The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

How To Get Insurance Reimbursement for Homebirth

even if you have an HMO or your plan doesn't cover homebirth or associated charges.
 
 

Overview - Basic Principle: Maternity Care is Expensive.  Homebirth is Less Expensive, has Better Outcomes and more Satisfied Customers

This graph shows 2003 facility charges for labor & birth.  Facility charges are JUST for the facility itself, i.e. either hospital or birth center.  The facility charges do not include:

• additional anesthesia services charge for an epidural - around $2000-$3000.
• additional newborn care charge - up to $5000 [Numerous charges, including nursery fees, pediatrician fees, medications]
• additional maternity provider charge for all births - around $3000-$5000 for the average four hours a doctor spends with you during prenatal care, the birth, and quick postpartum checks during hospitalization. [Procedure code 59400]

(In case you're unable to download this .pdf file, here are the Facility Labor & Birth Charges, U.S. 2003 By Site and Method of Delivery:  NOTE - These prices are nationwide averages.  The cost in the San Francsico Bay Area is about 3-4 times that of the least expensive areas.)

• hospital cesarean with complications - $15,519
• hospital cesarean with no complications - $11.524
• hospital vaginal birth with complications - $8,177
• hospital vaginal birth with no complications - $6,239
• birth center vaginal birth - $1,624 [facility only, not including midwife or pediatrician fees]

Remember the Basics - Basic Principle: You're Proposing to Save Them Money

Pre-Arranging Coverage - Basic Principle: The Squeaky Wheel Gets the Oil

Pre-Approval (probably best for Blue Shield or any other company that doesn't reliably cover all midwifery services): You send your insurance company a description of the services you expect to need, and they pre-approve them, so you know they'll be covered. This is probably best used with a customized description of services used with the procedure code: "59899 Unlisted procedure, maternity care and delivery".  The procedure would be something like "Comprehensive midwifery care providing all medically necessary care for mother and newborn" with a detailed list of the expected procedures.

In-network reimbursement rate for an out-of-network provider (Blue Cross calls this an out-of-network referral.)

1. Call your insurance company and ask them for the names of in-network homebirth providers in your area. You can tell them that you haven't been able to find anybody within a 15-mile radius of your home who provides the special service that you need, i.e. homebirth with a licensed provider.
2. If they have one - great, give them a call.  If they don't have one, or the provider isn't able to accept you as a client, then ask your insurance company how to go about getting in-network coverage of an out-of-network homebirth provider.  Ask them if they can make an exception about providing coverage for an out-of-network provider, which they routinely do for either medical or geographic exceptions.  A medical exception means that there is nobody in their network who provides the service you need (homebirth), and a geographic exception means that the providers in their network who provide homebirth services aren't close enough to you to be useful.
3. Follow the instructions they give you.  Here is a reasonable list of diagnoses and procedures involved in the typical cycle of care:
4. Diagnoses for moms under 35 on due date, having 1st baby

Prenatal Diagnosis:
V22.0 - Normal First Pregnancy - no complications
V22.1 - Other Normal Pregnancy (i.e. not a first baby) - no complications
V23.0 - Pregnancy with history of infertility
V23.2 - Pregnancy with history of abortion
V23.3 - Pregnancy with grand multiparity
V23.41 - Supervision of pregnancy with history of pre-term labor
V23.49 - Supervision of pregnancy with other poor obstetric history
659.53 - Elderly primigravida (over 35 on due date), antepartum only
659.63 - Elderly Multigravida (over 35 on due date), antepartum only

Labor/Birth Diagnosis:
650 - Normal Birth (under 35)
659.61 - Elderly Multigravida, delivered
659.81 w/"IHPR" - Other specified indication for care or intervention related to labor and delivery, delivered, w/"In-home Postpartum Recovery, Coverage Mandated by State Law" in Box 19

Postpartum Diagnosis:
674.84 - Other complication of puerperium w/"Recently delivered mother at home less than 48 hours after delivery" or various other complications which often arise postpartum

Newborn Diagnosis:
V29.9 - Observation and evaluation of newborns and infants for unspecified suspected condition not found or various other complications which often arise in the newborn period, especially jaundice.
 

Typical Procedures in a Cycle of Care:
Care for Mom:
99244 - New(>3yrs),comp OV/mod-60 min
99211, 99212, 99213, 99214, 99215 - Office Visits of varying lengths
99347, 99348, 99349, 99350 - Home visits of varying lengths
99354 - Prolonged Face-to-face care - 1st hour
99355 - Prolonged service in outpatient setting (each add'l half hour)
59409 - Vaginal Delivery Only
59020 - Fetal cont stress test-ea 0.5h
59025 - Fetal non-stress test.

