Continuing the insurance theme, let's take a look at how to use your insurance and what some of the terms mean. This process is confusing...intentionally...so hopefully, this post will help clarify. Many midwives do not file insurance claims. The reason is simple. It takes a lot of time, effort and quite frankly money to deal with insurance. Doctor's office have at least one full time person on staff dedicated to seeking reimbursement from insurance companies. And hospitals have large claims teams dedicated to working with insurance companies and claims. Many midwives are solo practitioners, meaning, we don't have a dedicated staff working with and for us, helping us with the various aspects of running a practice. However, some of us still file claims for you, hoping the compensation is fair.
Having said all that, it would be really nice to be able to use your insurance. After all, you are paying monthly premiums to have coverage for things like childbirth. So let's take a look at some of the terms used in the insurance industry. Premium - This is the amount of money you or your employer pay every month so that you can received the benefits of health insurance.
Deductible - This is the amount you pay each year before your insurer starts paying out benefits. Deductibles range from $0-$10,000. Any allowable medical care you have during the year can count towards your deductible. Sometimes in-network and out-of-network expenses count towards the same deductible, sometimes they have separate deductibles. Sometimes you have family deductibles and sometimes you have individual deductibles for each family member. Know your plan, so you can budget for your deductible(s). Deductibles must be met annually. Since pregnancy spans 9 months, it is possible that during the course of your pregnancy, your care may span two deductible periods. The result in a much lower insurance payout.
Global Maternity - This is the insurance term used in coding. Pregnancy could be broken down into the various office visits, lab work, birth, and post partum care. But for ease of the insurance company and the care provider, all care is grouped under one code.
Allowable Amount - This is the amount of reimbursement an insurance company will pay for each service. The amount is determined by industry standards and it can vary greatly depending upon your plan. Sometimes insurers will tell you what they allow, but most do not. If you'd like to explore, you can call your insurance company and ask what they allow for Global Maternity CPT Code 59400, that will help determine what they are likely to pay.
Co-insurance - This is the amount you must pay in addition to your deductible. It is calculated as a percentage. For example, after you pay your deductible, your insurance company and you share the remaining amount. The split can be 90/10 (insurance pays 90%, you pay10%), 70/30, 60/40, etc. It just depends on your plan. Out-of-pocket - This is the amount you are expected to pay. The formula to calculate this is: deductible + co-insurance + non-allowable amount = out of pocket amount.
Gap Exception - If your insurance company says your midwife is out of network, you can apply for a Gap Exception. Some insurance providers will make an exception and reimburse your midwife's fee at your in network rate if there is midwife in network in the area. See the previous blog's explanation of why midwives may choose to not be in network with your insurance company.
Insurance is confusing. And I think that sometimes insurance companies count on people being so overwhelmed or confused by their policies, they don't file appeals or question the decisions made by the companies. Hopefully, defining these terms will help you understand how to work within the insurance company paradigm. After all, midwifery and natural birth is all about empowerment! Good luck!