Are you a midwife who cringes when the topic of billing is discussed? Most midwives want to support families, not to sit on hold for hours with insurance companies just to speak with a representative who doesn’t know the first thing about midwifery care. If you are nodding “yes” as you read this, don’t despair – help is on its way! I love teaching midwives how to streamline their billing and coding processes to decrease the amount of time spent on billing, and to increase their payments. Midwives deserve to get paid what they are worth – and the tips described here can help you make that happen. Rather than choosing to be a cash-only business just to stay out of the ever-changing insurance world, you can learn how to tap into clients’ insurance plans to cover your services. This greatly expands the pool of potential clients while assuring the long term success of your midwifery practice.
First let’s address some of the most common questions about billing insurance plans for midwifery care. Top among these is what can be billed outside of the global maternity CPT code 59400. By knowing the ins and outs of coding, you can bill (and get paid) for services like breastfeeding support, home visits, and even for extra time spent at prenatal visits. Each claim should tell the story of all the services you performed and why – that’s what the CPT and ICD-10 codes are for. The next question I usually get asked is whether it’s best to become an in-network provider with insurance companies or stay out-of-network and only take clients with PPO plans. This decision can best be made by evaluating your community and the population you serve. Then there’s the ever-present issue of how to get your clients to pay co-pays, deductibles, and any outstanding balance that insurance didn’t cover. Most midwives find it very difficult to call a client months after the birth to discuss settling their bill. Unfortunately many of those charges end up in collections, unpaid, or being written off as a business loss.
I suggest that midwives be proactive versus reactive when they structure the financial side of their business. Plan ahead – and this is where Midwifery Business Consultation can help! You will save time and money by considering all your options and becoming aware of which decisions to prioritize when first establishing your practice, rather than waiting until you hit bumps in the road. This includes setting up billing and coding standards within your midwifery business from the start. There are so many things to think about with billing insurance companies. Let’s break it down step by step.
Before you dive into billing insurance companies for your services, you’ll want to make sure that your fee schedule accurately reflects your practice. If you haven’t assessed what you are worth – for starters, what you expect your take-home salary to be – or calculated the overhead expenses for your practice, you will have a harder time knowing what to charge. This is vital information to obtain prior to deciding whether or not to take insurance, let alone become an in-plan provider. And this is information you will need when talking with insurance companies and researching what they will actually pay for midwifery care.
Next consider the current population you are serving as well as the future clientele you want to reach. If most are in a religiously-affiliated community where cash comprises the majority of their income (and spending) stream, then staying out-of-network and doing minimal insurance processing might make the most sense. However, if that does not define the people you are serving, or if you want to expand into offering more gynecological and primary care for your clients, consider becoming an in-network provider. You might opt to contract with a variety of companies or opt only to participate with one or two that a good portion of your clients are part of. Many midwives find themselves walking a fine line, balancing quality of care versus quantity of clients. Since insurance plans typically pay less than the cash price – whether in or out of network – the more insurance plans you accept, the more clients you may need to take on.
Let’s say that you have decided to accept insurance. The next thing to consider is how you want to process the insurance claims. Do you want to file claims yourself via a clearinghouse or EHR system that has integrated billing capability? (This is often the hardest option for most midwives unless they come into midwifery with background knowledge on billing and coding.) Do you want to outsource this service to a billing company that specializes in midwifery? If so, how do you interview billers and assess the services offered versus their commission? Alternately you may decide to make a biller part of your midwifery team so you can process claims in-house. There are pros and cons to each of these options.
Typically smaller or solo midwifery practices start out accepting only cash payment, then gradually move into filing their own billing claims. However, they often leave money on the table due to lack of experience. I encourage midwives to budget for outsourcing to a biller as soon as they decide to start processing insurance claims unless they have a background in that specialty. There is a lot to learn, and it is well worth paying for expert help – many midwives find that an experienced biller saves them many times over by getting the maximum reimbursement for every claim.
Hiring an in-house biller makes financial sense if you can cross-train someone who is already working for the practice as a receptionist or office manager, or if you have a large-volume practice with at least three practitioners. Having an expert on your team can be vital to the success of a midwifery practice – this is the person who can focus on trends with payers, be alert for billing codes that may have been missed, and who can follow up on the appeal process for unpaid (or underpaid) claims. Remember, if money isn’t flowing in, it’s hard to pay your staff, your suppliers, and ultimately to pay yourself. Cash flow is the heart of your practice. Make sure you are getting paid for all the care you are providing.
Midwives who are out-of-hospital practitioners provide so many additional services above and beyond those offered in the hospital. We should be getting credit for all of our one-on-one labor support, birth supplies. birth assistants, breastfeeding support, home visits, newborn care, and extended time spent, whether at the birth or during each and every prenatal visit. Your expert biller will know which codes can be billed outside of the standard global maternity care services. They will also know which prenatal visits are considered to be included in standard obstetrical care and which ones can actually be billed as primary care visits.
Lastly, the toughest conversations tend not to be the ones midwives have with insurance companies, but the ones they have with their clients about money. The longer the process goes on, especially when there is more of a balance than a family anticipated, the harder it becomes in the end for the midwifery practice to get paid. Having a biller for families to talk to, whether in-house or available by phone, can help to improve the midwife/client relationship while also increasing both cash and insurance payments. In addition, an experienced biller can get claims processed more smoothly and with minimal need for appeals, so more of your clients can have their final obligations to midwifery care resolved quickly, and you can get paid. There can be so many advantages to accepting insurance plans and processing claims, but having the right experts on your team is vital to making a midwifery practice run as optimally as possible. Learn how to bill, or hire out those experts!
To learn more about billing and coding tips for your midwifery practice, check out our online course: Billing and Coding for Midwives | Empowering Midwifery Education (teachable.com)