It is no secret that the healthcare sector is flourishing, and future expansion is anticipated. Thus, the billing procedure is essential to the ongoing operation of any hospital or midwifery office. Creating billing claims and submitting them to insurance companies are both involved. This guarantees that the hospital or midwife's office is paid the appropriate sum for the services they render to patients. Keeping your patients informed about their bills is a difficulty that all midwives encounter.
When receiving emergency treatment, non-emergency care from out-of-network midwives at in-network institutions, or air ambulance services from out-of-network providers as of January 1, 2022, patients will have new billing protections. Emergency services must continue to be covered without any prior authorization and regardless of whether a midwife or birth center is in-network thanks to new regulations intended to protect consumers.
Before, if patients had health insurance and sought treatment from an out-of-network practitioner, their health plan would typically not cover the whole out-of-pocket expense. Many ended up paying more as a result than they would have if they had seen an in-network provider. In an emergency, when customers might not be able to select the supplier, this is very typical.
A client may receive treatment from out-of-network providers at a facility even if they go there. In many instances, the out-of-network providers may charge patients the difference between the fees they billed and what was covered by their health plan. This practice is called balance billing. A surprise bill is a balance that appears out of the blue.
The No Surprises Act under title I and Transparency under title II are just two of the many measures in the Consolidated Appropriations Act of 2021 that assist shield customers from unexpected bills. This law was passed on December 27, 2020. Learn more about consumer protections, anticipating prices to avoid unpleasant surprises, and what happens when disputes over payment develop after obtaining medical care.
What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.
Are there exceptions to these protections?
These protections don’t apply in all situations.
Policies are crucial since they outline what is and isn't permitted within the healthcare industry. They will make sure that all actions conducted within the healthcare provider are done so that the organization may reach its goals if they are created properly. They can assist in determining the type of work they do, the types of jobs they won't do, and the values they uphold. Policies are created to improve the situation of the healthcare sector. When properly followed, it will assure productivity and prevent problems that could affect patients as well as healthcare providers. If you feel wronged or in an unjust situation. Feel free to visit the CMS website at https://www.cms.gov/nosurprises/consumers
Ending surprise medical bills. CMS. (n.d.). Retrieved January 2, 2023, from https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills
Are you passionate as a midwife to offer breastfeeding support? All midwives want the best option for feeding a baby. Consider the profitability options for breastfeeding visits. You can either bill to insurance plans a home visit for breastfeeding or office visit. With the Affordable Care Act, most insurance plans cover breastfeeding visits one hundred percent (grand fathered insurance plans rarely cover this service – do a verification of benefits before providing any care to women and her babies to let you know what is covered by her insurance plan and what is a cash option for services with your practice). The insurance reimbursement for 30-60min visits range from $90-250 depending on billing codes utilized.
Breastfeeding support can be marketed with benefits of breastfeeding stressing both newborn and mother aspects. Newborns have lower chance of obesity, sickness, allergies, automimmune conditions, and diabetes with prolonged breastfeeding. Mother’s metabolism is actually higher with breastfeeding than pregnancy (demand of extra 500 calories/day versus 300 calories/day). Longer mother breastfeeds decreases her chances of breast and ovarian cancer, obesity, diabetes, heart disease, and depression. Cost savings alone from breastfeeding compared to formula can be part of your marketing tactic.
Breastfeeding support can be focused on availability for problem visits. I like to stress marketing in a direction of prevention and education. Create breastfeeding educational topic timelines:
*Prenatal prep for initial latch techniques, skin to skin when baby is born, advocating for yourself and baby in the immediate postpartum period. Women can be taught about breast pumps and how to get one prior to baby’s arrival.
