Midwifery billing and coding are the backbone of midwifery care revenue cycle, ensuring payers and patients reimbursed providers for services delivered. With midwifery care on the rise in the United States, people are starting to hear about midwives and home birth. Midwifery offices receive money from private insurances providers and various healthcare programs, such as Medicare and Medicaid, which are provided by the government. Receiving proper funds allows the midwifery business office to stay open. With suboptimal reimbursement, it is difficult for them to provide stellar healthcare to patients.
Midwifery billing process is a series of steps completed by billing specialists to ensure that birth professionals are reimbursed for their services. Depending upon the circumstances, it can take a matter of days to complete, or may stretch over several weeks or months. While the process may differ slightly between birth centers, here is a general outline of a medical/midwife billing workflow.
1. Patient Registration
Patient registration is the first step on any billing flow chart. This is the collection of basic demographic information on a patient, including name, birth date, and the reason for a visit. Insurance information is collected, including the name of the insurance provider and the patient's policy number, and verified by billers. This information is used to set up a patient file that will be referred to during the billing process.
2. Financial Responsibility
The second step in the process is to determine financial responsibility for the visit. This means looking over the patient's insurance details to find out which procedures and services to be rendered during the visit are covered. If there are procedures or services that will not be covered, the patient is made aware that they will be financially responsible for those costs.
3. Superbill Creation
During check-in, the patient will be asked to complete forms for their file, or if it is a return visit, confirm or update information already on file. Identification will be requested, as well as a valid insurance card, and co-payments will be collected. Once the patient checks out, birth reports from the visit are translated into diagnosis and procedure codes by a coder. Then, a report called a “superbill” may be compiled from all the information gathered thus far. It will include provider and clinician information, the patient's demographic information and history, information on the procedures and services performed, and the applicable diagnosis and procedure codes.
4. Claims Generation
The biller will then use the superbill to prepare a claim to be submitted to the patient's insurance company. Once the claim is created, the biller must go over it carefully to confirm that it meets payer and HIPPA compliance standards, including standards for coding and format.
5. Claims Submission
Once the claim has been checked for accuracy and compliance, submission is the next step. In most cases, the claim will be electronically transmitted to a clearinghouse, which is a third-party company that acts as a liaison between healthcare providers and health insurers. The exception to this rule is high-volume payers, such as Medicaid, who will accept claims directly from healthcare providers.
6. Monitor Claim Adjudication
Adjudication is the process by which payers evaluate claims and determine whether they are valid and compliant, and if so, the amount of reimbursement the provider will receive. During this process, the claim may be accepted, rejected or denied. An accepted claim will be paid according to the insurer’s agreements with the provider. A rejected claim is one that has errors that must be corrected and the claim resubmitted. A denied claim is one that the payer refuses to reimburse.
7. Patient Statement Preparation
Once the claim has been processed, the patient is billed for any outstanding charges. The statement generally includes a detailed list of the procedures and services provided, their costs, the amount paid by insurance and the amount due from the patient.
8. Statement Follow-Up
The last step in the billing process is to make sure bills are paid. Billers must follow up with patients whose bills are delinquent, and, when necessary, send accounts to collection agencies.
Like many other complicated midwifery procedures, billing may take up so much time on your end as a midwife. Billing takes a huge part on the success of your midwifery business as it makes sure that cash flow is good, making your midwifery practice run smoothly.
Bryant & Stratton College Blog Staff. (n.d.). 10 steps in the medical billing process. Bryant & Stratton College. Retrieved June 18, 2022, from https://www.bryantstratton.edu/blog/2018/january/medical-billing-process
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.
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!
Telemedicine Billing Tips
For services provided using telemedicine (real-time, interactive, audio and visual) between Jan. 27, 2020 (the day the public health emergency was declared) and June 30, 2020, CMS says to add modifier 95, synchronous telemedicine services rendered via real-time interactive audio and visual video telecommunication system, on the claim.
For services going forward via telehealth, until June 3, 2020, use modifier 95.
For telehealth services performed starting July 1, 2020 until the end of the public health emergency use HCPCS code G2025 to identify services that were furnished via Tele health in an RHC or an FQHC these claims will be paid at the $92 rate.
MACs will automatically reprocess claims with G0071 for claims processed after March 1. The new rate is a blended rate, based on the payment rates of 99421—99423, and the two HCPCS codes for virtual communication, G2012 and G2010.
Credit: Coding Intel @ www.codingintel.com