A health insurance denial happens when your health insurance company refuses to pay for something. If this happens after you've had the midwifery service and a claim has been submitted, it's called a claim denial. Insurers also sometimes state ahead of time that they won't pay for a particular service, during the pre-authorization process; this is known as a pre-authorization--or prior authorization--denial. In both cases, you can appeal and may be able to get your insurer to reverse their decision and agree to pay for at least part of the service you need. There are literally hundreds of reasons a health plan might deny payment for a healthcare service. Some reasons are simple and relatively easy to fix, while some are more difficult to address.
Why Would a Health Insurance Claim Be Denied?
A health insurance company may deny a claim for many reasons, including:
As a maternity care provider, claim denials are pain in the butt. Even practitioners who take precautions to avoid insurance payment pitfalls sometimes find themselves faced with a claim’s denial. Handling denied insurance claims can be a frustrating, time-consuming and complicated process for practicing psychologists and their administrative staff. Knowing some basic strategies for resolving claims denials can save practitioners time and improve their practice’s cash flow. Some basic pointers for handling claim denials are outlined below.
1. Take the time to review all notification regarding the claim Although it sounds obvious, this is one of the most critical steps in claims processing. You should carefully read any notification you receive from an insurance company about a claim. Notifications should state whether the claim has been paid in full, partially, delayed or partially. If the claim is deemed "unclean" or contestable, the carrier will provide instructions on how to resubmit the claim with any missing or corrected information. In the event that the claim is not paid in full or denied for any reason, the notification must state the reasons and the procedures and documentation needed to resubmit or appeal the claim.
For more information, contact the carrier if the notification is unclear. You may discover that the claim was incorrectly adjudicated by the payer, in addition to the stated reason for denial. It is possible that your submission processes do not meet the requirements of the payer. However, you may be able to make simple changes to improve your claims submissions.
2. Be persistent
If you feel the insurance provider has wrongfully denied your resubmitted claim, you can appeal. You should be clear about what information you must include with your appeal. Keep in mind, appeal procedures can vary depending on the state law and insurance company.
An explanation of your appeal and any supporting documentation such as a copy of the claim, and copies of communications to the company regarding the matter, should be included in your appeal. Additional information may be required to prove medical necessity if your claim is denied. It is important to comply with your obligations under the Health Insurance Portability and Accountability Act, (HIPAA), to protect psychotherapy notes and provide only the "minimum required" information.
Sometimes, you may have to submit the claim again or appeal multiple times to reverse an insurance company's decision. But don't lose heart. The insurance company will appreciate your persistence in resolving the issue and getting paid.
3. Don’t delay
It is crucial to submit and resubmit claims within the deadlines specified by the company, or any applicable laws in your particular state. If you don't, your claim could be dismissed based on information already provided.
4. Get to know the appeals process
Make sure to familiarize yourself with the appeals process of your carrier before you file an appeal. You will be better equipped to respond to your carrier's actions if you have a good understanding of their policies. You should keep current information about the appeals and claims adjudication processes for every carrier you work with. This information is often available on the websites of carriers. If applicable, you should also keep hard copies of it whenever you sign a contract.
5. Maintain records on disputed claims
Keep a written record of all information that you receive from an insurance company regarding a claim. Also, make sure to include the name and contact information of the representative you spoke with. This information should be kept with key information about your claim such as the reason the claim was delayed, partially paid or denied, the actions taken by your office to follow-up on it, and the final outcome.
These records could be used to help you in the future, whether it is to appeal to higher levels or to complain to the state insurance commissioner. These records can be used to help your office avoid or resolve future claims denials.
6. Remember that help is available
Although handling claims denials is frustrating, it can help you save time and money by alerting to the expectations of the insurance companies you contract with. You may be able to reduce rejections and denials by ensuring your billing procedures conform to the requirements of the company. If you have any reimbursement issues with an insurance company, please contact your state insurance commissioner for assistance.
Insurance denials are very frustrating. It will give a huge impact to your practice if you are not mindful enough of every action you take. But it is preventable if you collect the right information and verify it thoroughly.
American Psychological Association. (2005, March 1). Six tips for handling insurance claim denials. https://www.apaservices.org. Retrieved November 28, 2022, from https://www.apaservices.org/practice/business/finances/insurance-denial
Martin, E. (2022, November 16). How to appeal a health insurance claim denial. Forbes. Retrieved November 28, 2022, from https://www.forbes.com/advisor/health-insurance/appeal-health-insurance-claim-denial/
Insurance billing can be daunting with running your own midwifery practice. It is easy to bill for services with cash, but many families are very dependent on getting their insurance to pay for care. Especially maternity and newborn care since the Affordable Care Act legally requires insurance companies to cover preventative care.