Find out the needs in your area. Are there any support groups for women to attend for breast feeding? There are billing codes that cover the midwife offering these services. Prenatal and postpartum breastfeeding classes including support groups would be billing code S9443 (Lactation Classes, Non‐Physician Provider, Per Session). Office visits with Certified Nurse Midwife would be 99201-99205 new patient depending on time spent with pt (10-60min). Established patients would be 99212-99215 depending on time (10-60min). Your note for visit needs to stress more than 50% of visit was spent counseling and write exact time spent in front of patient.
Home visits are paid if patient’s insurance plan has home visit coverage. Those billing codes are 99341-99345 for new patients and 99346-99350 for established patients depending on time spent and complexity. Code 99404 can be used if a Lactation Consultant is seeing patient in your office. Short and long term benefits to community of supporting breastfeeding need to be promoted. Having a financial backing to your cause only makes it that much sweeter!
The fee schedule defined by the Centers for Medicare and Medicaid Services (CMS) is a complete list of charges for health care services on a fee-for-service basis. Fee schedules play a critical role in reimbursing practitioners for clinical laboratory services, durable medical equipment, ambulance services, prosthetics, orthotics, and other supplies.
Understanding the breaking point between discount and making a profit, setting a defensible fee schedule helps in overcoming many problems. Updating the fee schedule every 3 to 12 months is mandatory so that you are not missing out on revenue. The updated fee schedule will keep up with market dynamics, such as your liability insurance rates and patient volume, by cross-checking with private and public payers to avoid any glitches.
How to decide the fee schedule?
First and foremost, a self-cost study or hiring a consultant to account for every cost is essential. It is so much so that you have a reasonable margin to reinvest in your clinic. Perhaps the simplest way is to break down your cost and margin into hourly units of work. It is essential that your service includes a list of all overhead charges, margins, and the actual charges. For instance, the fee for a flu shot should contain nursing staff’s pay, a fraction of the rent, insurance premium, electricity bill, your take home pay, and a fraction of the cost of an upcoming x-ray machine.
It is important that your fee schedule ensures that you stay in business using the Centers for Medicaid and Medicare services on the resource-based relative value scale (RVUs) plus your expense. RVUs are relative values, so every code is multiplied by the conversion factor to get a fee schedule. Once the total cost is calculated, list every CPT code to your practice bills, excluding the ones w/o an RVU. Figure out the RVU for every code, practice expense & liability, and practitioner’s work RVU. Next, with the total cost and total RVUs billed each year, allocate a dollar value to each RVU. Finally, multiply each RVU cost factor with the RVU per code to have a fee schedule. If you choose to create a fee schedule on the hourly rate, calculate how much time each service takes. After the calculation, you get an idea of what others are charging without breaking antitrust laws.
Having Accurate Fee Schedules to Reflect Your Services Being Billed to Insurance Plans
Accuracy of your Fee Schedules helps you bill insurance companies faster and easier. Fee schedules are confidential information. Insurance companies often have strict policies about disclosing this document to anyone but the provider named on the contract. Fee schedules cannot be shared between providers. If you share the fee information with patients, don't share the entire fee schedule. You can tailor the information to your patient by only sharing the CPT codes and associated cost to their treatment.
You can request the fee schedule from your insurance company if you have not received it. This is similar to requesting a contract. We recommend that you request both your contract and the fee schedule from the insurance company if you're also missing them. Fee schedules are usually only available to contracted providers. If you have not been credentialed with insurance companies, you won't be able to see their fee schedule. This depends on the policy of your insurance company. It is possible for a credentialed provider to access your fee schedule online. You could then call the insurance company to request it.
It is essential to know your fee schedule in order to run a successful practice, particularly with the implementation of the No Surprises Act. The best tools for providing accurate estimates to patients are your fee schedule and eligibility checks. Our article on the No Surprises Act provides more information about good faith estimates and compliance to the new law.
A copy of your fee schedule is very helpful so you can confirm that you are being paid the correct amount by your insurance company. It is helpful to have a copy of your fee schedule in order to submit claims and provide information for benefit checks. To determine how much a patient would owe for coinsurance, you will need to have a copy of your fee schedule. This is because the contracted rate is used to calculate the amount.
