Insurance Reimbursement

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 health care costcompany. 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

insurance formClients 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.

Coding Resources can be found here and here.

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.

Be Sociable, Share!
FacebookTwitterGoogle+Pinterest 

One response to “Insurance Reimbursement”

  1. Dads: This Is For You! | Believe Midwifery Services | Central And Northern Indiana Homebirth Midwife

    […] a plethora of additional resources are available on our private privileged page. I have also blogged about a number of insurance issues over the years, which might help you understand this aspect of home birth. Here are a few other […]

Food For Thought

Food for Thought

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has."

Sir William Osler

 

Food for Thought

"Happiness is underrated and critically important to health. Seriously! Unfortunately, many people just have no idea how to be happy."

Aviva Romm

Food for Thought

"Physicians simply do not have time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs."

Snyderman and Weil

Food for Thought #1

"They say that time changes things. But you actually have to change them yourselves."

Andy Warhol

Food for Thought

"To think is easy. To act is hard. But the hardest thing in the world is to act in accordance with your thinking."

Johann Wolfgang von Goether

Food for Thought

"Birth isn’t about avoiding one set of realities in favor of another. It’s about embracing all facets of birth--contradictory, messy, or unpleasant as some might be--as vital to the whole."

Rixa Freeze PhD

Food for Thought

"Why I appreciate being a certified nurse-midwife, as opposed to choosing another route for midwifery: I feel learning the science is vital so the art of midwifery is safe and effective."

Dr. Penny Lane, nurse-midwife

Food for Thought

"When the debate is lost, slander becomes the tool of the loser."

Socrates

Food for Thought

"To accomplish great things, we must not only act but also dream; not only plan, but also believe."

Anatole France

Food for Thought

"Science and uncertainty are inseparable companions. Beware of those who are very certain about things. There are no absolute truths in biological sciences - only hypotheses... 'We need to train medical students and residents more in the art of uncertainty and less in the spirit that everything can be known or that it even needs to be known.'"

Grimes (1986)

Food for Thought

"American physicians are rewarded for doing things to patients, not for keeping them well."

Grimes, 1986

Food for Thought

"The false idol of technology. 'Having a widget screwed into one's scalp has become an American birthright.'"

Grimes, 1986

Food for Thought

"Between 1985 and 1987, a hospital instituted a successful program to reduce its cesarean rate. The rate fell from 18% to 12%, losing the hospital $1 million in revenues - no small sum in those days."

Goer & Romano, 2012, p 37

Food for Thought

"Obstetricians are much more likely to perform a cesarean when they wrongly believe the baby weighs 4000 g or more based on sonographic estimates than when the baby actually weighs this much but the obstetrician did not suspect it."

Goer & Romaro, 2012, p 35

Food for Thought

"If you play God, you will be blamed for natural disasters."

Marsden Wagner (2006)

Food for Thought

"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you know and what you don't."

Anatole France

Food for Thought #3

"Birth is not only about making babies. Birth also is about making mothers - strong, competent, capable mothers, who trust themselves and know their inner strength."

Barbara Katz Rothman PhD (1996)

Food for Thought #4

"Believe there is always, always, always a way. When you have exhausted all possibilities, remember this: you haven't."

Thomas Edison

Food for Thought #5

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident."

Arthur Schopenhauer

Food for Thought #2

"Yet you brought me safely from my mother’s womb and led me to trust you at my mother’s breast."

Psalm 22:9