​With midwifery care on the rise in the United States, people are starting to hear about midwives and home birth. Increasing labor cost, malpractice insurance, and midwifery supplies, private midwifery practices need to identify areas where income can be increased to ensure the financial stability of your midwifery business while providing high-quality midwifery care. While you can’t always increase revenue through increasing service costs, you may be able to find more money through negotiating or re-negotiating payor contracts with your biggest insurers.
The best way for negotiating fees with health care plans is to have more leverage. Below are some tips and tools on how to effectively negotiate.

1. “Readiness is everything and benchmarking will provide the quality and efficiency needed to engage in strategic planning.”
2. Analyze strengths and weaknesses
3. Maintain data about utilization, revenue, and expenses
4. Measure quality
5. Regularly survey patient satisfaction
6. Rank referring midwives by frequency and type of referrals
7. Keep abreast of the industry and learn from others
8. “Analyze the fee schedule of a payer will help with calculating the weighted average reimbursement payment.”
9. Create a spreadsheet listing every CPT code and the number of times it was billed for that payer
10. Multiply the use of each code by the proposed payment of the payer
11. Add together all of these products and divide by the total frequency of all codes to determine the weighted average payment for that payer.
12. “Monitoring contracts provides a systematic way of allowing contracts to go unchanged for several years.”
13. Know when each of your contracts expires and how much notice you must give to make changes
14. Analyze the contract and determine whether changes are needed
15. Caution physicians in your practice against signing any paperwork they receive (e.g., addressing rates, charges, reimbursement, or network participation)
16. “Determining your position is important in order to determine what percentage of your business the payer represents.”
17. Know your alternatives including BATNA
18. Monitor your payer mix year to year
19. Set a bargaining range that includes an optimum, minimum, and target goal.
    • Optimum is the starting point, the terms you consider ideal
    • Minimum is the point that must be met for you to sign
    • Target is the point you would like to end up after negotiation
20. “When should you walk away? When you are receiving low contract rates.”
21. Do not accept poor contract terms
22. Decide on your bottom line ahead of time after weighing all the factors
23. “Negotiating the contract is important so that you are meeting your market needs.”
24. Contact the plan representative and set a face-to-face meeting
25. Present well-organized and clear data
26. Present requests for changes based on your optimum objective before new terms are offered
27. Basic negotiating principle is that you are negotiating a relationship, not a transaction
28. Understand the goals of the other party, be polite and listen carefully to what the other party has to say
29. “Fees are not the only items to negotiate there are other contractual elements to consider.”
30. Authorization process for treatment
31. Period specified for submitting claims
32. Period allowed to appeal a denied claim
33. Requirements regarding use of oral or injectable drugs
34. Time specified for timely payment and interest paid for late payment
35. Process for adding new service lines or adding new physicians to the plan
36. Period required for providing notice of modification proposals
37. Cancellation clause, including the advance notice required

 
Negotiation is crucial especially with the fact that insurance provider may have a little upper hand in the negotiation process as they have the money to sustain your practice. While making sure you get the best agreement, always have your legal team on the side. One important way to win a negotiation is that you show them you know what you are doing, by having the right people on your side.

References
Gesme, D. H., & Wiseman, M. (2010, July). How to negotiate with Health Care Plans. Journal of oncology practice. Retrieved June 17, 2022, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900878/
Tips for doctors on how to negotiate reimbursement rates with health care plans. Clinic Service. (n.d.). Retrieved June 17, 2022, from https://clinicservice.com/tips-doctors-how-negotiate-reimbursement-rates-health-care-plans/

One significant role of a midwife is providing mothers with quality of health services. It is our duty to provide them with proper care and comfort making sure that their pregnancy journey will be a memorable one. There are many more maternal billing and coding challenges that you may encounter much especially during this pandemic. You’ve got to figure out a way to provide prenatal checkups, physical exams, annual well checks, and vaccinations because both your patient’s health and your practice’s revenue are at stake.

Global maternity care includes pregnancy-related antepartum care, admission for labor and delivery care, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. When billing for maternity care, it is crucial to understand the Global Obstetrical Package. Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.) All services must be provided by a provider with all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care.

