Stacy Carruth, CPM delivered her first child in a hospital in 1983 and had the rest of her children at home with midwives. She started her midwifery education in 1992. Stacy has been the administrator of two state-licensed birth centers and attended well over a thousand deliveries over the last 30 years.
Stacy used several highly recommended third-party billers to file insurance claims, and the results were the same: "Homebirth or birth centers are not a covered service. Midwives are not recognized as healthcare providers." The list of reasons to deny claims goes on. It wasn't fair that insurance would pay for a hospital birth but refused to pay for birth centers or home births. Stacy had personal experience with the injustice of insurance and homebirth. Her husband was a federal employee, and they had excellent insurance. If she had delivered in a hospital, her co-pay was $200. Since she delivered at home, Stacy paid thousands to her midwives, and the insurance paid nothing. Someone had to conquer this injustice; as a mother and a midwife, Stacy was the perfect person for this mission.
In 2009, Stacy was introduced to an attorney that won a $180M settlement from United Healthcare and a $120M settlement from Aetna for underpaying out-of-network claims. After that, physicians wanted him to terminate their in-network contracts because of the low-paying fee schedules. He formed Edge Medical Solutions, Inc. to submit out-of-network insurance claims for orthopedic surgeons, obstetricians, physical therapists, surgical first assistants, and family practice doctors. Shortly after they met, he told her about an upcoming meeting to negotiate out-of-network agreements for Edge Medical Solutions with several hundred insurance companies.
Stacy knew this was something she needed to be a part of and was the first midwife to join Edge Medical Solutions. Stacy had tried everything else to get claims paid; this was worth a try. The attorney didn't have high expectations for the claims, even with his Edge Medical agreements. She filed several claims for deliveries, and to their surprise, big checks started rolling in. After seeing the money Stacy was making, the attorney asked her how many midwives attended home and birth center deliveries. He was surprised when Stacy told him there are thousands of midwives, and out-of-hospital births are very popular. The attorney had a brilliant idea for a new company, and National Birth Centers, Inc. was born.
They incorporated his knowledge from years of experience as an attorney and Stacy's knowledge from years of experience as a midwife. They formed a nationwide business that focused solely on getting birth centers and home birth midwives paid by insurance companies. Through their system, midwives become contracted providers of National Birth Centers. They submitted claims to the insurance company with the midwife as the attending provider, and these claims were paid under the company's established agreements.
They built National Birth Centers, Inc from 2009 until 2011. In the Fall of 2011, the attorney called Stacy into his office and told her he wasn't making the money he had anticipated with the midwifery billing venture, and he was closing the business. They had come so far in billing for midwives, and Stacy knew more midwives needed this service. She couldn't let the momentum die. With his blessing, Stacy continued the business, and she has continued to a unique realm of billing for midwives.
Today, Stacy Carruth, CPM is proud to say that midwives in 38 states have realized the benefits of getting paid the Midwives Advantage way!
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.
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.
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!
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
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!