Midwives that deliver in the hospital typically don’t do newborn care (pediatrician on call covers that service). Even though it is part of the CNMs scope of practice to care for babies first month of life, most in hospital practices don’t provide that aspect of care. Out of hospital birth practices, midwives typically do the newborn care (especially the initial newborn exam). How is billing for babies done? Do all insurance companies reimbursement midwives for that service?
Most insurance companies are easy to bill for newborn care. CNMs are recognized with most insurance plans as a covered provider for that service. I have had a couple plans state as denial reason “not covered provider type.” That is part of importance in thorough verification of benefits (VOB). I have trained my staff to ask VERY DETAILED questions to insurance reps if a phone VOB is done. They don’t just ask maternity care coverage with plan. We state, “Does this plan cover a CNM in the home setting for delivery care?” “Does this plan cover an independent Certified Nurse Midwife for newborn care codes 99381 or 99391 in the home setting?” There are some plans that won’t cover a midwife not working under a physician, newborn care in the home setting, or home visit codes for these services like 99349.
Available billing codes for newborn services revolve around screenings and care offered in the first month of life. Our practice offered the vaccinations to families. We gave the Hepatitis B vaccination at the birth center prior to discharge if families desired it. We billed to insurance companies codes 90744 (Hepatitis B Vaccination) and 90471 (immunization injection). Some families wanted eye ointment and vitamin K injection given. Those billing codes were J3490 (erythromycin eye ointment), J3430 (vitamin K injection), and 96372 (IM injection).
Newborn assessments are vital to make sure baby is transitioning well to life outside its mother. Don’t you want to get paid for all your valuable being provided? You have two patients in the postpartum recovery period, make sure you are getting reimbursed for everything you are doing. Initial newborn exam billing code is 99381. Repeat exams 99391. If it is done in the home setting, some insurance companies want you to bill a home visit code and others want the initial newborn screening placed in home setting on claim paperwork. I would usually do 99350 for initial exam and then 99348 for subsequent home visits during postpartum care when insurance plan wanted home visit codes submitted.
Make sure families are aware that coverage level is different for preventative codes like newborn exams versus home visit codes. Many insurance plans don’t have home visit coverage. If coverage present, it may be a co-payment or completely count towards their deductible versus newborn exam codes being covered 100% in the office.
I have had families drive to office for 24hr postpartum exam versus me coming to the home purely because their insurance had no home visit coverage, but would cover a newborn exam 100% in office setting. Families should have a right to know their coverage level and be given options of your services based on what their insurance coverage is actually like.
Newborn hearing screen and newborn metabolic screening (state mandated in many places) are covered 100% by insurance plan. You can refer families out to local resources lab or audiology to complete these screenings or offer them as part of your services. Hearing screen code is V5008 and metabolic screen is 83516. Capillary sample collection billed in conjunction with metabolic screen is 36416.
Another state mandating testing in Michigan is pulse oximetry reading on newborn. That code is 94760. Some insurance plans will recognize all these subset screening codes and others won’t. Unfortunately when most babies are born in the hospital, many of these services are bundled with the hospital facility or nursery charge placed to insurance companies.
Newborn care is very important part of a midwife’s job. Being able to have another revenue stream come into your practice from those services that many people a Pediatrician can only do, really helps your bottom line of business success. I had an average extra $500 from each family’s care come into the practice by performing those newborn exams first month of life.
It was also great to keep the baby’s out of a sick doctor’s office and let mother and baby truly stay home the first few weeks after delivery. Last thing a recovering mother and baby need is getting out into Michigan winter to get all those check ups completed.
Billing plays a significant role in your practice’s revenue. When you have your patient, you either bill them out personally or through their health insurance coverage. Getting cash from clients may be easier but what if they will use their insurance? Not all insurance claims get approved, there are times that patients get rejected and as the healthcare provider, it will greatly affect you and your practice. Study shows that insurance claims can also be denied or rejected for a variety of reasons. Many of these denials are due to human error. 75% of claims were incorrectly coded. To avoid this to happen, you must get all the information needed and verify it first hand before submitting claims.
