Out-of-network midwife less than deductible - still bill insurance?

January 28, 2013 9:51 AM

My chosen midwife is out-of-network for my insurance company. She also costs less than the deductible for out-of-network providers. Should I still bill my insurance company?

(I don't know a whole lot about how insurance billing works and wouldn't know where to start, really, in my search terms. I'm sorry if this is an obvious question.)

My midwife will cost less than the deductible for out-of-network providers. My insurance would then cover a percentage after I hit the deductible.

We are lucky in that we can afford to pay the midwife's fee ourselves.

There are Out of Pocket Maximums, though. Should we still bill the insurance company (even though we'll have to pay ourselves) so that the midwife's fees get added to this Out of Pocket Maximum?

Related question: Is the Out of Network deductible something that adds up? Say I had to go to another out-of-network provider for something other than maternity care. Would that cost and the midwife's fee add together so I'd someday meet the deductible?

posted by jillithd to health & fitness (5 answers total)

Seems like a no-brainer. You want to hit that out of pocket maximum ASAP so that insurance dollar will kick in that much sooner, if needed, for other eligible expenses you might have.
posted by stupidsexyFlanders at 9:54 AM on January 28 [4 favorites]

I assume you're in the States? I agree that it's a no-brainer. Either way, you are paying that money out of pocket. Birthing and the first year of a child's life are quite expensive, so you want the insurance to start picking up costs as soon as possible.
posted by stowaway at 10:02 AM on January 28 [1 favorite]

Yes, bill them, so that if you need more medical care later in the year you will hit your maximum sooner and more of that care will be covered by insurance.
posted by tylerkaraszewski at 10:02 AM on January 28 [1 favorite]

Absolutely. You want every dollar you spend on health care to count towards your deductible.

But know that the mere fact that you haven't met your deductible yet doesn't mean that being out-of-network is without any extra cost. Any time you submit a claim to your health insurance company, they "adjust," i.e., deal with, the claim. This means a few things, some of which you don't care about, but two of which you do.

First, if you submit the claim to your insurance, they'll see if they've negotiated any discounts with the provider. If the provider is in-network, this means you could wind up paying half or so of what you would have otherwise paid. This is of benefit to you, obviously, but it's also of benefit to your insurance company, because it means you can get more health care services before hitting your deductible, increasing the chances that you won't. So even if the insurance company winds up paying out zero dollars on the claim, you can still save money. Everybody but the provider wins!

Second, if you submit the claim to your insurance, they'll credit any monies you pay towards your deductible for that year. This is true whether the care is in-network or out-of-network. Obviously, the insurance company would prefer you to stay in-network were possible, because as discussed above, they save money that way in the long run. But unless you're part of an HMO, you have almost unlimited control over who provides your health care, assuming you're willing to pay for it.

Oh, and one more thing. You're not just dealing with this claim here. You're building your claims history. In the property and casualty context (i.e., homeowners and auto, etc.), this is a bad thing, because more claims almost always means more premium. But in the health insurance context, that's only true in the private market, and the majority of Americans get insurance either through their employer or through the government, and claims history is of minimal effect there. But more than that, you're establishing that you are, in fact, getting treatment for this condition. This can be relevant later when you switch to a different carrier. If they look at your application and see that you're already under care for condition [x], they're much less likely to give you grief about providing coverage for condition [x] in the future.*

So yes: submit anything and everything to your insurance carrier. You only stand to benefit.

*About pre-existing condition exclusions: those only apply if you don't already have coverage. If you're switching from one carrier to another, the insurers don't care, because it all comes out in the wash. They're both gaining and losing healthy and sick insureds all the time. All they're really worried about is people who wait until they get sick to buy insurance. The system can deal with churn between companies, but not with the moral hazard of adverse selection. These conditions are being phased out, but they're still an issue for now.
posted by valkyryn at 10:09 AM on January 28 [3 favorites]

Thank you. I'm sorry it was such an easy answer, but medical insurance and billing is really all confusing to me. I appreciate the info!
posted by jillithd at 11:49 AM on January 28