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Waiving Co-Payment

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Some Doctors Letting Patients Skip Co-Payments

Published: December 27, 2003
New York Times

For years, health plans have sought to control medical costs by negotiating fees with a group of preferred doctors and requiring patients to pay extra for going outside the network. But some doctors and clinics - eager to help hard-pressed patients or calculating that it can benefit their business - have begun to foil the cost-control efforts by waiving those extra charges.

The move by these providers to dispense with collecting what are known as coinsurance payments comes as employers and insurers try to discourage overuse of health care by making patients pay more costs from their own pockets. But those efforts - and the squeeze on doctors as health plans shrink payments for in-network care - are generating resistance, experts say.

Health plan members are "going out of network for surprisingly expensive medical services,'' said Tom Farley, who audits managed care plans across the country for the Towers Perrin consulting firm. That behavior suggests "some sort of tacit agreement between the provider and the patient to not bill for some of those out-of-pocket expenses,'' he said.

Dr. Michael O. Fleming, president of the American Academy of Family Physicians, said that doctors' efforts to find ways around the insurers' cost-control strategies are "a reaction to the ratcheting down of managed care fees.''

Doctors are waiving coinsurance payments for several reasons, analysts say: to recruit patients who would otherwise go to doctors on a health plan's preferred list; to help people struggling with the cost of care, and to reduce their own costs for processing insurance paperwork and dunning patients who are slow to pay.

These doctors can afford to pass up the payments because the out-of-network fees they collect from insurers often are higher than those they would collect as members of a health plan's network.

Dr. Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey, scorns collecting co-payments. "I look at it as a demeaning process,'' he said. "I tell my secretary upfront, if there's any issue, just forget it.''

While most doctors still work within managed care networks, waiving patients' payments appears to be most prevalent in the Northeast, South Florida, the West Coast and the upper Midwest - "areas that are saturated with managed care,'' Dr. Fleming said.

In 2003, more than half of workers faced co-payments of 30 percent or more of the fees charged for visits to out-of-network doctors, according to a September report by the Kaiser Family Foundation. The average out-of-pocket costs, including co-payments and other charges, for employees of large companies doubled in the last five years, to $2,126, and are expected to jump another 22 percent next year, Hewitt Associates, a benefits consulting firm, reported recently.

From the health plans' perspective, moves by providers to waive the payments are "exactly what managed care plans are supposed to protect against,'' Mr. Farley said. "The physicians can go back to practicing without constraints,'' he said, for example ordering more tests and procedures.

For out-of-network care, doctors at the Alliance Surgical Group in Morristown, N.J., ask patients to pay any deductible owed under terms of their health plan, a sum that can be as much as several thousand dollars, according to Dr. David Ward, a member of the group. But they do not press for payment if a patient cannot pay a follow-up bill for 20 percent or 30 percent coinsurance. "The deductible could be the whole bill,'' Dr. Ward said. He does general surgery and specializes in bariatric procedures for people who are obese.

Not surprisingly, patients are pleased. "I was amazed that these doctors do not come after the patient demanding the uncovered costs,'' said Lauren Dasylva, one of Dr. Ward's patients, in a statement she posted on a patient support Web site. "I think that is a testimony to why they do this surgery, I am convinced that they have a heart.''

But patients who choose an out-of-network plan run the risk of paying more than if they selected one of their health plan's preferred providers, said Randy Kammer, a vice president of Florida Blue Cross and Blue Shield. "There is no obligation for an out-of-network physician not to balance bill,'' she said, using the term for collecting charges in excess of those approved by the health plan.

Regularly waiving co-insurance payments or co-pays _ the $10 or $20 payments many plans impose for office visits - is against the rules in the government Medicare and Medicaid programs. A few states - Colorado, Georgia, Nevada, South Dakota and Texas - also prohibit the practice for patients covered by commercial insurance, according to Dennis M. Barry, a Washington lawyer who studies health care reimbursement issues.

Colorado and Georgia also forbid advertising the waivers to attract business. A handful of states have banned the waiver of co-payments and deductibles by dentists and chiropractors. And Ohio prohibits routine waivers of co-payments, but not deductibles, by physicians, pharmacists, psychologists, physical therapists, nurses and optometrists, according to a survey published last month by Mr. Barry and Lori Mihalich.

Waiving payments for indigent patients or to placate those who have complaints about their treatment "should not pose legal issues,'' however, they said.