Care for Baby:
99464 - Attendance&initial stabilization (provided by assistant)
99440 - Newborn Resuscitation (PPV,CPR) (if necessary)
99344 - Home-New-Newborn Exam-Comp-60min
99211, 99212, 99213, 99214, 99215 - Office Visits of varying lengths
99347, 99348, 99349, 99350 - Home visits of varying lengths
99354 - Prolonged Face-to-face care - 1st hour
99355 - Prolonged service in outpatient setting (each add'l half hour)

Newborn Screen (has 8 different procedure subcodes in California w/diagnosis V77.3 - Screening for phenylketonuria (PKU) - The State of California's NBS program recommends the use of diagnosis code V77.3 for the entire screening panel.) This whole panel costs $108.75, so it might not be worth the extra effort.
82776 Galactose-1-phosphate uridyl transferase - $15.40 V773
83021 Hemoglobin fractionation and quantitation; chromatography - $15.40 V773
83498 Hydroxyprogesterone, 17-d (17-OHP) - $15.40 V773
83789 Tandem mass spectrometry; quantitavie (MS/MS) - $15.40 V773
84443 Thyroid Stimulating Hormone (TSH) - $15.40 V773
82261 Biotinidase (BD) V773
83516 Immunoreactive trypsinogen (IRT) V773
36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) - Newborn Screen - fee limited by law to $7 V773

Emergency Equipment, Supplies and Services as Necessary

5. If they are not helpful, contact your employer's Human Resources Department if the insurance is through their employer.  Health insurance coverage is an employee benefit, and if you feel that it's not benefiting you in the way you need, your Human Resources staff will want to know about this - after all, they're the ones who help to shape the decision about which plan to buy next year!  Especially if your company is self insured, the HR people should be very helpful about reducing the overall expenses of maternity care.  It is helpful to point out that the insurance company (and ultimately the employer) will save $10,000 to $20,000 on a homebirth compared to a hospital birth.
6. Be sure to get a copy of your health insurance company's approval for in-network coverage of homebirth in writing.
7. If they refuse to grant an out-of-network referral, ask what their appeals process is.

Timing the Filing of the Claims

So, I hope you're motivated to spend a little bit of energy educating your insurance company about why they should reimburse more than just the basic birth fee.  One way to help them appreciate this is to submit the claims separately.  I encourage midwives to generate and submit claims separately to reinforce this concept, but if yours just gives you a single sheet of paper, you might ask her to itemize it more accurately. Here are some guidelines for her.

Generally, it helps to submit claims that total less than $1000 separately, and to wait a couple of weeks between filing claims.  However, be aware that some insurance companies require that you file claims within 120 days of the date of service, after which they may reject them based on timing alone.  So don't let the paperwork sit around until you're getting enough sleep.

Here's a simple timetable that might help to maximize reimbursement:

Initial visit and extra prenatal care - file these as soon as they occur.
The birth claim - file this as soon after the birth as possible.
Followup Postpartum Care within 48 Hours - These are the home visits to check on the MOTHER in the two days right after the birth; wait a couple of weeks to file these.
Followup Newborn Care within 48 Hours - These are the home visits to check on the BABY in the two days right after the birth; file these as soon as you get them.
Followup Postpartum Care after 2 Days - These are home and office visits from 3 days to several weeks after the birth.  Wait a couple of weeks after filing the previous set of MOTHER claims to file these.
Followup Newborn Care after 2 Days - These are home and office visits from 3 days to several weeks after the birth.  Wait a couple of weeks after filing the previous set of BABY claims to file these.
Claims for Labor Monitoring and Immediate Postpartum Care - These are the claims for all the additional time the midwife was there during labor and in the hours immediately after the birth.  Wait a couple of weeks after filing the previous set of MOTHER claims to file these.
Claims for Newborn Care - These are the claims for all the additional time the midwife was there providing care for the BABY in the hours immediately after the birth.  Wait a couple of weeks after filing the previous set of BABY claims to file these.
Prenatal Home Visit - I'll often file this last, just because it's a smaller amount and doesn't fit conveniently into the other bunches.

So, for a birth that happens on Jan. 1, you will have previously filed the claims for prenatal care, excluding the home visit. File the birth claim within a few days after the birth and then submit the other claims according to this timetable: [Note that this timetable is slightly different than that suggested for the midwife, just because it's easier for families to understand.  If you want to get fancy, you can follow the timetable suggested for the midwife.]
Jan. 15    Home visits on Days 1 and 2 for mother.  Separate claims for home visits for baby on Days 1 and 2.
Jan. 31    Home visits on Days 5 and 10 for mother.  Separate claims for home visits for baby on Days 5 and 10.
Feb. 15    Labor monitoring and immediate postpartum care for mother. Separate claims for immediate newborn care.
Feb. 28    File any remaining claims, such as prenatal home visit and assistant services.

I know it seems counterintuitive to stagger the filing of the claims, but I have found that this reduces the holds on the larger claims and actually gets everything tidied up sooner.  And it really does reduce the insurance company's misperception that everything's lumped in with the global fee.  It's also easier to file the handling of appeals when you deal with them in smaller sets of claims, where all the claims in that bunch are supported by the same reasoning.

