s a midwifery practice owner, you must decide whether or not you'll accept insurance for healthcare or if you would like that your service be cash-based which means that the client pays on their own and at a predetermined fee for each appointment. There are advantages and disadvantages to accepting both forms of payment therefore your final decision will depend on the goals you have to achieve for the practice. There is no law which says that if you start with healthcare insurance, it is not possible to switch to cash-based services later on. date.
 
Most hospital-based midwifery services accept insurance. Nearly half of birth center practice accepts insurance. A smaller percentage of home birth clinics provide insurance processing. Families usually have to provide an insurance coverage with an itemized bills of service for reimbursement directly if out of network benefits are available.
 
Insurance plans with fewer benefits do not have out-of-network benefits, and being part of the network typically requires some type of malpractice insurance. Smaller midwifery practices may not be able to manage the monthly payments needed for that protection. The more extensive your practice or is expected to become more likely that to be insured and billing for services be essential to ensure that your business is profitable.
 
The choice between cash payment and billing insurance policies has numerous pros and cons every midwife should consider. Billing insurance plans do not just ensure that midwives receive the right amount of money, it also leaves a variety of benefits to the healthcare industry.
 
Functions of Healthcare Insurance and why Midwives Should opt to Billing Insurance Plans

In 2017, the average insurance premium for US families with employer-sponsored health insurance cost $18 764, an increase of 3% over the previous year. What this mean value hides, however, is the enormous variance in the amount of health care received by different people in the United States.

That variance is reflected in huge disparities in health care spending. In 2016, the top 5% of US health spenders accounted for 50% of total spending, or about $50 000 per person. The bottom half of the population, based on health expenditures, accounted for only 3% of total health spending, or $276 per person in 2016. People in both groups buy health insurance, but the benefits they gain from doing so are different.

In addition to helping people stay healthy and improving their health when they get sick, our system of health insurance serves at least several functions to enable everyone to benefit from being insured. These functions, however, are not always compatible.

1. Broad access for small usage fees. Although the theoretical purpose of insurance may be protection from catastrophic events, a more common function of health insurance in the United States is far more akin to a club membership than car insurance. In exchange for an annual fee, beneficiaries receive access to free or low out-of-pocket cost services, such as routine doctor visits. These services are largely predictable—such as well-child visits for people with children or medication refills for people on lipid-lowering medications. Policies aimed at the club membership function generally aim to customize policies to people’s needs. Medicare beneficiaries enrolling in Part D prescription drug coverage, for instance, enter the medications they are currently taking to find the plan that best subsidizes those items.
2. Negotiating health services. Health insurers leverage their market power to obtain price concessions from clinicians or hospitals and health care systems or, alternatively, to screen out high-cost providers from their networks. Covered patients benefit from these discounts even when paying out of pocket for services (with the exception of prescription drugs, for patients often pay list prices even when they have insurance). Policies that focus on this function of health insurance affect the negotiating leverage of clinicians and hospitals relative to insurers. Medicare, for example, sets payment rates via fee schedules, rather than allowing health care systems to use their market leverage to drive up the prices they charge. The Affordable Care Act (ACA) encouraged insurers to construct “narrow” networks of clinicians and hospitals to help commercial plans obtain lower rates through increased negotiating leverage. Insurance company consolidation strengthens the insurer’s negotiating position as well.
3. Enhancing and ensuring the quality of clinicians and hospitals. Both commercial and government insurers have developed measurement efforts that aim to monitor and improve the quality of hospitals. Examples include both quality ratings that help patients and plans select which hospitals to engage, and exclusion of certain hospitals from providing types of services based on quality. Medicare Advantage plans have quality ratings. Medicare limits which hospitals can perform the transcatheter aortic valve replacement procedure to those with adequate volume and expertise. Policies focused on this function of health insurance focus on more comprehensive measures and quality measurement.
4. Midwives get control over the claims. Midwives, along with all other healthcare providers, virtually always bill insurance companies far more than what we would expect in payments. Why? The simple answer is that we usually don’t know what to expect. Insurance companies will always pay whatever a medical provider bills up to the maximum amount they’re willing to pay for any service. So, if a doctor bills $100 for an office visit, and the insurance company is willing to pay $75, the midwife will get $75. If the midwife bills only $60 for that office visit then $60 is all he’ll receive. There is absolutely no penalty in health care for over billing, but any medical provider who under bills will short change themselves. This is why billing charges have exploded by so much in health care. This payment system is far too confusing for any health care provider to really understand, so the best strategy is to bill high for every service then take what they give us.

