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How We Got Reimbursement From Our Insurance Company For Our Out Of Network Homebirth

13 Comments 05 July 2011

Guest post by Jeremy

Even though homebirth was not covered in our our insurance policy, we were able to get 60% of the costs covered.

For us, that went from about $4000 out of pocket to about $2000.  And many people have been able to get FULL reimbursement for an “out of network” homebirth.  In a nutshell, here is what we did:

  • We called our insurance provider.
  • We wrote them a letter.
  • We followed up.
  • We followed up again.
  • We followed up again.

Basically, you need to be persistent.

Drive Home The Main Point: Home Birth Will Save Them MONEY!

The main point we tried to drive home in our letters is that our homebirth would save our insurance company money.

In other words, they save thousands to tens of thousands of dollars because we avoided all the costs associated with a hospital birth (the cost of any procedures, monitoring, staying in the room, etc).

A vaginal hospital birth with no complications can cost over $6000.  A cesarean birth with complications can cost over $15,000!  Compare that with our safe, comfy homebirth that cost just over $4000.  You’ll want to put these kinds of numbers into your letters.

Your Midwife Provides Thorough Care

The other thing we focused on was how thorough and safe our midwives’ care was.  One of the ways we did this was to list all of the care our midwives provided, including:

  • prenatal visits (list how many)
  • labor monitoring
  • immediate postpartum care
  • postnatal visits (list how many), which include postnatal care for both mom and baby.

Provide Proof

Homebirth is safe and natural.

You may know this, but the insurance companies either don’t know it, or have been convinced by naysaying doctors and organizations that it is risky.   Doctors and midwives have been attending homebirths for over 2000 years.  Homebirth for low-risk expectant mothers is neither unsafe or uncommon.

To drive home the point that homebirth is safe, you need to provide some proof.  One of the things we made sure to put in our letters were some quotes and studies.  You can find tons of supporting evidence online.

One study we referenced was by Kenneth C Johnson, which looked at outcomes of planned homebirths.  The study concluded that planned homebirth with midwives, for low-risk women, resulted in lower rates of medical intervention, and similar rates of intrapartum and neonatal mortality to low risk women with hospital births. [more on that study here: http://www.bmj.com/content/330/7505/1416.abstract]

Your Midwife Is An All-In-One OB, Nurse, Pediatrician and Lactation Consultant

Another thing to drive home is that your midwife is a specialist in several roles.

She provides the care of an obstetrician, a pediatrician, a labor and delivery nurse and a maternity and newborn nurse.  Our midwives certainly helped with breastfeeding in those early weeks, when it was quite a challenging transition for Madhavi.

Remember, most OBs will give you the equivalent of about 2 hours of prenatal care, about an hour to an hour and a half during the birth and about an hour of postnatal care.  Compare that with the care our midwives provided.  We had multiple prenatal visits each an hour long, and only with our midwives (not staff or nurses).  They were with us the entire day during Madhavi’s birthing time.  They provided several postnatal visits to our home, a few in their office and they were on call for us 24/7 for 6 weeks!

When To Submit Claims

If your midwife is willing, she can submit the claims.  Alternatively, you can make her life easier by just getting the billing from her for each visit and point of care, and submitting the claims and appeals yourself.  We chose the latter, as we knew our midwives were very busy.Also, it’s best if you submit claims separately.

So, you would submit for each prenatal visit, then submit for the birth, then submit for the first postnatal visit, etc.  It’s not critical that you do it this way, but it helps.  We didn’t do this quite that neatly, although we did submit a few separate claims.  Ultimately, our appeal was all-inclusive of all points of care.

The key is not to let lots of time pass before you submit.  I’ll admit, we started off okay.  But then we let some time pass before we submitted some of the later claims (kind of makes sense as we were adjusting to our new life as parents!).  Perhaps this is why we were only awarded 60% reimbursement…Or perhaps that is because insurance companies just don’t get it!

Be Persistent

The last point I want to make is that persistence will reap rewards.

I wrote a draft letter.  Madhavi edited it, and we kept resending it.  Although we were hoping for at least 80% reimbursement, we were proud to have fought the battle to reclaim some of our money.

We were also proud to have brought just a little more awareness about homebirth to insurance providers.  This is a fight worth fighting, even if it’s only to prove a point.

Feel free to email us at jm@dyenfamily.com if you have any questions.

We wanted to share our letters with you as examples, but unfortunately they have been deleted!

However, for a more in-depth discussion on getting reimbursement for homebirth, including sample letters, check out this post from Cafe Mom.

Also check out this super-detailed archive at Gentle Birth.  This is where we got most of info about getting reimbursement.

*******************************

Jeremy Dyen is a musician, father and husband who blogs at Stay at Home Papa. He and his wife Madhavi are advocates of hypnosis and affirmations for mindset shifts about birth, and they even created a free hypnosis mp3 download available at Fear Free Birth.

