Midwife360 Turns 7!

Insurance Midwife360 Updates

On April 1st, Midwife360 will be celebrating it’s 7th year of practice. As I sit here savoring my morning cup of herbal tea, enjoying the sunshine and beautiful weather only south Florida springtime can bring, I am remembering the early days – my big ‘why’, the successes and setbacks, the various people who helped (or hurt) along the way and the current state of affairs. 

MIDWIFE360 OVER THE YEARS

I started this practice to offer something different to the women and families of my community. After working in the hospital and OB office for 8 years, I know that many women, especially the millennials, want something different when it comes to the care of their gyn health and pregnancies. And I wanted something different and better for the babies. They don’t have a voice; I am their voice and I am shouting that babies want to come into this world gently, with love and respect.

“We” started out as “I” for years, along with various students that worked with me along the way. Most notably, I was able to help Rosalia Cannava become licensed after 3 long years of apprenticeship. Mandy Rojas (currently owner of Palm Beach Maternity Center) trained with me for a bit. And then in 2018 Lauren Danella, CNM moved to Florida to begin working with me. Last February Lauren left to work with Bliss Birth Center, but came back in November when we were getting so busy. Marlie Honorat started with us in September, and will continue having 2 office days a week. In addition, the people that have helped with keeping all of the details working smoothly have been essential to our success. These include Vanessa Scoz, Sandra Alandete, Kayleigh Taylor and Bruna Possobon. 

CHALLENGE IN BIRTH SERVICES

One of the consistently biggest challenges has been dealing with insurance companies. Like any business that sells services, the key to success is being able to charge appropriately for those services and to get paid for that work. Sometimes when I’m driving around and I see a landscaping truck or construction vehicles with the company logo or even the pool guy, I am envious that those people are providing services and getting paid. The healthcare industry is unique in the world of business in that most providers (if they work with insurance) do not do the work and then get paid. I am constantly shaking my head at the system that we have inherited from the last century. 

HOW INSURANCE WORKS WITH MIDWIFES

In case you didn’t know, here’s how it works. A provider has to go through a lengthy application process to become credentialed with an insurance company. They may have to wait 60-120 days to be approved. And one can be credentialed, but not invited into the network. If they are out of network, some folks with that insurance cannot see them and use their benefits or a request can be filed to have the services covered as if the provider were in network – this is called a GAP exception or single case agreement. This usually only works if the service is something no one else is providing – like home birth with a Certified Nurse Midwife (CNM). And this can be beneficial as the provider is allowed to balance bill the client for the difference between the contracted rate and the actual charges.

That’s another eye-opener. The provider’s charges are not what the insurance company pays. For instance, my charge for self pay full journey for pregnancy care with birth at home is $7000. This covers everything, no hidden fees. The rates that have been offered to me from insurance companies vary from $2300 – $3600 for what is called Global Maternity. AND the provider may not bill for the services until after the birth. So we provide 8-9 months of regular services, but cannot get paid until well after the main event and are lucky to receive half of our normal fees. In addition, some companies require us to apply for authorizations in order to qualify to be paid for certain services – services that are part and parcel of what we do, that they cover, and are part of our contract to be compensated. 

In addition to all of this, the system for filing claims is complicated, CPT (procedure) and ICD10 (diagnosis) codes must be accurate and present, and they only accept electronic claim filing through an electronic data clearinghouse. Therefore, a provider has to turn over a percentage of the already low amount of money they receive to a third party to file the claims and appeal any denials – which happen regularly. I’ve been told that insurance companies deny a percentage of all claims in the hopes that some of them won’t get appealed. It’s all part of the game. These are some of the headaches and drawbacks for the provider when playing the insurance game.

DOWNSIDE FOR PRIVATE INSURANCE PATIENTS

From the client’s point of view it’s just as bad. People get insurance thinking that they will be covered if they get sick or, I don’t know, have a baby. They are paying a monthly premium usually $300-500 per month and are always shocked at the sticker price when we do the breakdown of what their financial responsibility is even with insurance. If they have a deductible, they must pay up to the entire amount before the insurance will cover anything. In addition, if there is co-insurance then once the deductible is met, they will have to pay their percentage of what’s left according to the contracted rate. Then there are things not covered by insurance (birth tub rental, second licensed person at the birth, supplies, home visits) and this fee is added. They are typically paying us an average of $4000 in addition to their monthly premiums. 

Through the years this system has consistently been the limiting factor for Midwife360. I went through 7 different billing scenarios (including doing my own electronic filing for about 14 months until I couldn’t keep up with the appeals process) before settling on the current company that we use. Innovation Billing (thanks guys!) And they are great – really help me feel that they care about our success. However, all of this paper chasing has taken the joy out of the work. The constant need to keep up with figuring out who needs to have an authorization and following up on them. And the length of time that payment can take if there is a denial or any problems with the claim makes it impossible to know what the actual revenue is for any specific period of time. It’s a ‘keep churning out the work, fingers crossed and hope for the best’ situation. 