Appeals Process Insurance Company Resists Pre-Arrangement - Basic Principle: You Have Rights to Press the Insurance Company to Accept your Proposal for Saving them Money by Planning a Homebirth

Your state may have a review process that allows patients to appeal denials of care - it's important to follow these steps, and keep copies of e-mail and regular mail correspondence, and to take notes about your telephone calls (date/time/name of rep./what was said.)  It's also important to do this promptly, as your rights might expire after 30 days.

1. Try one last time with the insurance company and tell them you plan to file a formal appeal with them and, if necessary, a formal appeal through your state agency.
2. File the formal appeal with your insurance company through whatever procedure they provide.
3. If denied, then file the formal appeal through your state agency:
• “Consumer Guide to Handling Disputes with Your Employer or Private Health Plan,” available free from the Center and Kaiser.
• A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan in California
4. Proposing a safe, less expensive alternative to hospital birth is very reasonable.  If the state agency isn't able to help you, then make a call to the office your local state representative or state senator.  They should have offices very close to you, and they should be glad to help you with something so obviously "right".

Supportive Documents

In particular, here are critiques of the flawed studies that are sometimes used by obstetricians who claim that homebirth is unsafe:

Pang Study, Washington State, 2002 (showed that unattended homebirths are less safe than attended births in the hospital)

Australian Outback Study, 1998 (showed that high-risk births taking place far from a  hospital are less safe than in a hospital)

Basic documents to support homebirth as a reasonable "treatment" for pregnancy and birth:

Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. [NOTE - CPMs are equivalent to Licensed Midwives in some states.]

California legislative finding about the appropriateness of homebirth: "The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth."

Appeals Process if they Deny Coverage After Agreeing Beforehand - Basic Principle:  Again: The Squeaky Wheel Gets the Oil

Prodding insurers? Use patient power
May 20, 2005
By: Gail Garfinkel Weiss
Can't get a health insurer to pay up? It's customers might get better results.

Enlist employers in claims fights
May 20, 2005
By: Gail Garfinkel Weiss
Insurance companies are more likely to pay you after they hear from the folks who pay them.

Claims denials: Don't take No for an answer
May 6, 2005
By: Betsy Nicoletti
Your office should be appealing denied claims, and learning from them.

There's a separate section about Appealing Denial of Insurance Claims for Homebirth Maternity Care.

Transporting

All women in true labor are considered to have an emergency medical condition, and are therefore unstable. "Labor" is defined under EMTALA as the process of "childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta."[1,5] The presence of an emergency medical condition triggers all of the obligations of EMTALA.

So if you end up transporting to a hospital that isn't a preferred hospital, the care should still be covered as a preferred hospital because of the emergency condition, i.e. active labor.

Governmental Recourse - Insurance Commissioner - Basic Principle: Get them to do the hassling

Legal Recourse - Basic Principle: Just a Little Bit of Agitating Should Get Your Reimbursement

Small Claims Court is your trump card.  Don't be afraid to use it.  It's actually quite easy.

Sample Letters

<Date>

Appeals Resolution Team
<Address>

Re:  Member ID# ???  Claim for <Midwife Name>, CPM, LM  <Dates of Service>

Dear Sirs:

This is a formal letter of appeal to the above referenced claims.  Aetna’s assessment that the prevailing costs for homebirth services in my geographical area is entirely unfounded and inaccurate.  Certified Nurse Midwives do not provide homebirth services in our area.  The appropriate providers for such services are Licensed Midwives and/or Certified Professional Midwives.

Please refer in our file to a homebirth claim for services rendered by <Midwife Name> for my baby's birth on <Date of Birth>.  We believe that the $<amount> fee assessed for my prenatal exams and birth for <Midwife Name> were more than fair for services provided.

Homebirth is a low cost safe alternative to hospital birth.  Please see the attached study by the British Medical Journal.  I am a small woman who has had three very large babies – naturally, and safely.  Had I elected to have my second and third births at the hospital, I would have been a likely Cesarean Section, episiotomy or other intervention candidate, due to the babies’ sizes and length of labors.  This would have significantly increased all of our costs by tens of thousands of dollars.  Aetna should be supporting homebirth for healthy mothers because pregnancy is a normal condition, not a medical condition.

I believe your studies regarding homebirth are flawed and cite references that are unproven and unfounded.  Should Aetna be interested in saving shareholders’ money by supporting families who chose a safer alternative to hospital interventions, I refer you to the following for a list of appropriate and widely recognized studies:

http:

We expect full and prompt reimbursement for expenses incurred by <Midwife Name>.  If this claim is denied again, we will undertake the following steps:

1) Our benefits coordinator at <Employer> has already been contacted
2)  We will file a formal complaint with the State Department of Insurance and Banking
3) We will attend your annual stockholder meeting to inform Aetna stockholders that Aetna is not interested in saving stockholders’ money by supporting lower cost healthcare options.
4) We will pursue this matter in small claims court
5) We will continue to be advocates for families under Aetna plans who elect safer lower cost alternatives to the medical model (including choice on childhood vaccinations) and we will not stop until changes are made.

Please contact us at <phone number> if you have further questions.