A policy statement by the American Medical Association's Council on Ethical and Judicial Affairs says that "physicians should forgive or waive the co-payment'' if it would pose "a barrier to needed care because of financial hardship.'' The statement warns, though, that "routine forgiveness or waiver of co-payments may constitute fraud under state and federal law.''

One Hospital Gives Its Patients Free Care; If Only It Were Legal

BROWNS MILLS, N.J. -- "There should be no price tag on life." That's the motto of a little-known hospital here with a remarkable policy: It won't send a bill for care to any patient, rich or poor.

Deborah Heart and Lung Center is a throwback to an era when many hospitals saw themselves as charities. At a time when care is costly, when many hospitals are riveted on the bottom line and when millions of Americans are uninsured and struggling to find care, Deborah's free service would seem to be a godsend.

If only it were legal.

The U.S. Department of Health and Human Services says that Deborah, because it accepts Medicare without requiring patient co-payments, is in potential violation of an array of civil and criminal laws. HHS is currently trying to decide what to do about it. The hospital has asked for a waiver so it can stay as it is. If it doesn't get one and persists in defying the laws, the hospital faces the possibility of prosecution and stiff fines.

Money Trail

There is more to the story, though, than a saintly institution under the gun. The government says Deborah could get itself right with the law if only it would bill those patients who can afford to pay. But Deborah's philosophy inspires an army of volunteers who troll states up and down the East Coast for contributions. Ceasing to be free to all patients might spoil a potent fund-raising pitch that brings in millions of dollars each year, the government says.

Deborah (pronounced deBORah) was founded 78 years ago by Dora Moness Shapiro, the wife of a garment manufacturer, as a tuberculosis sanitarium for poor immigrant Jews from Manhattan's Lower East Side tenements. Yellowed ledgers in the lobby of what was once called Deborah Jewish Consumptive Relief Society bear the scrawled names of early patients and their native countries: Russia, Hungary, Poland and Austria. After the scourge of TB faded, the hospital took on another specialty, cardiac care. Although it started billing insurers -- and thus isn't really "free," the government says -- Deborah has never charged patients. The reason is a deeply ingrained part of the 161-bed hospital's philosophy: Wealth shouldn't matter when it comes to access to medical care.

The U.S. used to have a number of free hospitals, such as the City of Hope Cancer Center in Los Angeles, which didn't even have a billing department until the 1970s. But one by one, most changed or vanished. The City of Hope now bills patients, though it tries far harder to collect from the affluent than from the poor. Deborah and St. Jude Children's Research Hospital in Memphis, Tenn., founded by the actor Danny Thomas, are among only a handful left that never bill patients.

Thou Shalt Not Waive

Generous? Sure. Legal? Almost surely not, according to the HHS Inspector General's office. To accept Medicare money but waive the patient's co-payment flouts several statutes, it says.

A federal antikickback law says a provider can't give "remuneration" in exchange for getting Medicare business. And a co-payment waiver counts as remuneration. There is also a civil statute that bars giving inducements to "influence" patients.

Moreover, Medicare has no obligation to pay for hospital care if the patient is getting it free. After all, Medicare is insurance, which covers potential losses, but there is no loss to cover if the hospital is giving care away. So such a hospital risks filing a false claim, as barred by the False Claims Act, the Inspector General's office says.

**Finally, routinely waiving co-payments while other hospitals demand them may amount to an unfair competitive practice, says the Inspector General's office.

The office is trying to be flexible. "We recognize these policies are a singular vestige of their charitable origin and continuing mission," says HHS lawyer Kevin McAnaney. "We recognize that and appreciate it. But standing alone, an institution's history will not protect an improper practice from sanctions."

There are sound reasons for laws requiring some Medicare co-payments, he says; patient co-payments, even if nominal, clearly protect Medicare from being overused and misused. And if one hospital is allowed to collect Medicare but not bill patients for a co-payment, what's to stop a less-ethical provider from doing the same simply to attract business, and then performing services, perhaps excessive, that Medicare gets stuck with?

"Look," says Alwyn Cassil, a spokeswoman for the Inspector General's office, "we don't stay up nights thinking, 'How can we go after the good guys?' " Deborah appears to be in that category, in the view of many at the Inspector General's office, even though it once overbilled Medicare. When the office set up a voluntary fraud-disclosure program in 1995, Deborah quickly came forward, settled allegations of overbilling, and paid $840,000.