MIDWIFE360 IS A CONCIERGE PRACTICE

Another consideration – we are a concierge practice. We offer hour long prenatal visits with at least one home visit during the prenatal period. The client has prenatal care with the provider that will attend the birth. We come to the home for the active labor and birth and stay 2-4 hours after, providing immediate postpartum care to the mom and immediate newborn care to the baby. We come to the home twice in the first week of the baby’s life. We draw labs in the office. We can perform some simple ultrasound procedures. Clients who have had standard OB care in our community are familiar with the 5-10 min prenatal visits after waiting an hour in the waiting room, sometimes having to go to the lab for blood draws, getting a provider at the birth they’ve never met, and another stranger to care for the baby. And on top of all that, insurance companies are paying the OB providers more for that level of service than they pay us for the concierge level services we offer.

NO LONGER ACCEPTING INSURANCE

In light of all of the aforementioned issues, Midwife360 is going to discontinue working with insurance companies as of November 1, 2021. We will continue all of our current contracts through October 31, 2021.

We encourage prospective clients to come in for an hour long consultation. We charge $50 for the hour, and apply that to the fees once the client has decided to come in for care with us.

We will do our best to make our services affordable for everyone who decides that they want this level of care for one of the most important days of their lives! 

The Health Insurance Rant

Palm Beach Water Birth at Home Midwife

Health Insurance A Lose:Lose Situation for Consumers and Providers

How did we come to this juncture where we are supporting the lumbering giant that is the insurance industry particularly as it relates to healthcare? I am an NPR person; I listen to NPR when I’m driving in my car and I heard a piece yesterday that really got me upset! They were talking about the rising cost of healthcare insurance. All of the big companies were planning on raising their rates next year and  Humana was going to be raising their rates higher than everyone else – like by 40%! It is predicted that for someone earning around 27K, their premium would be about $150/m. I remember when I earned less than 30K per year and paying out $150/m for health insurance would have been extremely difficult. So that’s one thing. The other, more important thing that really concerns me – and this, my friends, is the elephant in the room – is how the heck did we get to this place where we support this industry that has absolutely nothing to do with our health?

Difficult Contracting

I have been running my own small healthcare practice for 2 ½ years now. I have been struggling for recognition and compensation from these insurance companies from day 1. Achieving in-network status was the first thing. Cigna updated my new tax ID with my NPI (National Provider Identifier – a national registry that lets them know that the person is legit and bestows a unique identifying number) and we were good to go right away. I thought that all the other companies would do that. However, I found out that even though I’d been providing care for their members for nearly a decade. All of the other companies required me to apply for a contract, and most of the big guys denied me initially. Aetna came around after my national body (ACNM – American College of Nurse-Midwives) wrote a letter for me. Humana is just starting to consider a contract – after multiple Humana members applied for a gap exception for coverage for my care. Blue CrossBlue Sheild won’t even talk to me, doesn’t contract with non-MDs and is extremely difficult to deal with – even for their members. The rest of the companies fell somewhere in-between and eventually granted the in-network status.

Difficult Reimbursement

The next insult is the rates that I am bound to accept now that I have achieved the holy grail of in-network status. My clients pay their premiums and want to use their insurance plan. However, they are subject to their deductibles and co-insurance amounts which require a certain amount of investigation to discover and interpret. The industry standard requires those of us providing maternity care to refrain from billing any services until after the baby is born. This puts all maternity providers in a precarious position because everyone knows that most people are not as keen to pay for a service once the job has been completed. So the trick is to estimate what the insurance company is going to say that the client owes (the deductible and co-insurance up to the amount that is in the insurance contract for the service) and make payment arrangements for this to be paid off prior to their due date. This is irrespective of my charge for the service. If we overestimate, then we have to refund money to the client. If we underestimate, then we have to try to collect for the services that have already been performed.

The Game of Claims and Coding

Submitting forms and getting paid is the other side of this game. The act of submitting a claim is like a ritual or a game – literally. They will deny payment if the coding isn’t correct, but they won’t tell you what’s wrong with it. Most providers pay someone to do this for them and they have to subscribe to a billing platform that electronically submits the claim through one of several national clearinghouses that pass it along to the insurance company. If a paper claim is submitted, it has to be on a particular form that is printed in red ink – if the ink isn’t red, then they won’t accept the claim. All while the status of the claim is communicated to the provider through many forms that are generated, printed, and mailed. So much paper! So many people involved who are making an hourly wage!

Keep the Money Between Consumers and Providers

The bottom line is that all of this detracts from the relationship between me and my clients. The longer I participate intimately with this system, the more I am confused as to the purpose of the insurance industry in health care. Instead of paying out large sums of money for insurance premiums to people whose only job is to move paper around (accept or deny claims and issue checks or take-back letters) we could be using that money to pay for health care. Obviously, the industry is making money – record gains even – and that is off the backs of their members and their providers. I think those folks ought to find another career and we should move away from this cumbersome system.

#getridofhealthinsurance #protectsmallhealthcarebusiness #ontgetbetweenmeandmymidwife