To Be In or Out of Network: That is the Midwife Business Question

To Be In or Out of Network: That is the Midwife Business Question

As a midwife, you have the option to have a self pay system or accept insurance plans. Most CNMs working in private practice accept insurance plans to keep competitive with the US healthcare system. But there are a lot of questions involved in insurance coverage. How do you decide which insurance plans to accept? How do you decide if you want to stay out of network?

My suggestion to look at the major payer in your area. Does your competition accept this plan? Does the majority of your patient population have a certain insurance plan?Do you want families to find your services in their insurance directory when they are looking for an in-network provider?

In my experience, it was a big advantage to be in-network in my area. It provided me with a huge benefit when client’s were looking at my competition. Many people picked me because I was the only home birth midwife their insurance plan covered.

If an insurance plan doesn’t have out of network benefits (HMO plan), the only way you can get insurance plan to cover some of your services is to contract with them. Read the contract carefully, request a copy of their fee schedule, and estimate how many families would see you if this plan was part of your participating insurance list. You don’t want to accept an in network contracted rate if the fee schedule is less than your overhead costs to provide care. Learn your bare minimum to get paid before ever making a fee schedule and contracting with insurance companies.

Learn the steps needed for coverage (collaboration with a physician, prior authorization, referral from primary care provider to see a specialists, etc). Obstetrics is a specialty. Even though midwives are primary care providers, very few insurance plan list CNM as patient PCP (primary care provider).

When creating your business plan, always think about your overhead costs for care, mission of your practice, and what population you want to serve. This will help determine if becoming in-network with insurance plans is the best option for you.