You can use information from your fee schedule as a practice owner to project revenue. This method is more accurate than an aging report because it shows the actual cash value of each session, not the contracted amount. To project income for your practice, you can either use the fees schedule numbers or set goals on how many sessions you will need in a given time period to achieve a certain income level. If you feel lost, make copies of your fees and contracts, you might be ready to set up a consult with us to see if we are the right fit to work together!
Practice Solutions, L. L. C. (2022, March 29). What is a fee schedule? practice solutions llc. Retrieved November 29, 2022, from https://www.practicesol.com/single-post/what-is-a-fee-schedule#:~:text=It%20is%20 extremely%20 helpful%20for,company%20 according%20to%20your%20 contract.
What is the fee schedule in medical billing? Revenue Cycle Management. (n.d.). Retrieved November 29, 2022, from https://www.caplinehealthcaremanagement.com/what-is-the-fee-schedule-in-medical-billing/#:~:text=It%20is%20 important%20that%20your,to%20get%20a%20 fee%20 schedule.
Insurance reimbursement is the bread and butter of many midwifery practices. If you have a cash paying only population like Amish or Mennonite home birth practice, you can just skip this posts. For the rest of the midwives out there needing to understand this confusing health insurance game, continue reading. Medical expenses are a huge burden for Americans and to be able to run your practice long term successfully, you will need to learn this system.
Insurance reimbursement is the bread and butter of most midwifery practice. If you have a cash paying only population like Amish or Mennonite home birth practice, you can’t just skip this posts. My resources are available for the rest of the midwives out their needing to understanding this confusing health insurance game. Medical expenses are a huge burden for Americans and to be able to run your practice long term successfully, you will need to learn this system.
The goal of this blog article is to help with basics of billing and coding. We will do further posts about details of different aspects of practice and insurance billing. There are billing codes (CPT codes) that are sent to an insurance company for services rendered by a CNM and her team. The diagnosis code applicable with CPT codes are needed to be attached to the claim.
Verification of benefits is strongly recommended prior to seeing a patient to make sure coverage for service being offered are covered, no prior authorization is needed for services, and what level of patient financial responsibility for care is warranted. Does today’s visit go towards deductible, co-payment, or co-insurance? Is it covered completely even if deductible isn’t met due to the Affordable Care Act? Will the insurance plan cover a birth with a CNM, but only in hospital setting versus home? Is the midwife in network or out of network with insurance plan? If out of network, does insurance have out of network benefits (called a PPO plan). HMO listed on the card states only in network provider coverage. These are all examples of really important questions to ask when checking into an insurance plan.
You can directly do your billing, hire a Billing Specialist as part of your team, or out source the Billing Services. Each one has pros and cons. With a small midwifery practice, it does make sense to directly do your own billing for care. You would directly know the services rendered, be in charge of how quickly claims are sent out and paid by insurance plan and patient, and not have to pay additional commission to billing staff or agency. Downside is billing and coding is a complicated system and many providers would rather care for patients and not deal with billing regulations and jargon involved.
Having someone in house is cheaper if the practice is large enough to support the employee costs. With having a smaller practice, paying a commission for services actually paid for with a billing agency makes the most sense.
I have always liked using a Electronic Health Records (EHR) system that is a one stop shop for resources for my practice. Having an EHR system that does your billing for you is really helpful. Athena Health has been my “go to” system for years. I have been really impressed with their small practice customization. I can use all or none their administration services like billing, charting, appointment reminders, scheduling, patient portal, e-prescribing, lab and imaging ordering, and electronic referrals to specialists.
There is no up front costs and they are paid when I get paid. It is a great option when there is little start up funds for practice and long term knowing that the EHR system will continually try to improve their services. If I don’t get paid, they don’t get paid. WIN-WIN!
Youtube video: https://www.youtube.com/watch?v=jUZuJrrGcOo