Should I file a grievance with my health insurance for midwife's bill?
February 28, 2014 9:56 AM   Subscribe

I used a midwife throughout my pregnancy but ended up with an emergency c-section. My insurance company has denied part of the claim leaving me about $3,400 poorer. I'd like to recoup as much of this as possible from my health insurance but I'm not sure the best way to go about it...

My son was born via c-section in September last year. I used a midwife (CNM) for all my prenatal care and was due to give birth in the hospital birthing center but due to complications ended up with an emergency c-section. (the midwife was present in the birth center throughout my 24 hour labor and in the operating theater for the delivery. She basically did everything BUT retrieve the baby from my uterus!)

The midwife was covered out of network with my insurance company (Empire BCBS in New York), and I paid her $5000 prior to the birth. At the time I chose the midwife her financial person told me that they usually bill the insurance company for around $8000 (including all prenatal and postnatal care and the delivery itself) so after my deductible and coinsurance I was due to get reimbursed around $4200 by the insurance company. But because of the c-section, Empire refused to pay for the delivery component of the claim and I got reimbursed only around $800. The midwife's office has resubmitted the claim twice and got denied, so told me my best bet is to file a grievance. So, my questions are:

1. Am I out of luck - is it a waste of time to even try to appeal? (with the baby napping 40 mins twice a day I don't exactly have a lot of spare time to be navigating the grievance process, but a few thousand dollars would come in useful right now!)

2. If I'm in with a shot, how should I go about filing a grievance?

I'm from the UK and have a near-zero understanding of the healthcare system here. I guess I was a bit naive in the first place and didn't ask the right questions about reimbursement, but the US birth scene scared me into going with a midwife and i could not find one in-network.
posted by hibbersk to Health & Fitness (12 answers total) 1 user marked this as a favorite
 
I don't know about 1 - but for 2:

On the back of your EOB, or in attached pages of the EOB where insurer denied the claim should be a very explicit set of instructions on how you file the grievance.

My EOBs come with 3 pages: 1 of the actual EOB, and 2 pages (double sided) of instructions, translated into a multitude languages explaining how to file an appeal. (like, seriously, 8 or 9 languages)

Out of network can be a PITA, so double check all the out of network deductibles, R&C coverages etc etc as well.

(For our kids, we paid co-pays at OB office for checkups, but didn't pre-pay delivery until child was born. Insurance might be balking at essentially being billed/paying for 2 deliveries)
posted by k5.user at 10:20 AM on February 28, 2014


Did the insurance pay for the c-section?
posted by CrazyLemonade at 10:20 AM on February 28, 2014


Let me start off by saying, I'm not familiar with the particulars of billing for OB/GYN services, but I have general billing knowledge. The first thing I would do in your shoes is collect and review all of the EOBs for claims submitted to Empire (you should be able to access these online). Look at each service/code that each provider billed, and try to isolate which service you feel was reimbursed incorrectly. Unfortunately, I doubt you will convince Empire to pay the midwife for any services that were performed by the doctor. Did the midwife receive reimbursement for her extended time at the hospital? Perhaps there's an opportunity there to bill there and get some reimbursement on that front.
posted by ThePinkSuperhero at 10:22 AM on February 28, 2014 [1 favorite]


Another question I would ask is, if you prepaid the midwife for your delivery and she did not deliver your baby, why is she keeping your money? Did you sign anything with that practice that said the money you prepaid was non-refundable, that they would keep it whether or not your baby was actually delivered by the midwife?
posted by ThePinkSuperhero at 10:26 AM on February 28, 2014 [8 favorites]


My personal opinion is it's never a waste of time to file a grievance.

Yes, most likely the insurance company will deny your grievance just as they denied the first claim. That's what they do. You will most likely have to follow up with a second appeal. Get them to spell out exactly what they covered and exactly what they denied. Don't pay the bill yet. Keep a record of names and dates that you spoke to people.

When my child was 9 days old I got a medical bill for $6000 related to something for my hubby. You better believe I told everyone I spoke to that I had a newborn in my arms and didn't have time to dicker around. Don't be afraid to remind people at the insurance company that you are a new mother, and that you expect them to follow up with you, rather than the other way around. But do follow up.

Once you have an explanation from the insurance company, work together with your midwives' practice, they are the pros at dealing with insurance companies, and this is what the billing people get paid for. They should help you sort it all out. You might still end up with some out-of-pocket expenses, but hopefully it will be a lower amount.

Good luck.
posted by vignettist at 10:28 AM on February 28, 2014


Don't think of it as a grievance, think of it as an appeal.

One thing you need to do is to understand the billing codes. American insurance runs on billing codes.

If the codes the midwife is submitting are the same as the codes the OB is submitting for the same procedure, then they're only going to pay one claim. If your Midwife's practice can submit the charges under DIFFERENT codes, you may get reimbursed without hassle.

Call BCBS and ask to speak to a second level billing person (or just ask for a supervisor) and ask about what codes they need to submit to have this covered.

Yes, multi-payer insurance SUCKS! But there are ways around everything.

Good luck!

Mazel-tov on your new arrival!
posted by Ruthless Bunny at 10:40 AM on February 28, 2014 [3 favorites]


the midwife was present in the birth center throughout my 24 hour labor and in the operating theater for the delivery. She basically did everything BUT retrieve the baby from my uterus!

