tricare- how do hospitals get more than the "allowed amount" - Mothering Forums

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#1 of 3 Old 04-13-2011, 11:52 AM - Thread Starter
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Ok I know there are lots of threads on tricare and homebirth I have been weeding through them for a week. I want to know how hospitals can get paid more than the "allowable rate" and it seems that midwives are only geting the measly 1500. I happened to save all my statements from when my first son was born at a cilivilan hospital with a cnm on prime. just the hospital (not prenatals or pedi for baby) charged tricare over 7000 and tricare paid over 5k of it. this was a compleatly drug free birth and i only stayed 24 hours after birth. some of the services listed were semi-private room 680$, pharmacy 130$, supplies183$, delivery room 1979$ nursery 575$ more supplies and labrotory 402$..tricare paid all of those billed amounts in other bill from an MD that I dont know (may have been th one overeseeing my MW charged 3050$ for the birth but was only allowed 1458$. so I am wondering since the tricare website says that it will pay1746.31 for vaginal hospital MD delivery with pre and postnatals how do they get away with so much more. the numbers I found were just the birth not my prenatals, screenings or u/s



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#2 of 3 Old 04-13-2011, 07:42 PM
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My understanding was that there is an allowable charge for "in-hospital birth" and a separate charge for any "out-of-hospital birth". Those charges vary by geographical area, too, so if you lived in a different area that might make the difference. When I was trying to push to get my first homebirth covered (didn't work, BTW), the person I talked to told me that they base the allowable charges off the Medicare allowable charges. Why a health service for people over 65 even has an allowable charge for birth services is beyond me. From the threads I've read on here and my personal experience, the allowable charge for home birth is no where near what midwives charge. I was told  that if I went on Standard, I'd get $993, and my midwife would be expected to write off the rest of her $3200 fee.


Tricare is so backwards as far as homebirth is concerned, though. I have no idea how any of it works.

Mom to blahblah.gifDD (5/07), diaper.gifDS1 (02/10)h20homebirth.gif and babyboy.gif DS2 (11/11)h20homebirth.gif !

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#3 of 3 Old 04-14-2011, 07:13 AM - Thread Starter
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talked to tricare and they said that it all has to do with the billing codes and of course the place in charge of those TMA does not take phone calls only letters if you have a question. the tricare webiste says the same amount for south dakota as for iowa 1500 for homebirth and 1700 for hospital Dr birth. I know that they should at least pay the 1500 since I will be on prime remote and the midwife is a CNM but I wish I could get more because we would have to pay the rest of her 3000 fee ourselves..along with the birth assistant fee and birth kit. hospital birth would be compleatly free. I think that the hospital just has creative billing codes, my midwife has a billing company do her insurance claims but I dont know if they would just settle for the 1500 or take the time to fight for more. will call tricare again to see if i can find answers.


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