Getting HMO to Pay for Birth Center - Mothering Forums

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Old 02-18-2004, 02:59 AM - Thread Starter
 
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Our lovely new HMO doesn't have any midwives. None. And even though we have a wonderful birth center in town, the HMO said they won't pay anything for out-of-network care. (Although they have paid twice for our emergency care out-of-network.) I can pay the birth center out-of-pocket, but if something goes wrong, we end up at an out-of-network hospital.

So...

Has anyone had luck with having an HMO pay for birth center/midwives out-of-network? I mean, it would be cheaper for them for gosh sake.

TIA for any tips!

mama to DS 9 and DD 5 and
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Old 02-18-2004, 03:44 AM
 
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Hi there,

I've been going through something similar; I'm trying to get my PPO to pay for a home birth with a licensed midwife. There is an exclusion in the contract, apparently. Anyway, I would look into your state insurance laws first thing. Here in Oregon, Certified Nurse Midwives are on the list of approved women's health care providers, and I think that insurance companies are required to cover their services (I could be wrong about this). Also, your state insurance board ought to have some sort of statement of your rights posted on their web site. I bet you do have the right to appeal...not that it will necessarily do anything, but you can always try. I know that HMOs are much more difficult than PPOs about covering out-of-network stuff. It's possible that you could write a series of really well-researched appeal letters and have something happen....

I can't believe the hospital doesn't have midwives on staff! What gives?

Good luck!

Oh, if you want a copy of the appeal letter I wrote, PM me. It might not be especially helpful since it is a homebirth focused letter....
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Old 02-18-2004, 03:59 PM
 
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Ummm, sort of. When I had my DS, I had an HMO. After doing some digging and research I found out that the midwives billed all their fees for prenatal care through the back-up doctor who *was* in network. Therefore, all professional fees were covered and I only had to pay about $1500 in facility fees for the birth itself because the facility was not "in network." I fought and fought that but they couldn't do anything for me. But fortunately, the back-up hospital was also in network, that really sucks that yours isn't.

I heavily argued the "cheaper for them" angle but they countered that they would be opening themselves up for liability if they paid for me to birth at a facility that had not been credentialled.

They have since changed my plan to a PPO but in this pregnancy I have medicaid for pregnancy and they pay anything my insurance doesn't.

Tamara
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Old 02-18-2004, 04:01 PM
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Old 02-18-2004, 07:56 PM - Thread Starter
 
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Thanks for your good ideas, Hera & curlygrrl. Meanwhile, I think I've found midwives hidden at both our network hospitals, maybe only during daytime hours, though. They certainly don't advertise it & they don't even want to tell you the truth if you ask! Good grief, what a hassle. But worth it.

mama to DS 9 and DD 5 and
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Old 02-21-2004, 12:24 AM
 
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Some birthcenters are accredited; perhaps you can find a birth center that is.

Also, some of our clients have been able to get insurance to reimburse us by saying that they do not provide the option of a maternity out-patient clinic, as opposed to the inpatient hospital setting.

Some insurance companies have reimbursed us after we have sent them our stats as well as the breakdown of prices.
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Old 02-22-2004, 04:41 AM - Thread Starter
 
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this is useful info, thanks! my b/c of choice is accredited, no problem there, just not a network provider. i'm assuming clients got their care approved beforehand rather than after the birth... i'm going to get to work on the insurance company. the "outpatient" vs. "inpatient" thing sounds like a good place to start. thanks!

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