Don't Be Afraid

In 1996, a federal statute warned hospitals they could face substantial penalties if they routinely waive Medicare deductible and co-payment charges for outpatient care. At St. Jude, "we were all amazed that we were violating the law by giving free care," says Richard Shadyac, head of the hospitals' fund-raising arm. He sought a waiver in the form of an advisory opinion, which would give some protection from prosecution. The Inspector General "made us jump through hoops," he says, but granted one last April.

The Inspector General's office had to struggle to find a way to let St. Jude continue. "If you read the St. Jude's decision, it is not a totally legal analysis. It is a recognition that this is an old historical practice and to the extent we can honor it" the feds will, Mr. McAnaney says.

Deborah sought a waiver, too. But its case is more complicated.

This old-fashioned hospital is facing some very modern problems. One involves its corps of volunteer fund-raisers, largely women, who rattle coin canisters at street corners and malls, sponsor raffles and organize bus trips to Atlantic City. As more women work, fewer young women have time for such efforts. Volunteers' median age has risen to the mid-70s, and some ply their rounds with canes or even wheelchairs. There are 48,000 volunteers now, down from 75,000 at the peak.

In 1996, the volunteers raised $6 million, while estates of the dead brought in just slightly more. Within two years, the proportion dramatically shifted: The volunteers brought in $4 million while estates generated $11 million. (Foundations and corporations chipped in $3 million more.)

Scramble for Patients

The contributions cover Deborah's losses, which ran about $14 million last year. One reason for the losses is that fewer patients are coming in. It might seem that a free hospital would be flooded with patients, yet Deborah's in-patient count is only 58% of its beds. The hospital's remoteness, in the Pine Barrens of south-central New Jersey, appears to be a factor. Another reason is that, given the legal challenge, the hospital doesn't dare tout its free-to-patients policy in its marketing.

And above all is today's fierce competition for heart-surgery patients -- the well-insured ones, that is. There is money in open-heart surgery, so much that it now is done by 15 hospitals in New Jersey alone. Yet Deborah does 30% of the heart surgery on uninsured patients in the state, it estimates. Deborah says it sees signs that some heart doctors are referring their uninsured patients to Deborah -- which then must absorb the full, huge cost of open-heart surgery -- while sending their insured patients to other hospitals.

It is Deborah's effort to combat this that has complicated its relations with the HHS Inspector General's office. Deborah, whose surgeons are salaried, has begun allowing outside cardiologists to perform procedures on its premises. This alarms the government because unlike salaried doctors, outside doctors stand to benefit -- by getting more business -- from the hospital's policy of exempting all patients from Medicare co-payments.

There are indications it would have been possible to render an advisory opinion favoring Deborah before this issue arose, but since then the situation has been at an impasse.

Just Bill Them

Still, the Inspector General believes there is a way to allow Deborah to stay faithful to its past while poking its toe into the future. Mr. McAnaney says it is perfectly legal for a hospital like Deborah not to bill the poor: There is a provision in the law that says it is permissible to waive Medicare co-payments for patients who really can't afford to pay them. So, his suggestion is this: Start sending out bills to those who can afford the co-payments.

The problem is that this would amount to a fundamental shift in Deborah's long-standing mission and philosophy. "Who is rich and who is poor?" asks Spero Margeotes, Deborah's chief executive. "You can't turn around and say, 'Well, I am going to bill you but I am not going to bill you,"' he says. Referring to the Inspector General's office, he adds: "We have been doing this from long before they even came into existence."

He acknowledges that an additional factor -- though he says it is a much lesser one -- is that the fund-raising network might falter if Deborah began billing some patients. Some of its dedicated volunteers say they might drop out if the hospital changed its policy.

"You know what it is like to come out of a major surgery and know that you are not stuck with $50,000 in bills?" asks Richard Barney, a 62-year-old former Port Authority cop who had heart surgery at Deborah in the 1990s and is a volunteer fund-raiser. "Everyone is treated equally here, whether you can't pay or whether you can pay."

The hospital's reach, as it turns out, extends almost to the Inspector General's office. An attorney there recently attended the funeral of her grandmother in Philadelphia. Exploring her room later, the attorney was moved to find a pin showing that her grandmother had been part of Deborah's army of volunteers.

The Federal government, and several of the states, have specific laws governing financial transactions between health care providers. These laws include the Medicare Fraud and Abuse laws and the Stark I and Stark II, which apply to care paid for in whole or in part by the Federal government.

Some related articles:

WAIVING OR DISCOUNTING PATIENT COINSURANCE BY OUT-OF-NETWORK PROVIDERS: A SLIPPERY SLOPE by Sheryl Tatar Dacso, J.D., Dr.P.H. [Note that most of this article is about billing Medicare/Medicaid or about "participating providers" who have signed contracts with private insurance companies.]