Her presence in the operating theater sounds medically unnecessary since there was presumably a certified obstetric surgeon and medical facility, being paid to deliver the baby. That might be how your insurance thinks about it too.
posted by grouse at 10:51 AM on February 28, 2014 [3 favorites]


the US birth scene scared me into going with a midwife and i could not find one in-network.

FYI: That's hardly surprising. Most US midwives are basically independent practitioners only loosely affiliated with a hospital. That means they're usually not part of any health insurance network. This is partly because the profession of midwifery is only just now starting to become part of the broader health care system. In some states it's actually not regulated at all. I know of one state that banned midwives entirely for a year or two until the legislature and health department could institute the state's first set of laws and regulations for the profession. Prior to that, anyone who wanted to could call themselves a "midwife" and go around delivering babies. This led to quite a few deeply unfortunate outcomes which made the papers.

In short: what's going on here is partly just the sorry state of health insurance billing in general, but it's exacerbated by the unique problems associated with midwifery at the moment. I expect that that will sort itself out in the next decade or so.

posted by valkyryn at 10:51 AM on February 28, 2014


Hard to say without know a lot more detail. But to better your understanding a bit...
Surgical billing in the US uses something called the global surgical package. It means that all the typical pre-op and post-op care/follow-up are rolled into one charge for the surgical procedure. Allowances are made for atypical factors, complications, etc. But in general, one surgery with everything involved = one charge.

Maternity/delivery is handled the same way. Even a v-delivery is considered a surgical procedure for billing purposes. All the prenatal and post-partum care is often rolled together - the entire pregnancy = one charge. Of course, in cases such as yours, the surgical package has to be split apart due to the circumstances.

It sounds to me like your CNW billed for the entire package, but didn't provide a portion of the care. Ins cos. tend to use formulas to break the package apart and pay percentages of that charge based on what components were provided. My guess is that the CNW billed for a 3 components (prenatal care, delivery, post-partum care) but the reimbursement was based upon the CNM not doing the delivery. The surgeon who performed the delivery gets reimbursed for the surgical/delivery component.

I don't believe the insurance company is the problem. The problem is the CNM is billing for a delivery that was performed by another provider.

Had the CNM been in-network, it's very likely the payment would have been the same but with the caveat that they (the healthcare provider) can't bill you (the patient) for the portion of the charge they did not provide.

Before going back to your insurance company, I would ask the CNM why they are billing the full amount for the delivery package without providing all the components.
posted by thatguyjeff at 10:58 AM on February 28, 2014 [5 favorites]


Yes, I think it's been alluded to but the delivery is explicitly the part where the baby gets out of your uterus, i.e. the part that your midwife didn't do. Labor-associated charges that she did perform would be the part in question. The 'package' billing for services as mentioned above mean that if you go with an obstetrician in the US they often bill the same package amount regardless of how the delivery happens. Mine was a $10K package regardless of whether it was vaginal or C/S delivery. There are plenty of OB practices out there that include CNMs as part of their group (mine did and I saw the CNM for many of my prenatal visits as well as in the hospital during labor), that might be something to look for in the future if you require OB services again.
posted by treehorn+bunny at 11:32 AM on February 28, 2014 [3 favorites]


and was due to give birth in the hospital birthing center but due to complications ended up with an emergency c-section. (the midwife was present in the birth center throughout my 24 hour labor and in the operating theater for the delivery. She basically did everything BUT retrieve the baby from my uterus!)

What was the exact sequence of events here?
  1. You go to the hospital expecting to have the baby delivered by the midwife. The midwifes helps you through 24 hours of labor, hoping throughout that she will be able to deliver the baby. Eventually things turn, your care is transferred, and you are given an emergency c-section.
  2. Although you planned to have the baby delivered by the midwife, when you went into labor there was an emergency such that it was clear you would need the care of an OB/GYN and possibly a c-section. The midwife accompanied you to the hospital and stayed with you throughout this emergency procedure.
If it's #2, then it sounds like your midwife ultimately functioned more as a doula. Her delivery charges should be reduced, she should reimburse you some money, and she should bill the hospital under a different billing code.

If it's #1, then the question is how does the hospital and/or insurance company pay medical staff for services when care is transferred from one provider to another.
posted by alms at 8:01 PM on March 8, 2014


Thanks so much for all the replies! Only now getting chance to sift through the piles of EOBs and paperwork, the joys of having a 6 month old sick baby...

What was the exact sequence of events here?
#2 is exactly what happened. Midwife was assisting me for many hours until it became obvious that the baby wasn't coming out (posterior and face presentation, ugh). So off to theater we went.


It sounds to me like your CNW billed for the entire package, but didn't provide a portion of the care. Ins cos. tend to use formulas to break the package apart and pay percentages of that charge based on what components were provided. My guess is that the CNW billed for a 3 components (prenatal care, delivery, post-partum care) but the reimbursement was based upon the CNM not doing the delivery. The surgeon who performed the delivery gets reimbursed for the surgical/delivery component.

Yes - the insurance company paid for the c-section so clearly wasn't happy about paying for the CNM to hang out and watch.

I guess I'll go ahead and file a grievance/appeal, but I don't hold out much hope.
posted by hibbersk at 6:35 AM on March 12, 2014


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