Some of the benefits of outsourced medical billing include:

• Dedicated specialists: Medical billing and coding companies have dedicated staffs of medical billing specialists, whose sole job is to ensure that claims are filed correctly and denied claims are resubmitted properly. Because of their specialized experience and duties, they can pay attention to the minutiae medical office employees can miss in the bustle of their daily duties.
• Fast submissions: Highly trained staff members can submit claims much more quickly and with greater attention to detail.
• Greater focus on patients: Once they’ve eliminated the time spent on billing and staffing concerns, doctors and nurses can better focus on their patients.
• Up-to-date standards: Medical billing companies are compliant with the most recent health care laws, and they are required to stay up-to-date with the most current regulations in order to meet the changing demands of serving hospital-based specialty practices.

 
There is no certain reason for you to choose between choosing cash payments or billing insurance policies for your practice than knowing what you truly need. You need to look at your specific mission, goals, area, and services wanting to provide to the community. Typically, care is a hybrid between insurance reimbursement and cash discount prepayment models of payment. It will give families choices that can fit a family that doesn’t have good and poor health insurance coverage.
 
References

Midwiferybusinessconsultation. (2020, December 11). Cash versus billing insurance for midwifery care? MIDWIFERY BUSINESS CONSULTATION. Retrieved September 30, 2022, from https://midwiferybusinessconsultation.com/cash-versus-billing-insurance-for-midwifery-care-2/

Hoffman, A. (2022, March 8). 6 proactive medical billing tips to maximize revenue: HAP. Healthcare Administrative Partners. Retrieved September 30, 2022, from https://www.hapusa.com/6-proactive-medical-billing-tips

Pranammya Dey, B. S. (2019, April 2). The 6 functions of health insurance. JAMA. Retrieved September 30, 2022, from https://jamanetwork.com/journals/jama/fullarticle/2729357

When we talk about matters pertaining to your client’s insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by different healthcare provider including midwives. But what do these terms actually mean, and more importantly what do they mean for you as a midwife? How will these affect your practice and you be able to apply these terms to your midwifery practice?

What does in-network mean?

In-network refers to a midwives that has direct contract with the health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, clients pay a lower cost-sharing when they receive services from an in-network midwife.

What does out-of-network mean?

Out-of-network refers to midwives who does not have a contract with the health insurance plan. If a client use an out-of-network provider, health care services could cost more since midwives don’t have a pre-negotiated rate with the client’s health plan. Or, depending on the health plan, the health care services may not be covered at all.
 
Depending on the coverage the client have purchased, the plan has established deals with a wide range of midwives and other specialists. These are the health care providers that the insurance company considers in your client’s “network.”  The insurer has identified a group of providers who are “in-network” and has contracted with these providers on the client’s behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that your client receive this negotiated or discounted rate for your services, and the insurance provider generally picks up a larger portion of the bill than with an out-of-network provider.

This means that as a midwife, once you’re in an agreement with the insurance company to accept your client’s plans and contracted rate as payment for your full services. This contracted rate that was negotiated by your client and its insurance company includes both the insurer’s share of the cost, and the part that your client will be responsible for paying. The part that your client’s responsibility for paying may be in the form of a co-payment, co-insurance or deductible depending on their negotiation.

Simply speaking, as a midwife, when you accepts your client’s health insurance plan we say you’re in network. You will also be called as “participating providers”. When you don’t take your client’s plan, we say you’re out of network. The two main differences between them are cost and whether the plan helps you receive enough value for the care you provide as out-of-network provider.
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Healthcare is an important aspect aspects of our daily lives. As a healthcare provider, we are expected to give the best services to our clients and in order for our practice to keep on growing we must receive proper compensation out of that service. Remind your clients that they can avoid unexpected medical bills by knowing how their plan works. Certain choices they make can affect what they'll pay out-of-pocket. Know the difference between in-network and out-of-network care to help them save on health care expenses.

Reference

Outreach & Education. CMS.gov Centers for Medicare & Medicaid Services Health Insurance. (n.d.). Retrieved May 13, 2022, from https://marketplace.cms.gov/outreach-and-education
https://www.desertridgeperiodontics.com/pdf/In%20Network%20vs%20Out%20of%20Network.pdf