​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/

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!
 
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

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.

• The visit must use real-time, interactive, audio and visual telecommunication systems
• Practitioners can furnish these services from any location, including home

Although CMS says practitioners can also bill on-line digital E/M codes, 99421—99423 and virtual communication code G2012 and G2010, these are reported with HCPCS code G0071. G0071 will be paid at $24.76 beginning March 1, an increase from the prior rate of $13.53.
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

Midwives Advantage is a very unique billing resource for midwives in the United States.   We have created a collaboration of midwives that work together to get amazing out of network insurance contracts.  You would be joining our team of midwives that are already benefitting from the collective nature of this business approach.  

Most billing companies are working as an independent contractor of you to process claims for your low volume service needs and really have a hard time negotiating great reimbursement for you.  You pretty much get what they give you.  Our highly qualified team of billers have perfected the out of network billing system to a science for out of hospital midwives.  We are the best of the best when it comes to getting payment for midwives when no other billing company can get things done! 

Midwifery billing is such a unique specialty that many experienced billers in other service lines really don't understand all the billing and coding charges midwives offer as part of our amazing midwifery practices.  It isn't just billing 59400, but really understanding all the codes being performed and making sure that those charges are being sent out and paid promptly.  When a midwife joins our team at Midwives Advantage, we have created systems honed on specifically the midwives needs in the home and birth center setting.  Many small-scale billing companies can't compete with our results due to many billers advocating for your claims and many midwives pulling together our strength in numbers to negotiating those better contracts.

Last, but not least, we don't charge anything for our services and time up front!  Most billing companies have an enrollment fee, credentialing per insurance plan fee, retainer fee, verification of benefit fee, and other hidden charges that add up fast.  We are a flat, simple commission basis off the insurance claims you get paid on.  We get paid when you get paid!  What do you have to lose by trying our services with a couple claims and see the difference of prompt processing and high value reimbursement for your amazing midwifery care? Get paid the Midwives Advantage way today!