**This post is an addendum to The Global OB Fee Trap: How to Find and Fight It. It probably won’t make any sense unless you read that first!**
Fighting your insurance company is a pain the ass. There’s no way around it. But persistence pays off and if you fight hard enough you will usually win – whether you’re actually right or not.
In this case, you’re actually right so it should be a little bit simpler. Here’s what to do:
- Have your insurance card, your doctor’s bill (that shows what the insurance company paid and what you still owe) on hand. If the bill from your doctor doesn’t have this information on it, you can obtain it from your insurance company by requesting (or printing out from their website if you’ve set up an account) a claims summary statement. Shoot me a message if you need help locating this information.
- Call the Member Services Center and tell them you have questions about a medical bill.
- When you get someone on the line, save your breath. Give them your member ID number and confirm your birthdate – yada yada yada – before launching into your story.
- When they ask what’s wrong, tell them which claim you are disputing so they can bring it up in their system. Then proceed by confirming facts with them one step at a time – so that they walk themselves into a little trap. Start by confirming that your plan covers all preventative care with “first dollar” coverage as required under the affordable care act.
- Then, confirm with them that routine prenatal visits are considered preventative care. (They should say yes – but if they don’t, remind them that all well-women visits, including well-women prenatal visits, are considered an essential preventative health benefit under the ACA. My insurance rep initially fought me on this one, and then after I insisted, she put me on a brief hold to check with her supervisor. When she came back she apologized for being misinformed.)
- Next let them know that your received a Global OB bill that included the cost of the delivery, as well as the cost of your prenatal visits – and ask them why your prenatal visits aren’t being paid for in full AS REQUIRED BY LAW. When they tell you it’s because of the way your doctor billed them, remind them that according to their own provider handbook (this is true for Harvard Pilgrim, and I bet most other insurance companies, but check with Google) doctors are NOT ALLOWED to bill OB visits separately and MUST use the Global OB code instead. Then piece the puzzle together for them and tell them that if they can’t pay the preventative portion of your bill in full, and they won’t let your doctor bill them differently, then they are breaking the law. Tell them that you would prefer not to get your lawyer involved, but that you will if you have to.
- When the rep gets exasperated (and likely confused – they probably don’t understand the system) they will probably tell you they’re sorry but there is nothing they can do. Be sympathetic, but firm. Remember – there really is nothing a front line member services rep can do. Their hands are tied and you don’t need to shoot the messenger. Tell them that you understand they can’t do anything personally, but that you feel strongly about this and would like to speak to a supervisor. They’ll resist this is long as they can. Just keep repeating yourself. If they really resist, use phrases like: “If I can’t speak with someone who can handle this directly, I’ll have my lawyer contact you via certified mail” and/or “I really would like to resolve this on my own, but if I need to file a claim with the state insurance commission, I will.”
- You will probably end up either being transferred to a supervisor (in which case repeat steps 3-7 until you get someone on the phone that can actually reprocess your bill) OR they will tell you they’re going to “look into it” and call you back. If that’s the case, ask for the representative’s name, direct phone number and when you should expect to hear back.
- If you don’t hear back in the specified time frame (you won’t), call back and ask for the status of your claim. Call every day until you get a response. Remind them each time that you intend to fight this claim in court if you have to. Use the word lawyer, use the word insurance commission. DON’T BE INTIMIDATED. Insurance companies win these battles because they wear people down. Be a
beemean-ass wasp in their bonnet. Pester them incessantly until they eventually throw their hands up and reprocess your bill. It took me almost 3 weeks, but they did eventually give in. - Remember, the goal is to have your bill reprocessed so that the preventative portion is paid in full, and the diagnostic portion applied to cost sharing. If they ask “what do you want/expect us to do about it” tell them that. You can also share with them that other insurance companies (United Healthcare) are using a percentage basis to pay out Global OB claims, with 44% being considered preventative and 56% considered diagnostic. This can help them to realize that this is an actual issue other companies are having to deal with and not just some nut job on the phone making shit up.
- All in all, try to keep your tone polite but firm. Don’t freak out and yell because then they’ll write you off. And if after weeks of persistence you still aren’t seeing results – file a complaint with your state insurance commission. Here is the link to the Maine Insurance Commission – but if you live in another state you can Google it or ask me and I’ll find it for you 🙂
I know this seems like a LOT of work (it is). But it’s worth it. Because if enough people do it, eventually they’ll have to change the system. And if they change the system that’s a lot of dollars we will have collectively kept in our pockets. And those dollars pay for diapers, ok? They prevent shit from getting all over your house.
So if you don’t like shit, then just do it. Basically.
Oh Baby Richards 
Hello!
