As most of our clients are aware, Believe Midwifery Services has pulled out of the game with regards to managing insurance reimbursement. It simply brought more stress than it was worth and negatively impacted both our client relationships and our profitability. Insurance companies are increasingly dictating the care provided by clinicians as well, which directly contradicts our mission of informed consent and self-determination of what best serves each individual consumer. Believe Midwifery Services strives to keep the integrity of our work intact.
The insurance industry is a business entity in which the goal is to make a profit. They aren’t driven by altruistic beliefs. Currently, the system is a bit erratic and as a small business we simply weren’t able to ride the tides of each inconsistency. A lot seems to ride on the mood of the claims adjuster, as well as the ever-changing policies of each specific insurance company. A company might honor a claim one time and refuse payment on the next. Each company has different general rules that apply to coverage and payment, and each company offers a variety of insurance coverage policies that yet again, have their own rules and benefits. As a result, mastering the terms of each policy was nearly impossible. The inconsistencies were simply too great.
In short, there was no way to predict if an insurance company will authorize payments, and we had no ability to prepare a client for what they might expect their insurance policy to cover. Worse, verifying coverage with a specific policy didn’t always guarantee payment. Our clients even experienced having obtained an in-network exception, complete with approval number, yet later having that approval retroactively denied after all care had been provided.
Our client financial agreement attempted to prepare consumers for these unforeseen and very unfortunate circumstances, and making clear that ultimately the responsibility for any unpaid balance is the client’s, yet when insurance companies failed to follow through per the client’s expectations, it was most often the midwife that suffered the burden of a disappointed client. This almost always meant our fees went unpaid, but more importantly, far too often it also meant a soured relationship. For this reason, it has become more and more common for practitioners to require each payment up front and then provide the appropriate documentation for the client to submit to her insurance for reimbursement.
We’ve found in making this change, we have drastically increased our clinical productivity and both client and staff satisfaction. We aren’t spending time on the phone verifying policies and filling out paperwork, or arguing for reimbursement. In the best of worlds, all practitioners would be fairly and promptly reimbursed for delivering a competent service of proven effectiveness. This day hasn’t come, but even if it did, we’re not confident we would reenter that arena. Our desire is to be excellent midwives and that in itself, is no simple feat.
Understanding Procedure and Diagnostic Codes
Procedure codes are critical pieces of the insurance puzzle. All insurance carriers require these codes to process insurance claims. Procedure codes are also known as Current Procedural Terminology (CPT) Codes. They indicate the type of services performed during the session to improve function. These codes are defined and maintained by the American Medical Association.
A procedure is the main service clinicians provide, such as maternity care or well woman care and as an adjunct to that care, the midwife may provide additional services such as fetal well-being testing, hydrotherapy or one-on-one on-going assessment. This additional care is also coded for reimbursement.
The diagnostic codes for licensed healthcare providers are listed in the International Classification of Diseases-Tenth Revision-Clinical Modification code book. These codes are used by advance practice nurses or physicians when diagnosing and prescribing treatment and therapies for clients, and are correlated to the procedure code mentioned above so the claim adjustor can determine if the care provided is appropriate, and therefore reimbursable, for the diagnosis.
Basic Steps in Submitting a Claim
Clients should verify coverage by calling their insurance company and asking what deductible they are responsible for and how much is unmet for the calendar year. Are there any co-payments? Does your policy cover Certified Nurse Midwives? Does it cover maternity care? Will they provide an in-network exception? Always note the name of the insurance company representative you spoke with and if possible, get codes for any verified service.
Believe Midwifery Services will provide an invoice with the procedures performed and the appropriate diagnosis. This should be submitted to your insurance company after care has been completed. For example, if seeking maternity reimbursement, the claim should be submitted following the birth of the child even if paid in full at your first prenatal visit. It is important to file your invoice in a timely manner as this alone can be reason for denial.
Medical forms can be submitted electronically through Office Ally. This will typically increase processing success and speed of reimbursement. Those who submit electronically have fewer denials and reduced disputes.
Finally, the best time to follow-up on your insurance claims is during the middle of the week, and not close to lunch or closing time.