Insurance claim data entry is very challenging. It is common for insurance claim documents to be copied, shared, and reviewed by multiple departments depending on the type of claim. Multiple employees cannot work on the same claim simultaneously if they have to deal with physical documents. These steps can cause errors or omissions in claim management software by manually entering data from different documents in a claim. This could lead to chaos, delay payments, mishandling the claim, and/or create delays in payment.
It is vital to have a healthy revenue cycle to support the expensive work of every midwife. However, it can be difficult to ensure that your practice receives payment for the services it rendered. This can be especially difficult because midwives often get reimbursed by third party payers after the patient has left. There is also a delay between rendering services and receiving payment. Below are the reasons why it is important to get all the information from clients with billing insurance claims out:
Having your midwifery business is worthwhile, hence deciding how to get paid what you are worth is challenging. It can be difficult to decide how much you should charge for your midwifery service since midwives just started to be recognized with the value they put in the healthcare industry. You could be priced out of the market if you charge too much. If you charge too much, you might be earning nothing. As a midwife, you must charge a reasonable amount of money that can help you survive your practice in the long run. To help you decide, here are some ways you can use to determine your pricing point for your midwifery business.
1. Do not be a discount queen Although it might seem tempting to offer sales to get new business, if you discount certain things without asking why, you could lose money.
2. Take into consideration all costs This is an important step in pricing your services. Calculating your cost of sales (COS) is essential. You should make a list of all the steps involved in creating or delivering your midwifery services. This includes your time and the cost of outsourcing or hiring help.
3. Calculate Your Overhead Percentage
You must also include costs related to staying in business. I think overhead costs are like a roof above your head. Freshbooks offers a detailed guide which explains everything. These costs include utilities, taxes, office equipment, and office rent. Direct costs refer to the costs associated with each project, such as gas, filing fees and your time. These are the overhead costs listed above. Divide the indirect costs by direct costs to calculate your overhead percentage. Then multiply 100 by 100.
4. Avoid Low Balling Your Prices at First Although it might seem tempting to offer low rates to attract customers and undercut the competition, don't. It will be harder to raise your prices later if you do. Customers might be price sensitive and you could lose customers if your prices are raised to a livable level. Instead, determine the price you would like them to be at the beginning.
5. Fee for Value Consider the value of your services when pricing your services. A professional midwife who has had experience delivering babies will charge a mom more than someone who doesn't. It is important to invest in your education and training. Be valuable to your customers.
6. Don't confuse Rate and Price It's simple to do but don't let your personal rate get in the way of the price you charge. You don't want to charge $100 an hour if you want your hourly rate to be $100. Also, you need to factor in overhead and COS. You might earn less than $75 an hour if you take these into account. If you would like your hourly rate to be $100, then calculate the costs first, and include your rate within those costs. You should then charge $125 and not $100.
7. Take into consideration the market demand You can make changes to your midwifery service if there isn’t much demand. Printing paper flyers is not a popular service in today's market. Consider offering social media graphic design as an alternative if this is your business or skill.
8. Find Ways to Increase Sales Upselling is a great way to increase your income. Do not include additional fees in your base price. These extras should be kept secret and offered to clients as valuable options. You may add ancillary services to your midwifery practice such as ultrasound and other test that will be helpful to the customers
9. Invest in the business to increase rates Find ways to invest in your business to increase your rate of return. You might be more productive with a new technology. Continuing education can give you more authority, knowledge and confidence. Clients will pay more if you offer faster turnarounds and other value.
10. Identify Your Ideal Customer When setting your prices, keep in mind your ideal customer. If you offer discounts and set extremely low rates, you will attract this type of customer. Midwifery services are quite expensive if you don’t have insurance coverage in the US. It is important to determine that your customers have the ability to pay for your services rather than expecting to get discounts in every service that you offer.
11. Create a written fee agreement Make sure everyone signs the fee agreement after you have established your fees. Make sure you are clear and answer every question upfront. This will prevent any confusion or arguments later. Pricing is the first step to establish your business, and you must remember that the first step is always the hardest. Yet, if you realize the value of the midwifery service you can offer to your community, along the way things will go smoothly as how you perceived your practice to be. Have patience and you will get there.
Inks, S. (2020, May 23). How to price your services and get paid what you deserve. SMI Financial Coaching. Retrieved November 28, 2022, from https://smifinancialcoaching.com/how-to-price-your-services/