In Texas, the Attorney General has made it clear that . . . Although the Opinion does not impose a mandatory obligation on the collection of co-payments and deductibles, it does suggest that telling the prospective patient that these will be waived may be interpreted as an “inducement” for the patient to use the facility. In cases cited by the Attorney General, these may be deemed an unfair trade practice or violate Texas illegal remuneration laws.

Provider Strategies for Minimizing Legal Exposure

Reducing the co-payment or deductible amount so it is based on the total payment that the provider expects to receive and not based on usual and customary charges.  [For example, if the provider’s usual and customary charge is $2000, but it expects to receive $1,200 from the payor, and the patient’s co-payment is 20%, of the fee-for such-service, the 20% could be based on the “expected payment” amount and not the usual and customary amount.]

Sunday, December 28, 2003 - Some Doctors Letting Patients Skip Co-Payments from The New York Times

Regularly waiving co-insurance payments or co-pays _ the $10 or $20 payments many plans impose for office visits - is against the rules in the government Medicare and Medicaid programs. A few states - Colorado, Georgia, Nevada, South Dakota and Texas - also prohibit the practice for patients covered by commercial insurance, according to Dennis M. Barry, a Washington lawyer who studies health care reimbursement issues.

Colorado and Georgia also forbid advertising the waivers to attract business.....

OK TO WAIVE CO-PAY? by Bette Robin, DDS, JD 8/98 - this is about in-network providers.

 The legality of requiring co-pays was recently upheld in Smilecare Dental Group v. Delta Dental Plan of California. In that case, Smilecare offered a supplemental plan (Smilecare Coverage Plus) which provided coverage for the co-payment. Delta does not recognize co-pays made by supplemental insurers as contractually valid and finds dentists who accept such payments to be in breach of contract. Smilecare’s position was that Delta’s policy violates the Sherman Anti-trust Act by restricting competition.

The court found in Delta’s favor and uttered a profound statement: “insurance creates a moral hazard because it desensitizes patients to costs and induces them to seek inordinate amounts of care; co-payments offset this hazard by forcing patients to reflect upon the cost of services and moderate their demands for treatment.” [Again, we see that the issue is about enticing patients to seek care they otherwise would not seek, which isn't an issue for midwifery care.]
. . .
Attorney General’s Decisions
In taking a contrary position, the California Attorney General, the prosecuting and enforcement arm of the State Board of Dental Examiners, has stated in a written opinion that a dentist who waived a co-payment did not violate any California laws against misrepresentation and fraud even though the patient’s dental insurance plan provided that the co-payment had to be paid. However, note that this case is from 1981, but has not been superseded by any other Attorney General’s opinion. Also, such opinions may not be controlling law on the issue when the courts have taken an opposite position.

LSU Law Center's - Medical and Public Health Law Site - Professional Courtesy By Katharine C. Rathbun, M.D., and Edward P. Richards, III, J.D.   - this is about federal programs and contracted providers

"the co-pay is meant to discourage casual trips to the physician." - not an issue for midwifery care!

"As far as the authors have determined, none of the private insurers bans waiving the entire charge for the care. You may also charge for some visits and not for others. Many pediatricians do not charge for the first follow-up visit for otitis media. This increases the likelihood that the child will be brought back for the recheck The insurance company is also getting a free visit, but at least the patient is getting the care."

DISCOUNTING OR WAIVING PATIENT CO-PAYMENTS AND DEDUCTIBLES - AN OVERVIEW PRIMER By: Scott Becker and Melissa Szabad