I had some issues with billing for a women’s wellness appointment last year, so when I got pregnant recently, I started doing a lot of research before choosing a doctor. I’ve been reading all your articles about the Global OB fee, and would really like to talk to you more about it if possible. Your advice for fighting a global maternity bill is great, but how can you avoid it before the fact?
Every doctor that I’ve called in the area says they have Global Maternity packages and will be accordingly with the average being about $6000, for normal vaginal delivery (59400). Your $2950 bill didn’t seem so bad once I started hearing that!
Hope to talk soon!
Hi Maria,
Thanks for getting in touch! Unfortunately there isn’t too much you can do about it before hand because I doubt you will be able to find a doctor that bills without a global OB code, since that is standard now and most insurance companies require it. It isn’t the global code in and of itself that is the problem, rather, how your insurance company processes it. What you could do is call your insurance company ahead of time and ask how they process global OB bills in terms of separating the prenatal preventative portion and the delivery (diagnostic) portion. If they tell you they bill it as one service and do not separate the preventative portion then you can let them know they are in violation of the ACA. It may help to do this ahead of time, although I suspect it will be harder to fight them when you don’t have an actual bill to actually refer to yet – but you may be able to make some headway. I’d be happy to talk to you more about it if you’d like – I’ll drop you an email!
Hi Hannah, thanks so much for the info. My insurance contract says that prenatal care is subject to copayment and coinsurance. When I called to ask about the prenatal appointments they said that deductible applies to those and then it is my coinsurance amount. When I brought up ACA and the question of shouldn’t those be preventative, they said that what my contract says is what correct info is. If this is the law, then is my insurance plan in violation of the law? I know your post is from 2016, so I’m wondering if there were any changes in 2017 that allowed insurance companies to make it non-preventative. Your help would be huge! Thank you so much!
Hi Elena,
This will be a bit tougher of a battle to fight, only because the issue isn’t global billing, it’s that your insurance company isn’t covering prenatal care as preventative, period. This IS in violation of the ACA, but as usual, it comes down to semantics within the law so the insurance company will certainly have some kind of justification for interpreting the law to not include prenatal visits as preventative.
There is precedence to fight it but you will likely want to involve you state insurance commission to help you – I promise, it’s not as hard as it sounds!
This piece (the IOM report used to update the ACA in 2016) will likely be helpful to you when fighting your insurance company. The fact that they told you nothing in pregnancy is considered preventative care (and wrote that in their handbook) is in direct violation of the ACA. The link below quotes the exact text from the IOM report and states that all prenatal well-woman visits MUST be covered without cost sharing beginning December of 2016. If your plan year started before that date, it may be grandfathered until your new plan year starts, but if they change(d) the plan or price AT ALL in 2017 they will be required to adopt the new rules.
http://www.healthlaw.org/issues/reproductive-health/well-women-visits-prenatal-care-under-the-acas-womens-health-amendment#.WilmnhNSxTY
Also, be prepared that your average customer service agent is NOT going to be able to fix this for you, since it requires actually changing their policy. You will likely need to either get (or threaten to get) a lawyer, or get your state insurance commission involved to help you pressure them. I know it sounds like a lot of work, but if you do it you will create wonderful change for so many other women! This is what I did in my state and my insurance company did end up having to change their policy and reimburse hundreds of thousands of dollars to women across Maine. So it does work!
When you initially speak with the insurance company, insist on being escalated to the “higher ups” in the company – they are the only people with power to change this for you. Lastly, if your insurance is through your employer, they likely have a company that is managing the policy for them. If that is the case, ask for that company’s contact information, explain the situation, and they may be able to help you fight this. Good luck, and let me know how it works out.
Wow! Thank you so much for such a detailed and quick response, Hannah! It’s much appreciated. I think going through the state insurance commission might be a good call. In my case, it’s a bit tricky since the plan that I have is the plan of Oregon, and I reside in California. I think going through the state insurance commission of Oregon would be a place to start since this is where the insurance company is and they operate under their governing laws. I’ll let you know if we get anywhere with it. Thanks much!
Hi
This is really a useful post. I am in the same boat as you were. I have not delivered yet but struggling to get this straightened with my OB and insurance. My OB wants me to pay 600 dollars up front before delivery which is 20% of all the charges. Please provide suggestions on how to handle this.
Thanks in advance.
Hi Harini,
Unfortunately, if your OB requires you to pay upfront you will either need to make the payment, or find a new OB. They aren’t doing anything wrong by charging for their services – and in all likelihood you will owe at least 20% of the global OB bill (depending on your deductible and cost sharing). SO they are basically just covering themselves by getting that money up front. Once you deliver, you’ll want to make sure your insurance company pays at least 40% of the global bill in full (not subject to cost sharing or deductible) as that is the preventative portion of the fee. The remaining (delivery) portion of the global fee would be subject to your deductible/cost sharing. So, unfortunately there isn’t much you can do ahead of time except call your insurance company and confirm with them what portion of the global OB fee they plan to cover. If they aren’t planning to pay at least the preventative portion of the bill then you should fight them on that (see some of my responses below for tips on how to fight them). Best of luck!