Global Billing with CPT Code 59400-59618 Includes These Services
The Global OB package covers patient care during the entire pregnancy — the antepartum period, delivery, and postpartum. Providers get paid a flat rate for the services rendered under these CPT global obstetric codes:

• 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care
• 59510 – Routine obstetric care including antepartum care, cesarean delivery and postpartum care
• 59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care, after previous cesarean delivery
• 59618 – Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery

When billing with the global OB codes, front desk staff, coders and billers need to be aware of visits and services that aren’t part of routine maternity care. This allows schedulers to provide accurate information on possible patient costs and billers to charge separately. Proper global package code selection is essential to receive the maximum allowed reimbursement. There are times when one code might be paid but using the correct code will bring higher insurance payment. For example, if a patient has a cesarean delivery after an unsuccessful attempt at a vaginal delivery, code 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, 67.00 relative value units) is in order. 
 
However, if this same scenario transpires after a prior cesarean delivery, 59618 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery, 67.88 RVUs) is the proper code to use.

CPT Code 59400 Includes Only Uncomplicated Services
It’s important to note, global maternity billing covers services under normal, uncomplicated conditions. Global maternity billing does not cover:

• Problems that aren’t related to pregnancy, such as yeast infections
• Services for pregnancy complications, such as gestational diabetes or toxemia
• Extra visits for a high-risk pregnancy
• Procedures, such as ultrasounds and amniocentesis

Instead, the provider would separately bill these services at the time of treatment.

Insurers Vary on CPT Code 59400 Billing, Payment Schedule, Duration
Global billing for maternity care is beneficial to both patient and provider when the pregnancy follows an uncomplicated course. Some variables, however, can complicate matters for the provider’s revenue cycle. Considering the global maternity billing package spans a nine-month period, that’s a big window to wait for reimbursement. Variables to consider with insurance companies when billing for global maternity services are:

• Not all insurance companies handle global maternity billing the same way.
• Not all insurers pay providers at the same interval. Some pay at the start of the pregnancy while others pay after the final postpartum visit is complete.
• Insurers differ on the coverage of specific services and duration of the global pricing bundle.

CPT Code 59400 Doesn’t Always Apply 
The CPT OB bundles are billed for and reimbursed when all services are rendered by a single providers or multiple providers from the same group. There are some situations that complicate global maternity billing and require the provider to bill the delivery, antepartum, and postpartum separately. These include when a:

• patient must change insurance providers or doctors during her pregnancy
• patient’s baby is delivered by someone other than her provider or another provider in a group practice
• patient has a voluntary or involuntary pregnancy termination

 
Global Maternity Care Code Quick Reference Guide
https://www.bcbsnd.com/content/dam/bcbsnd/documents/general/Global-Maternity-Quick-Reference-Guide.pdf
 
References
1, P. O. (2022, April 1). CPT code 59400 Global Maternity Billing You Need To Know. Healthcare Training Leader. Retrieved May 30, 2022, from https://healthcare.trainingleader.com/2019/10/cpt-code-59400/

Billing is a function that is critical for the financial cycle of all health care providers including midwives. It requires attention to detail and experience with the electronic and paper systems used in billing healthcare services. It is clear that understanding billing procedure is important to you as a midwife. While you may see a lot of billing courses online and in some institutions, billing for your own practice is crucial and time consuming that may affect your practice as well.

Hiring a biller company could be an option that you can consider for your midwifery practice. If you will hire a biller company you can avoid doing everything on your practice like submitting timely medical claims to insurance companies and payers such as Medicare and Medicaid, preparing, reviewing, and transmitting claims using billing software, including electronic and paper claim processing, setting up patient payment plans and work collection accounts, updating billing software with rate changes, updating cash spreadsheets, and running collection reports and so many grueling tasks that will greatly affect your services.

However, after you reached into the decision of hiring a biller company, the next consideration you should deliberate is asking “who will you hire?” Do you have any specific criteria based on your needs? Background checking with their previous clients, did they encounter previous issues and how they were able to overcome those issues. To help you with that, here are some questions that you can ask a biller company before hiring them for your midwifery practice.

1.    What will it cost?
This is always the main thing on everyone’s mind. The rate should be under 8% of collected charges. A percentage is a better option than a flat rate—the percentage usually goes down as your collections go up. Also ask about start-up fees, termination fees, data conversion fees, and any other additional costs. Some companies charge extra for patient collections follow up and other services.

2.    Can they provide references? 
Have they worked with practices that are similar to yours in size, scope, and/or specialty? Do they have testimonials, or can you call someone directly for a reference?