With regard to discounting co-payments or deductibles in the commercial payor context, a provider may choose to pursue the following options:
...
3. Another fairly safe course for a provider to take would be to reduce the copayment or deductible amount so that it is based on the total payment that the provider expects to receive from the insurer as opposed to the usual and customary charge. For example, if the provider’s usual and customary charge for a particular service is $2,000, but it expects to receive $1,200 from the insurer, and the patient is responsible for a co-payment amount equal to 20% of the fee for such service, the 20% co-payment amount may be based on the expected payment amount. Thus, the patient would only be responsible for 20% of the total expected amount (e.g. 20% of $1,400 or so).
. . .
To help reduce the risk . . . , the provider may notify the payor that a discount was provided to the patient by sending a letter to the payor and indicating on the claim form submitted to the payor that a discount was provided. Further, a provider also risks allegations of insurance fraud if it does not offer a similar discount to the payor.  [Ed.: - This may be interpreted as offering discounts of the same monetary value, i.e. waiving the payor's obligation by the same amount discounted to the patient.]
2 Certain states actually require the payor to consent to any discount provided. See e.g., OHIO REV. CODE ANN. § 4731.22(N) (Anderson 2001). A physician will not be disciplined if he or she waives patient deductibles and co-payments “[i]n compliance with the health benefit plan that expressly allows such a practice. Waiver of the deductibles or copayments shall be made only with the full knowledge and consent of the plan purchaser, payer, and third-party administrator. Documentation of the consent shall be made available to the board upon request.” OHIO REV. CODE ANN. § 4731.22(N) (Anderson 2001); See also, GA. CODE ANN. §§43-1-19.1(a) and (c)(2001). A health care provider’s license may be revoked, suspended, or otherwise sanctioned if the provider advertises “as an inducement to attract patients, the waiver of a deductible or copayment required to be made to such person under the patient’s health insurance policy or plan.” GA. CODE ANN. §§43-1-19.1(a) (2001). A provider will not be sanctioned, however, “if the waiver is authorized by the insurer or if the waiver is based on an evaluation of the individual patient and is not a regular business practice of the person providing the health care services.” GA. CODE ANN. §43-1-19.1(c) (2001).

6. A provider should consider determining an “in-network” charge. If the provider and the insurer are able to agree on an in-network charge, the provider greatly reduces its risks of allegations of insurance fraud, as well as claims asserted by the insurer for overpayments. Alternatively, a provider may charge the patient the in-network co-payment or deductible amount, inform the insurer of this practice and offer the insurer the in-network billing charge or the discount discussed in 2 or 3 indicated above. The provider should be aggressive about disclosing such practice to insurers. This option still involves some financial and legal risks.  [Ed.: It's my experience that some insurance companies pay out-of-network providers the same amounts as in-network providers, so they're already getting this discount.]

The Insurance Carriers May Not Forgive You If You Forgive Co-Payments by Peter G. Fernandez,DC

Whether you get into hot water for not collecting deductibles and co-payments depends on three factors:

1. how often you do it, and under what circumstances; 2. whether you paid your bills to make up for your loss; 3. whether the carrier thinks that an investigation could pay off (either by restitution, or by using you as an example to deter other DCs).
. . .
Forgiving co-payments eliminates the financial incentive for the patient to act as his/her own gatekeeper, resulting in overutilization. [Ed. - Once again, we see the real motivation for co-payments, which doesn't apply to midwifery care.]
. . .
I don't think the insurance will prosecute anyone collecting 80% of the patient's responsibility.

Read their section on "How Can You Protect Yourself from an Insurance Company Misunderstanding about Deductibles and Co-Pays?"

Rethinking professional courtesy - Financial, legal and ethical pressures bearing down on the once-common practice of extending free medical care to colleagues and their families. By Diane M. Gianelli, AMNews staff. March 8, 1999.

This article best captures the attitude I've seen towards these issues:

"I think it's because there's such a paranoia out in the field that the government considers everything to be criminal, that people are saying, 'I don't think it's bad, but I'm just not going to do it. ... I just don't want the government climbing down my back, claiming that I'm doing something wrong.'á"

McAnaney adds that although the OIG's purview was federal health care programs, "waivers of private insurance co-payments may raise similar issues."

GI Practice Management News - Volume IV, Issue 7, December, 2004

If the practice has no intention of pursuing the patient for the co-insurance and/or deductible, the claim is considered a “false claim” and a violation of federal law. In addition, waiving co-insurance and/or deductibles can be considered an inducement to the patient, violating anti-kickback regulations. Unless you have documentation of financial hardship and a policy for discounts that is applied for all patients with the same financial hardship regardless of insurance, you can not waive any co-pay, coinsurance, or deductible. [This sounds like Medicare policy, even though the article is clearly about out-of-network providers.  This is in contradiction to all the other sources, especially with regard to California.  I'm tempted to say the authors don't really know what they're writing about.]

Billing practices have caught eyes of HMO, state - Glenn Howatt,  Star Tribune - December 23, 2003 BILL23 - this is about clinics, not individual healthcare providers.

Co-payments are one tool that insurers use to control costs. State and federal laws prevent clinics from routinely waiving them. [Ed:. - Again, co-payments are cited as a way of keeping patients from obtaining unnecessary healthcare.]

