Are home births covered by insurance companies?
There are some insurance companies which do cover homebirths, and we ask this question when we verify your benefits. There are also times when an insurance company will state that this service is not a covered benefit, but when billed for it, using the proper coding and explaining the procedure, it pays! This is why Larsen Billing Service exercises the right to bill for reimbursement on services rendered midwives, allowing the insurance company an opportunity to pay. Word of caution: if you contact your insurance company and call attention to your homebirth, they will likely red-flag your account, causing processing delays and possibly preventing your claims from being paid at all. Unfortunately, we have seen a few parents do this, so please be careful.
Having LBS call to verify your benefits for you helps to alleviate drawing attention to your account.
Verifying Benefits; can you explain this to me?
To determine if a health care service or procedure will or will not be covered by your insurance plan, a call will need to be made to your insurance company. The benefits department will be contacted by phone to verify what is covered by your plan. Obtaining this information is an important first step in the reimbursement process. Larsen Billing Service has a department dedicated to obtaining verifications of coverage for midwives and birth centers. Read more about Verification of Benefits »
What if my insurance company says they will not cover services given by my midwife?
We suggest you submit a request for coverage to the HR department of your employer. Many times, a good HR representative will go to bat on your behalf with the insurance plan, and that can make a huge difference. We have templates to assist you with this process. Read more »
When a claim denies, is that the final ruling or can we appeal?
Larsen Billing Service will automatically create and send appeals on claims we feel have denied unfairly, but there are times when you, as the member, will need to get involved as insurance companies respond more favorably to letters from their members rather than an outside billing service. If we see that we need your assistance, we are there to work with you each step of the way. We have several appeal templates for you to choose from and are happy to review your appeal letter before you submit it. Read more »
I want to have a home birth. Can you advise me on what to look for in choosing an insurance company that would cover my midwife and home births?
When determining which insurance plan to choose, you will want to look at three main factors.
- Does the plan cover your midwife’s provider type? Some plans only cover Certified Nurse Midwives (CNMs) while others cover Licensed Midwives (LMs) and Certified Professional Midwives (CPMs). Verify that your midwife’s credentials are covered by the plan.
- Does the plan have out-of-network coverage? Many midwives who we bill for are not contracted with the various insurance plans, so you’ll want to choose a plan that has out-of-network benefits (unless your midwife is contracted.)
- What is the out-of-network deductible and co-insurance? Knowing these numbers will help you have an idea of what your out-of-pocket expense might be.
How can I know if my midwife will be covered by my insurance plan?
Each insurance company has a Verifications of Benefits (VOB) department. You can contact them to find out if your midwife’s services will be a covered benefit.
Because midwives are considered a specialty practice with a majority of them being out-of-network providers, finding the right answers when calling to verify benefits can be a frustrating ordeal. Larsen Billing Service has a team of VOB specialist prepared to get the right answers to benefit questions so both the midwife and the member (you) can know what to expect. Read more (links to VOB dept.)
What is the difference between In-Network and Out-of-Network?
When a provider is contracted with an insurance company, she is said to be “in-network.” This means that she has agreed to a discounted amount for her services and cannot bill the insured beyond the amount that is allowed by the insurance company. Typically, in-network benefits have less out-of-pocket costs to the insured. If a provider has not signed a contract with an insurance company, she is considered “out-of-network.” Providers who are out-of-network can bill the insured for amounts above what the insurance company allows, as they have not agreed to a discount. Not all insurance companies contract with midwives; therefore, most midwives are considered out-of-network. Check with your midwife to be sure.
Want a Crash Course in Understanding the outcome of processed claims?
This document will help clarify a few of the basics. Read more about Understanding Your Insurance Claim on our Information Resources Page »
How much will my insurance company pay on my claims?
Unless your midwife is contracted with your plan, we cannot predict the exact amount that an insurance company will pay on a claim, but a few factors come into play:
- Allowed amount: Each insurance company pays claims according to the allowed amount they have determined for each procedure, regardless of the amount that the provider charges for the service. For example, if a provider bills the insurance company $200 for an office visit, the insurance company may only allow $150 and then apply plan benefits from there.
- Deductible: In general, before an insurance company will make a payment on a claim, the yearly deductible needs to be satisfied. If a plan has a $500 deductible, the first $500 that they allow on claims will apply to the deductible. This then becomes the insured’s responsibility. Your deductible is not met simply by you paying $500 in advance to your midwife. Your deductible is met by the first claims billed to your insurance company for that year by any provider that your plan deems payable. Therefore, if another provider has billed your insurance company before your midwife does in a calendar year, the previous provider’s claims will be applied to your deductible first. Once the deductible has been met for a calendar year, it is no longer an issue until the next calendar year. (Most plans go by calendar year, but there are a few exceptions to this.)