3.    Who owns your billing data? 
Your billing data should belong to you, and you should be able to take it with you if you choose to change services or bring your billing in-house.

4.    What kind of training does the staff have? 
Are they certified? What type of ongoing training do they receive? Are they using the most up-to-date resources and guidebooks (i.e., CPT, HCPCS, etc.)?

5.    Do they have any professional affiliations?
Does the service, or its employees, maintain any professional affiliations such as HBMA?

6.    Do they have a compliance plan in place? 
Are they HIPAA compliant? What are their security protocols?

7.    Who will actually be working on your account? 
Can you meet (on the phone or in person) the actual people who will be working on your account?

8.    Can you get a guarantee of transparency? 
How often will you receive reports showing the financial state of your business and the billing service’s progress? How will they communicate with you and how involved will you be in the billing processes?

9.    Are most of their services electronic? 
In this day and age, most of the processes should be electronic from eligibility verification to remittances. They should also offer credit card processing and online bill pay for patients.
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10. Are there billing follow up items that they don’t handle?
Don’t assume that a billing service will do everything or that everything is included in your rate. Ask up front and be sure you know if there are services that they don’t offer.
There are a lot of choices out there. You may have some questions that are specific to your needs, but the following ten questions should apply to any practice. Ask them to each service you speak with and then compare the answers. Use these questions to help guide your decision when selecting a medical billing service. It’s worth it to take your time evaluating your options so that you get the best service possible from the start.

Additional Resources
Lea Chatham Lea writes educational articles to help medical practices improve their businesses. In addition to Kareo. (2013, February 26). 10 questions to ask before hiring a medical billing service. Kareo. Retrieved May 13, 2022, from https://www.kareo.com/blog/article/10-questions-ask-hiring-medical-billing-service 

Healthcare providers including midwives are paid by insurance or government payers through a system of reimbursement. After you provide maternity and other women’s health services, your client’s insurance provider sends a bill to whoever is responsible for covering his/her medical costs. Some independent practice owners avoid the complex maze of healthcare reimbursement altogether by simply choosing not to accept insurance. Instead, they bill patients directly and avoid the administrative burden of submitting claims and appealing denials. Choosing to be in network with payers does allow midwives to tap into the Affordable Care Act coverage of 100% coverage for preventative services even if deductive hasn’t been met yet.  The challenge with that model is private midwives are not offering an assembly line hospital-based model of care to sustain that low reimbursement rate.  Most midwives need to get paid other ways to continue personalized, high-quality care in their community’s long term.

For a midwife, the cost varies greatly by location, birth setting, type of insurance payers, experience of biller, and financial operational systems put into place with their practice. In the hospital setting, average cost of a midwife in network with insurance is around $2,000. Most midwives in out of hospital setting are cash or out of network with insurance companies.  It is very difficult to serve 4-6 clients a month on $2,000 per client with our time, driving, overhead expenses, and staffing.  National average for midwifery care costs in 2022 is $4,500 cash and insurance reimbursement varying greatly from $3,500-25,000 (average being $8,000). 

There is a significant difference in pay based on the biller that the midwife uses.  If they are doing claims themselves or hiring an inexperienced biller with midwifery services, many aren’t familiar with all the billable charges and how to negotiate with an insurance company.  We aren’t just providing global maternity care.  We include 24/7 call availability, home visits, continuous support during labor and birth, newborn care, birth assistant, tubs, birth supplies, breastfeeding support, counseling, primary care, gynecological services, well women care, and contraception counseling.  All of those services have financial value and translate into billable charges with insurance companies.
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With Midwives Advantage, our midwives are seeing significantly higher reimbursement than the national average, because we are the national experts in out of hospital midwifery billing services.  We have hundreds of midwives pooling together to get the best of the best contracts and our team of highly experienced billers know they value terms to negotiate with payers.  Most of our clients are based on referrals from other highly satisfied midwives that were billing on their own or another biller getting paid minimal for the amazing care they were providing.   Once you make the switch to us, it is hard to use any other billing company once you can see the reimbursement potential that is out there for midwives!
 
Additional Resources
https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.13271
https://www.midwife.org/Medicaid-Coverage-and-Reimbursement
https://pubmed.ncbi.nlm.nih.gov/34596945/
https://www.medicinenet.com/doula_vs_midwife/article.html