insurance reimbursement tooo much?! - Mothering Forums

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#1 of 13 Old 03-14-2014, 07:33 AM - Thread Starter
 
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so i have yet to see someone with this dilemma:  when we hired our midwife, her fee was $3500 ($350 non-refundable deposit, not even refunded after full insurance reimbursement) and she said she bills insurance $5000, and most client's insurance reimburses 80%, therefore getting about the original $3500 back.  during the pregnancy, she hired a billing service.  about 3 months after the birth, we started getting checks from our insurance, which total over $10,000.  we kept our $3150, and had to sign everything over that over to her (illegal to "make money" off your own birth).  this just doesn't seem right, that she billed our insurance for over double what she charged us.  there are many odd items in the explanation of benefits that are wishy washy, such as "miscellaneous diagnostic procedure" and some items of things i know did she did not do (on one pp visit, she billed a separate home visit fee for the baby as well as me, but all we did was talk.  no exam, bp check, she didnt even hold the baby). also on separate checks are duplicates of fees (home visit fee for one date pp billed on 3 separate checks),  there were bleeding complications after the birth which led me to a hospital transfer, but the only thing she did was administer pitocin, which she cannot bill for (she is a cpm).  i've just never heard of this happening and it is unsettling.  if she was ever audited i would not want to get caught up in it.  don't get me wrong, i'm so happy i got my money back and i understand that $10,000 is still farrrrrr less than an ob charges for prenatal care, birth, and postpartum care.  but still.  any insight?

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#2 of 13 Old 03-14-2014, 08:43 AM
 
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Her math has been fuzzy from the get go - 80% of $5K is $4,000, so she's getting more from the insurance then she would bill you directly.  AND she's keeping your deposit despite the fact that she has, as of that point, been paid in full and then some.  These are incredibly shady business practices.  (If I or my insurance overpays my doctor - and that's happened - they have to send the overpayment back.  They can't keep it.)

 

If insurance overpays you, you are NOT obligated to sign the overpayment straight over to the midwife.  I'm not saying you're entitled to keep the excess, but that doesn't mean the midwife automatically profits from the insurance company messing up.  The insurance might well argue that you're obligated to send the overpayment back to them.

 

It really doesn't matter what OBs would charge.  What matters is that your midwife laid out a fee structure that she's disregarding.  I'd be calling the insurance and asking to review the case - you feel they are being billed for services you did not receive, and in excess of the amounts the midwife agreed to in the first place.

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#3 of 13 Old 03-14-2014, 09:01 AM - Thread Starter
 
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i contacted the billing company, specifically for the repetitive charges, and they insist everything was billed correctly.  insurance didn't mess up, they're just reimbursing for what my policy allows and all the medical codes that were billed for.  i had a great experience throughout my pregnancy with my midwife, so so experience with the delivery itself, and this is just putting an awful taste in my mouth.  i may have to work with her in the future (with my own clients), and i don't want bad blood between us.  my postpartum period has been a looong road and i just want to be done with all this.

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#4 of 13 Old 03-15-2014, 11:09 AM
 
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http://www.mothering.com/community/t/1364408/moral-dilema

 

Here's a link to another thread where the parents had similar concerns about how the charges for their home birth with a midwife was billed to insurance.

 

It's not straightforward, and quite complicated. And since midwives charge their clients a 'down payment' or 'deposit fee' the reimbursement becomes tricky. $10,000 is the on the upper end of what I've heard insurance reimbursed for home birth.

 

The billing company usually earns a percentage of fees collected, so it is in the billing company's interest to bill as much as they can.

 

I don't really agree with this. But I know this happens. You are not the first home birth client to bring up these concerns.

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#5 of 13 Old 03-15-2014, 11:58 AM
 
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What she done is fraud and since you are aware of it and participate in checks singing, you can be considered an  accessory to fraud. You need to report this to your insurance company ASAP>

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#6 of 13 Old 03-15-2014, 11:58 AM
 
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My OB global fee was far less than $10K

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#7 of 13 Old 03-15-2014, 04:07 PM
 
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....yeah, that's fraud and she's probably doing it with every other client she has too. Definitely report her, because what she's doing is illegal.