- Co-insurance: Co-insurance refers to the percentage of the allowed amount that the insurance company does not actually pay out but deems the patient’s portion/responsibility. For example, if a plan pays 70% of the allowed amount, then 30% would be the insured’s responsibility. If that same plan allows $150 for an office visit, and the deductible has already been met, the insurance company would pay $105 and would apply $45 to patient responsibility. That $45 would be your amount that you should pay your provider to cover your out-of-pocket portion of your care. (It is up to your midwife ultimately to decide how much of your out-of-pocket expenses to hold you responsible for.)
What do I do if the insurance reimbursement check comes to me?
Please send all insurance checks to your midwife immediately. If you are due a partial refund, depending upon how much you prepaid and how much of your claims were applied to your deductible and co-insurance, your midwife will calculate that and send you a refund check as needed. It is illegal for you to profit on your healthcare. Therefore, you are not entitled to keep any insurance monies beyond the amount you prepaid.
Furthermore, a portion of your prepayment may be non-refundable to cover services not billable to insurance. Your prepayment should also be applied to your portion of the claims (deductible, co-pay, etc). Please refer to your financial agreement with your midwife for specific details.
How quickly can I expect reimbursements from insurance companies?
Each state has different rules; however, insurance companies typically have 30 working days to process a clean claim. Verifying ones benefits at the beginning of this process sheds a lot of light on what can be expected from an insurance company and can speed up the turn-around rate.
How much will you be billing to my insurance company?
We will not know exactly how much we will be billing to the insurance company until services have been rendered, as care for each mom is given according to her specific needs. The amount that we submit for a particular service varies based on the region in which the services are performed and the preference of the provider. As a billing service, we typically send claims to insurance for the initial visit, global maternity fee, facility fees for birth centers, prolonged labor management hours, IV therapy as needed, newborn exams and screens, postpartum home visits and many other services. Please expect to see several different claims submitted to your insurance company and know that this is standard for maternity and newborn services.
If the global maternity fee includes prenatal care, delivery and postpartum care, why were additional charges submitted?
The global maternity fee includes routine OB care and delivery. Any services beyond routine care are to be submitted as separate claims in addition to the global fee, such as extra prenatal visits to address specific problems, visits that occur after the due date, prolonged time spent during labor, etc.
Why did you bill my insurance more than what I paid my midwife?
The amount that you pay your midwife is a deposit to provide cash flow to your midwife throughout your pregnancy; this amount has no bearing on what your midwife charges insurance companies for her services.
When will you be submitting claims?
We will submit claims as soon as we receive the information from your midwife. For routine pregnancies, we submit claims three times during the course of care:
- The first claim we submit is for the initial visit. We prefer to bill this visit out as soon as possible after that visit takes place.
- The second time we submit claims is after the delivery takes place. In most cases we bill global maternity care which includes routine prenatal visits, delivery, and the six-week visit. This charge is billed as one claim with the date of delivery used for the date of service. We also bill any services for mom not included in the global fee, and we bill all newborn care separately.
- The third time we submit claims is after all care for mom and baby has been wrapped up. At that time, we bill remaining postpartum visits as applicable and all remaining newborn visits.
How long does it take for the claims to show up in my insurance company’s system?
Once we receive the paperwork from the midwife, we submit claims within 3-5 business days. Whenever possible we submit claims electronically; occasionally we have to mail them. The amount of time that it takes for the insurance company to show receipt of the claims varies, depending on their system. Please allow up to 30 days for claims to show in their system.
What if I have a high deductible and most, if not all, of the claims submitted by my midwife will go towards deductible? What happens then?
Good question. In cases where high deductibles ($1500 or more) are to be met, it is not to your midwife’s advantage to submit such claims. This actually creates undue work for her billing service and will not see compensation for doing so. On the other hand, you (as the member) may want to use your maternity and delivery care claims to help bring down that high deductible. In such cases, you can ask your midwife to submit your claims and for a $100 non-refundable flat fee, Larsen Billing Service will submit the claims and follow them through until each one has processed. Both you and your midwife will receive an Explanation of Benefits on each claim showing the ruling on the submitted claims.
Is there anything I am to do when it comes to submitting a claim?
Some claims, like the global maternity fee, process pretty easily without being help up. Other claims, like prolonged labor management hours, take longer to process and sometimes require that we send in chart notes. We follow-up on all claims until we feel they have been properly processed. We fight denials over the phone that we don’t agree with, and we send appeal letters to insurance companies on behalf of our providers as applicable. We sometimes will need your help in appealing for care to your insurance company or HR department as needed. There are times when a insurance companies will put a lot more weight on an appeal from you, their insured, than from an out-of-network provider’s office. Therefore, if you are happy to assist us in getting top reimbursement for your claims, we are happy to have your help! See our sample appeal templates »
How do we know if we owe our midwife anything further or if we are possibly eligible for a partial refund?
Whether you owe your midwife more money or are due a refund depends on the amount of the deposit you paid and the details of how your claims processed. Once all claims have finalized, your midwife will be able to discuss this with you. In any case, you should never expect to get a 100% refund. Most midwives apply at least some of the deposit to services not billable to insurance (such as set-up fees, billing fees, etc.), so that means your refund will be reduced by those amounts. This refund may also be reduced by your applicable deductible and co-insurance amounts applied to your claims.