they are aware of that. Charging you more is considered fraud.

As an example, I see an OB/GYN who is not a listed provider with TC. He is a licensed medical professional. I have Standard. I go to him without a referral and everything is covered. They file the claims for me and then send me a bill for the remainder. So far, my largest bill from him has been about $13. When I needed some lab work done I wanted to use the MTF lab because it's free. All they had to do was contact my ob/gyn and get an order for the tests. They took care of the rest as far as making sure he was an authorized provider. Again, all that means is that the person is a licensed medical professional.

You can always call your TC office and ask about CNMs in general and the particular CNM that you know. She does not have to become an in-network or preferred provider in order to be an authorized provider if she's not willing to accept the TC allowable charge as her full fee. I hope all of that makes sense. It can be very confusing, especially when the people at the TC office don't even know what half of it means. If you do call, ask to speak to a supervisor.

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Old 07-15-2009, 11:11 AM
 
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You are not legally obligated to pay her more than 15% above their allowable amount, but she's also not legally obligated to accept you as a patient if their rate is not acceptable to her. In that case you have the option to pay the difference yourself out-of-pocket.
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Old 07-15-2009, 05:19 PM
 
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You are not legally obligated to pay her more than 15% above their allowable amount, but she's also not legally obligated to accept you as a patient if their rate is not acceptable to her. In that case you have the option to pay the difference yourself out-of-pocket.
I am trying to find a solution that will feel comfortable to my CNMs as they want to do this all legally (meaning that we can't charge Tricare a certain fee, and then I pay the midwives under the table for the rest). My CNMs were all set to fill out the out of network provider paperwork and then they found out about the 15% rule. Since they charge way above 115% of what Tricare will pay for a birth, they are unwilling to do the Tricare paperwork.

I respect & understand their decision, but I'm still trying to find a way to get some $$ back. If I could find something in writing from Tricare that states I can waive the 15% rule, my CNMs will probably be willing to sign up.

I've seen previous posts that state the patient can waive the 15% on army or air force sites, but I was wondering if anyone has found this specifically written in a manual or Tricare site? That would be a HUGE help to me!

Thank you
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Old 07-15-2009, 08:11 PM - Thread Starter
 
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Originally Posted by shannon_na_gig View Post
I am trying to find a solution that will feel comfortable to my CNMs as they want to do this all legally (meaning that we can't charge Tricare a certain fee, and then I pay the midwives under the table for the rest).
it's only fraud and, therefore, illegal if you are not informed of and do not agree to pay the additional amount above the 115%. if you agree to pay them more, that's perfectly legal. if it makes everyone more comfortable, you can call it a gift or a tip for excellent service. i bought my mw a gift above and beyond her fees. that's not necessary, though, because the are not doing anything illegal if they inform you and you agree. put it all in writing and have everyone sign it and have it notarized so everyone is legally covered.

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Old 07-15-2009, 11:18 PM
 
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I know that tricare only covers a small percentage of what midwifes charge for the actual "homebirth". But this got me thinking. Instead of charging a "lump sum" why couldn't they charge for each prenatal visit just like an OB does?? And then of course the allowable amount for the actual homebirth?

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Old 07-15-2009, 11:53 PM
 
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That's actually a different procedure code with a different allowable amount.

Where are OBs charging for each prenatal visit? That's a no-no in the insurance industry, regardless of what letters are printed after your name.
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