Insurance Frustration

[geminigirl]

So we're planning a homebirth this winter with the new baby. That means we have to go with out of network providers...and that's fine. By law, in Florida any insurance company that provides maternity benefits must cover homebirths. So we looked at that, looked at the numbers and decided we could afford our expected contribution...insurance is supposed to pay 70%, leaving us with 30% of the midwife's fees plus assorted other expenses like a birth tub if we want one.

A few weeks go, I got a number back from the midwife for our estimated contribution. That number was almost $1000 more than what 30% of the midwife's total fees would be. In other words, nearly 50% instead of 30%. So something doesn't sound right here, and I need to figure out why and where and how to correct it.

I just don't know where to start yet.

Comments

[barking-iguana.livejournal.com]

Is it "usual and customary" nonsense? They pay 70% of an unrealistically low maximum and you pay everything over the maximum, as well as 30% of the first part?

[geminigirl]

They could go with "usual and customary" but they've got no one else doing homebirth as far as I know.

From the conversation I had with the midwife, it sounds like someone misquoted my deductible in the calculations (added an extra 0 to the number) which would account for part of it. Even if we're going with usual and customary rates, the difference of $1000 doesn't sound right-a few hundred, would make sense though.

[entirelysonja.livejournal.com]

Oy. Good luck getting it straightened out!

[erinmdmd.livejournal.com]

Ugh, I'm also planning a homebirth next month and my insurance company isn't exactly homebirth friendly (though my state is). I've just been ignoring the issue because it is what it is at this point and I don't feel like arguing the issue with the insurance company right now.

[geminigirl]

Florida actually has this thing where if an insurance plan covers maternity care they have to cover homebirth...the problem however, lies in the fact that my insurance, as far as anyone can tell, has no midwives who do out of hospital births-at least not in my area. I spoke with someone this afternoon about it, and she called me back about a half an hour ago-the only midwives she could find are the ones at the practice where I had my care during my pregnancy with Naomi...Susan is a great midwife, but she doesn't do homebirths, only hospital births. So now that that seems to be established, I need to figure out how to pursue the next step-a gap exception (which means they cover the homebirth like they would an in network provider) or just to get them cover it as an out of network provider.

We've decided that we're willing to take the insurance company to court if we need to, but I'd rather not let it get there.

[3-black-cats.livejournal.com]

Could the difference be that while Florida law requires your insurance company to cover homebirth, they are covering it under a different rate due to the provider being out of network? Most insurance plans will cover, say 70% if you use an in-network provider, but will only cover at say, 50% if you use an out-of-network provider. They're still providing coverage under the law, but they force you to pay more out of pocket. And they have no obligation, as far as I know, to make sure that they have in-network providers so long as they offer out-of-network benefits (even if those benefits are suckier). Just a thought, and obviously I don't know what type of insurance coverage you have, but that's the first thing that came to mind.

The second thing that came to mind is that perhaps the amount is $1000 higher because you have a deductible which they're assuming you haven't fully met. A fairly good-to-average deductible would be $1000 (which you pay) and then you add 30% of whatever is above and beyond the deductible to figure out your total cost. The 70% co-insurance thing usually only kicks in after you've fully met your deductible.

Also, if you really want to get serious with pursuing this with your insurance company, my advice would be to get the CPT codes that your midwife will be billing with. Call the insurance company when you have those codes, and they will be able to tell you exactly what the allowable expense is. Then ask them if they're going to assess your share of the expense as an in-network service (since they have no in-network midwives who do home birth) or if you're being forced to use your out-of-network benefits.

I deal with this stuff every day at work, and would be happy to offer any help I can to help you sort this out. Good luck! :)

[geminigirl]

My out of network benefit is 70%. My deductible is $200. The midwife's entire fee is $4500. The only thing they could be doing is going with "usual and customary rates" but there's no one else available according to them who does homebirth, so there is no "usual and customary" rate-the only midwives they could refer me to who were in network were the ones in the same practice I got prenatal care with Naomi...and they only do hospital births.

So something, somewhere doesn't make sense.

[3-black-cats.livejournal.com]

Wow, you have an awesome deductible and out-of-network benefit. You're totally right, something doesn't make sense.

And, I envy your insurance coverage. But not the current hassle of trying to figure this thing out.

Unfortunately, the only way to truly know what you'll end up paying is to have the bill submitted to the insurance. And then to defy them and challenge them after the fact. Contrary to popular belief, insurance companies are NOT in the business of providing health care -- they're in the business of making money. Sad but true. Not sure what the solution is, unfortunately.

So sorry you're having this hassle!

[geminigirl]

Someone mentioned a gap exception while I was on the phone today, so I'm thinking I may pursue that. It should be eligible assuming there's no one else in network in the area.

[fairion.livejournal.com]

Wow what a lot to deal with. Good luck.

On a separate note, is there any chance you and Naomi would be willing to come down towards Clermont for a visit? I am afraid to go more than about 5 minutes from Mom's but would love to see you guys. We could do lunch or go swimming in the pool or whatever.

[geminigirl]

Absolutely, we'd be willing to come down that way. I would love to see you but wouldn't dream of asking you to come up here.

I have an appointment this afternoon but I'll get in touch with you later today.