William Mahon, president of the National Health Care Anti-Fraud Association, said that any health care institution that waives a patient's co-payment "is waiving something that is not his to waive."

"That co-payment is part of the contractual agreement between the insurer and the enrollee," he added. [This is another funny issue that gets thrown in from time to time.  I suppose it would be a nice thing to point out to your clients that they might be in violation of their health insurance contract, depending on the specific terms. But this is their legal obligation, not yours.]

Consumer-Directed Marketing: Do's and Don't's for Physician Practices - By John W. Jones, Esq. - Published October 2003

This article has a very  nice description of how to waive co-payments in a completely legal way:

• The waiver of coinsurance and deductible amounts by a physician, if the waiver is not offered as part of any advertisement or solicitation; the physician does not routinely waive coinsurance or deductible amounts; and the physician waives coinsurance and deductible amounts after determining in good faith that the individual is in financial need or failure by the physician to collect coinsurance or deductible amounts after making reasonable collection efforts.

Incentives given to individuals to promote the delivery of preventive care services as defined in the current U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services, including prenatal services or a post-natal well-baby visit, provided that the delivery of such services is not tied either directly or indirectly to the provision of other Medicare or Medicaid reimburseable services. Incentives may not include cash or instruments convertible to cash or an incentive the value of which is disproportionately large in relationship to the value of the preventive care service.

Although this article is mostly about Medicare, you can feel confident that if Medicare allows the waiver of co-payment for prenatal care and post-natal well-baby visits, then it's fine to do so for private insurance payers.

March 11, 2005 - The Gradually Changing Landscape: The New OIG Enforcement Guidance For Hospitals

B. Preventive Care Services

As discussed above, the BIA prohibits hospitals from offering beneficiaries gifts or gratuities in the form of free health services. This prohibition does not apply to a narrow set of incentives offered to promote the delivery of certain kinds of preventive services. This exception is limited to prenatal services, post-natal well-baby visits, or specific clinical services payable by Medicare or Medicaid and described in the current U.S. Preventive Services Task Force's Guide to Clinical Preventive Services. Even with regard to these types of services, hospitals offering free preventive care services of this type must take care to ensure that the arrangement is not intended to induce patients to obtain other services. If so, the hospital is at risk of violating the AKS and the BIA.

Inspector General Announces Eight New Anti-kickback Statute Safe Harbors

The new safe harbors, which protect certain arrangements from prosecution under the anti-kickback statute, address the following payment or business practices: investments in underserved areas; practitioner recruitment in underserved areas; obstetrical malpractice insurance subsidies for underserved areas; sales of physician practices to hospitals in underserved areas; investments in ambulatory surgical centers; investments in group practices; referral arrangements for specialty services; and cooperative hospital service organizations.

Anti-Kickback Safe Harbors - 42 CFR § 1001.952 from Compliance Land - This site is a legal research resource for participants in the health care industry.  . . . Compliance Land is the only website where you can search the full texts of all of the OIG's Advisory Opinions at once, for free.

The general issues of improper referrals is a tricky one for midwives.  If someone hires you to be their midwife, are you self-referring also to be the one to provide labor monitoring and additional care in the immediate postpartum period?  What about newborn care?  I think it's probably a good idea to alert your clients to these issues and offer the recommendation that they investigate their options to hire additional care providers to come provide these services.  Do I honestly think they're going to be able to find other care providers (such as pediatricians) to be on call to come to their home and wait around for the baby to be born so they can do the newborn exam?  No . . . it's a waste of healthcare provider time, it would result in substantial additional costs in terms of physician standby time and an additional home visit, and it eliminates the benefits associated with continuity of care.  But it's an easy thing to do to make sure that your clients understand that comprehensive homebirth midwifery care encompasses quite a number of different roles, and that they have the option of hiring other people to fill this roles.  That should satisfy the "unfair competition" issues.

In some bizarre way, I wonder if homebirth midwives could complain of "entrapment" by the insurance companies, which often deny them acceptance into their networks because of the lack of malpractice insurance, which they simply cannot get.

For those who do not routinely waive deductibles or co-payment because of legal concerns, there are still ways of helping your clients, e.g. if a large chunk of the claims is denied.  Then you could re-submit the claims with an explanation as to the coding scenario until you reach an agreement with the insurer re: waiving co-payment for the denied charges.

For all those extra ancillary charges that the insurer doesn't pay, most often the client isn't expected to pay either.

Those "negotiated settlements" also offer a way of legally reducing the charges and thus the required co-payment.