Your Comments

13 Comments so far

  1. Amanda says:

    This is the best info ever! I am wanting to use a midwife that has a birth center but also does home births of course she is out of network. However, I already planned on writing a letter to try to get pre authorized this was VERY helpful info!

  2. Katherine says:

    I hope more people try this! Midwives need to wise up about how they bill, too. My policy “specifically excluded” home birth, but my midwives broke their fee down and billed for prenatal exams separately. Since one of my midwives was a hospital-employed CNM, they had no reason to reject the claims for the prenatals–and they paid for 100% of that portion. The remaining portion was a pretty small amount, comparatively, and our deposit covered most of it. I ended up having to transfer with 10 minutes to go in my labor (the midwives were actually only with me for 2ish hours) so they didn’t charge me the full amount for delivery, but I went to them for all my postnatal appointments too. I am quite sure we didn’t pay over $400 total. So yeah–be persistent, and CREATIVE! It’s not like insurance companies don’t come up with CREATIVE ways to screw you out of coverage ;)

  3. Kiki La Roo says:

    Patience and persistance…you said it! Your advice is excellent. I was able to petition my insurance (UHC) and received 100% coverage last year. It took a lot of persistance on my part. I cited studies, explained how much money I would save them, told them I was a good candidate for hb, and basically opened their eyes to the entire concept of out of hospital birth. At one point, it came down to the simple fact that, Yeah, my hb mw was “out of network” but that there were no “in-network” hb mw’s and they may want to take a proactive stance to change that. It worked :D

  4. Kat says:

    In 2006, we had a homebirth with a CNM who was out of network for our insurance company, Blue Cross Blue Shield. I called first and asked about in-network midwives. They didn’t have any listed, but did cover midwifery care. I asked them to confirm their policy that they had to cover O-O-N providers if no providers within 50 miles offered the service I desired. They confirmed that was, in fact, their policy. Then, I sent a letter documenting that there were no in-network midwives offering the services we wanted within 50 miles, so we wanted her care paid at in-network rates. We received a letter saying that they could not agree to pay at in-network rates in advance, they would pay whatever they deemed appropriate and then we would be able to appeal. I never once mentioned homebirth in the letter or on the phone, I just emphasized that there would be no facility charge, just the midwife’s fee.

    After the birth, our midwife billed prenatal care, birth care and postpartum visits separately. The prenatal and birth care were paid at 80% and the postpartum visits were paid at 100%.

    Now that there are billing codes for doulas, you can also send a bill to your insurance company for reimbursement for doula services. Why not? Let them see how much cheaper homebirth midwife + doula and even + waterbirth tub rental is vs. hospital birth!

  5. Jeremy says:

    Thanks for all your fantastic comments. It’s great to see that so many of you are having success with this (better success than us even!).

    We started out wanting a hospital birth at the hospital where Madhavi practiced (100% coverage)…Then we switched to a different hospital b/c Madhavi felt a little weird birthing where colleagues, residents and students of hers worked. That switch meant only 80% coverage. And then we switched to a homebirth, which meant nothing was covered…Of course, triumphantly, we got 60% covered.

    Kat, great to know there are billing codes for doulas as well. This shouldn’t go overlooked.

    People need to keep pushing to make homebirth more mainstream!

  6. cara says:

    My midwife billed my insurance (United Healthcare) and she was covered as an out-of-network provider and was covered at 60%. It was no hassle on my part. I considered petitioning for 100% coverage since that would have been the coverage for an in-hospital birth and at least 3 times the cost. In the end, I was happy it only cost just over $1000 and I had a new baby and a great birth.

  7. Crystal says:

    I was covered 100% through Tricare Prime. Persistance is definitely what was needed, as I was turned down a couple of times. I wrote up a professional letter referring to myself in the 3rd person as unable/refusing to have a hospital birth (I had had an unpleasant hospital birth previously.)and had my doctor’s nurse fax it in with my doctor’s midwife referral (she was familiar with my midwife and had no problem referring me to her.) The only issue was my midwife- I think she didn’t get paid as well as if I’d done cash. Last I knew she thought she wasn’t going to accept Tricare Prime anymore. I live in Oklahoma.

  8. Gretchen says:

    Thank you for sharing this information. My first home birth we sent the insurance company the letter and proof of payment and went from 2000 out of pocket- got back 1800!! For our second home birth we payed 2000 out of pocket -got back 2000! Totally covered! We have a flex account and all we did was deduct the amount from the account for a home birth. No questions, no problems! Please don’t let money be the reason you don’t have the amazing birth you deserve. Do what you feel in your heart and it will be perfect. :)

  9. Sarah says:

    Maybe we gave up on the “persistent” part, but we stopped trying after two years of follow up and badgering.

    The stress of dealing with it just wasn’t good for anything and I wanted to think of the birth as a good thing!

    We’ve since moved on from that insurance company to one that at least has an HSA so it’s covered even though everything is out of pocket at first.

  10. Angelita Nixon, CNM says:

    This is a successful appeal letter written by a client. She gives permission for (and encourages) widespread use!