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#8 of 13 Old 03-15-2014, 05:14 PM
 
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There are two billing services that I am aware of that work specifically with OOH midwives. (There could be more - I know of two)

 

Their objective is to "insure maximal reimbursement." for the midwife.  http://midwifesbillingservice.com/examine-our-success/

 

Often, this means billing beyond the global maternity fee.

"Newborn care, labs, non-stress tests, and complications throughout the pregnancy/birth/postpartum care can be billed separately from the global fee, as well as facility service fees."

http://larsenbilling.com/midwives/faqs/

 

I don't know that this is fraud. But often these billing arrangements are not made clear to the midwife's clients. The clients believe, for example, a midwife's fee (the TOTAL fee, because there has been no indication otherwise) is $3500. The client believes that the billing service is used to get insurance to pay for the midwife's services at an out-of-network rate. The client assumes (and why not) that the amount billed to their insurance company will be $3500. The midwife usually charges the client up front, and so the client pays this amount in advance and assumes that any payment from the insurance company will be reimbursed back to the client. (Again, why not assume this, this is a reasonable thing to assume.)

 

It gets dicey when amounts in excess of the amounts the clients stated they would be charged are reimbursed by the insurance company.

This happens because the biller DOES NOT bill the global fee, but creates an itemized billing statement which is often in excess of the stated global 'fee'. This is how they insure maximal reimbursement. Sometimes this amounts to more than double the original fee charged to the clients.

 

Is this insurance fraud? Not sure, but it is definitely not honest to the clients.

 

Worth looking into. Sorry this is happening to you. You are not alone, though, in this predicament. I think this situation has arisen many, many times with midwife clients.

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#9 of 13 Old 03-15-2014, 05:48 PM
 
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i understand that $10,000 is still farrrrrr less than an ob charges for prenatal care, birth, and postpartum care. 

My ob charges a universal fee of $4000. Did you mean to include the hospital bill in that number? My last birth in 2012 I believe they were charging around $7500 for uncomplicated vag. birth. Also all labs and US are on top of that.

 

My last homebirth was in 2008 and was probably about $4000 for everything excluding the birth kit and nb screen.

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#10 of 13 Old 03-15-2014, 05:58 PM
 
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IF the birth is at home, lab test and medical interventions are limited, what sort of facility fee one can even talk about?

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#11 of 13 Old 03-16-2014, 06:18 PM
 
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This is rather lengthy, but does a pretty good job of describing all the itemization that would go into billing insurance for a home birth. It also explains why (in the writer's opinion) the global fee is not sufficient for billing for midwifery services out-of-hospital.

 

http://www.gentlebirth.org/archives/sampleBillingScenarios.html

 

It's not that I'm advocating for this (please don't shoot the messenger!) - just want to provide information regarding how a home birth midwife's bill to insurance could tally $10K.

I think this link provides a pretty good example of how these charges could add up.

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#12 of 13 Old 03-16-2014, 06:41 PM
 
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Somehow global fee is good enough for OB. 

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#13 of 13 Old 03-16-2014, 09:25 PM
 
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This is exactly how all billing thru insurance works. The provider sets a charge for their services based on whatever. They have a contract with the insurance co for how much is reimbursed. The provider agrees to not bill the patient for the difference as a part of that contract. Foe example- Annual exams with an md around here are billed at like $250. That bill is sent to (ie) blue cross blue shield who has already agreed it will only reimburse $180. The rest gets dropped. The OB May bill only the global package for birth, but that doesn't include the lab running tests or any extra ultrasounds or if you came in for an unrelated problem (like, say, a skin lesion you needed removed from your breast) during the pregnancy. Someone commented once that the point of having insurance is like getting protection from the mob- so you don't get gouged paying the full billed price, which is NEVER the full reimbursed price by the insurance. The midwife may offer a discount to uninsured patients so it ends up only being the same cost. There are specific codes for visits where all you do is talk, no exam- you can bill by time spent. I don't think you have to worry about audits.
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