    Facsimile
    To: Highmark West Virginia Insurance
    Attn: Precertification Nurse
    Fax #: 888-820-4197
    Re: Reference #

    I am a SuperBlue Plus policy holder (Member ID –; Group –), and I am writing to appeal for an in-network exception for my chosen care provider, Angelita Nixon, CNM. I am requesting this exception, as there are no in-network home birth midwives in my community, Charleston, WV, and Ms. Nixon is the only home birth care provider within a 90 mile radius. It is my understanding that an in-network exception was initially denied stating that home birth was not medically necessary. My insurance policy does not require me to have a hospital birth. It is unclear to me the basis of your request for medical necessity. Do you require letters of medical necessity for all women having hospital births (what seems would be a more logical request)? Ms. Nixon successfully bills PEIA and Medicaid on a regular basis for births and has been granted an in-network exception by Mountain State Blue Cross Blue Shield prior to its change to Highmark West Virginia.

    I find it curious that an insurance company, who is undoubtedly concerned with cost containment, would provide preference to a hospital birth when a home birth is far less expensive. In Charleston a basic hospital birth with no interventions (which I am certain you must know is rare, as interventions are provided on a routine basis in hospitals) costs approximately $10,000. A typical home birth costs an average of $4,000 in Charleston, WV. It is true that home births are not appropriate for every mother/child, but in a low-risk pregnancy, research shows home births to be just as safe as hospital births, if not more so. In addition, planned home births safely provide an environment in which expensive interventions are not normative, something that should be of keen interest to your company in a state where a 40% cesarean rate is undoubtedly causing your birth costs to skyrocket.

    Your company’s denial of my in-network exception based on the fact that home birth is not “medically necessary” leads me to wonder if your decision is intended to be discriminatory or punitive in nature. Are your company’s standards based on current research on birth safety? It seems this is not so. I am aware that judicious use of medical care is a top priority in the health care industry, and especially for insurance companies. Given the fact that I had a safe home birth with my first child with no need for medical interventions and that my current pregnancy is progressing normally makes me a good candidate for this judicious use of care. However, your denial will force me to have a hospital birth, costing your company many times what your granting of an in-network exception would have cost. In addition, given the fact that the two local hospitals at which I would birth have a high likelihood of cesarean (~48% at CAMC and ~70$ at Thomas), it is likely that a hospital birth would result in a cesarean section. Perhaps an easy way to avoid rising medical and insurance costs (and to make you more money!) would be to re-evaluate your agency’s policies on home birth. I have included a chart below showing the cost savings to your company if an in-network exception is granted.

    Birth Estimated Cost Cost to Highmark
    Planned home birth (with in-network exception) 4,000 3,200 – 2,500 deductible = 700

    Hospital birth 10,000 to 15,000 8,000 to 12,000 – 2,500 deductible = 5,500 to 9,500

    Hospital birth with cesarean section 30,000 to 35,000 24,000 to 28,000 – 2,500 deductible = 21,500 to 25,500

    I would also like to note that I am the decision maker in my company regarding insurance policy purchasing. I will certainly consider my personal experience when re-evaluating our options in November.
    Thank you for your time and consideration.

    Sincerely, –

    cc: Dennis Garrison, Consumer Advocate, West Virginia Insurance Commission
    Don Perdue, Chair, WV House Committee on Health and Human Resources
    Nancy Tyler, Chief Counsel, WV House Committee on Health and Human Resources
    Kate White, Chief Counsel, WV Senate Committee on Health and Human Resources
    William R. Laird, IV, State Senate, grandfather of baby-to-be

    M. MacDorman and G. Singh, “Midwifery Care, Social and Medical Risk Factors, and Birth Outcomes in the USA,” Journal of Epidemiology and Community Health 52 (1998): 310-17.
    A. Durand, “The Safety of Home Birth: The Farm Study,” American Journal of Public Health 82 (1992): 450-53.
    W. Schramm et al., “Neonatal Mortality in Missouri Home Births, “ American Journal of Public Health 77, no. 8 (1987): 930-35.
    M. W. Hinds, G. H. Bergeisen, and D. T. Allen, “Neonatal Outcome in Planned vs. Unplanned Out-of-Hospital Births in Kentucky,” Journal of the American Medical Association 253, no. II (1985): 1578-82.
    P. A. Murphy and J. Fullerton, “Outcomes of Intended Home Births in Nurse-Midwifery Pracitce: A Prospective Descriptive Study,” Obstetrics and Gynecology 92, no. 3 (1992): 461-70.
    O. Olsen, “Meta-Analysis of the Safety of Home Birth,” Birth 24, no. 1 (1997): 4-16.
    M. Enkin et al., “Social and Professional Support in Childbirth,” in A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. (New York: Oxford University Press, 2000), pp. 247-54.
    Data on maternal mortality by country, World Health Organization, http://www.who.int/reproductive-health; 32 countries have lower rates than the United States; see in conjunction with who attends births in these countries at World Health Organization, Having a Baby in Europe (Copenhagen: World Health Organization, 1985)


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