Thanks for these great articles and for sharing. I am presently pregnant and have had these questions but could not find answers. How do you find the billing handbook for your insurance provider? I have googled to no avail. Any help is appreciated! thanks
Hi Elizabeth, are you looking for the benefits booklet (the one that tells you what services are covered and to what extent), or the billing handbook (which is given to providers/doctors to instruct them on how to send in claims)? If you’re looking for the benefits booklet, just call your insurance company or plan sponsor (employer) and request a copy be mailed or emailed to you. If the latter, you may need to ask your doctor to share it with you since that is technically for the doctors, not the members. I would think if you called your insurance company and requested a copy of the billing handbook they are likely (I don’t know for sure) legally obligated to show it to you but I’m guessing they will give you some resistance. Be confident and persistent and I think you would be able to get them to send it to you, especially if you are threatening legal action.
Question for you: my OB pre-billed memfor the delivery before it even happened. Is that normal? Would I be allowed to decline that and make them bill through my insurance first? The OB made it seem like that was just how it was done (pre-paying $3,000) but now I’m really questioning that!
Unfortunately, yes, your OB is allowed to pre-bill you. What they likely did is run the cost through your insurance model to determine what you are likely to owe after insurance – then after your delivery they will bill your insurance and if the insurance pays more than expected, they will reimburse you, if they pay less, they will bill you the remainder. Basically, they are just covering themselves financially by billing you for your portion in advance. Once you do deliver and you get the explanation of benefits from your insurance company, make sure they are paying the preventative portion (at least 40%) of the global OB fee. If you do end up having to pay the full 3k, I would say the insurance did NOT properly process the claim and I would look into it further. Good luck, let me know how it works out!
Hey Hannah-
Building on this question or asking again because I’m not clear. Are we as the patient able to decline the prepay and just pay after delivery once the code has been submitted? It seems like that should be a patient right but just curious. Especially because the majority of the stuff before delivery shouldn’t even cost anything or much at all.
Hi Grace, unfortunately most providers do require you to pre-pay. However, it’s not really their fault. They have to do this to protect themselves because they can’t submit a claim to your insurance company until after the delivery – so they would be treating you throughout your pregnancy (almost 10 months) without any compensation – and then if for some reason your insurance company doesn’t pay, or pays less than anticipated, they would be stuck trying to collect that money from you which is a difficult and time consuming task for providers, especially for smaller private practices OBs. My experience has been that providers are caught between a rock and a hard place in terms of being forced by insurance companies to use the global OB fees (vs. submitting individual claims throughout the pregnancy) and you should focus on working with your insurance company to ensure they pay the correct portion of your global OB fee, vs. trying to get providers to waive the prepay, which puts them in a tough spot and doesn’t fix the issue with the insurance company not paying their fair share. Hope that’s helpful – and sorry you’re struggling with this!!
Could you tell me what labs or screenings are covered? I’ve seen conflicting information on the iron deficiency anemia screening.
Hi Vivian, this is a good resource for what is specifically outlined in the ACA as preventative care for women: https://www.hrsa.gov/womens-guidelines/index.html. However, there are other routine tests (such as anemia and iron deficiency) that some doctors bill as preventative and others get coded as diagnostic. The cloudiness of all this is a huge frustration for patients and doctors. Since those tests are not specifically outlined, I would ask you doctor how they code them, or call your insurance company to find out specifically what they consider preventative. Good luck!
My experience dealing with my wife’s insurance and the entire process of trying to get them to pay for her prenatal care has been a nightmare. This past year I have been a frequent visitor of your ACA and global billing blog post for information/inspiration. My wife had a high deductible insurance plan with Anthem that followed the 2017 calendar year. At the start of 2018, her insurance switched to a new insurance and our daughter was born shortly after. The doctor’s office had to split the bill between two insurances, so they couldn’t “global” bill for all services. Her doctor billed all prenatal services to Anthem, and delivery + postpartum to the new insurance. In February we got the bill from the doctor for prenatal care. Anthem considers prenatal to be part of the maternity benefit, and therefore according to the benefit plan, maternity charges are applied to the deductible. In my opinion, this is a workaround to try and get around paying for the service. I tried to handle it though customer service, but I got the standard language of prenatal is considered maternity, not preventive…etc. Her doctor’s billing office tried to fix but got the same responses. We requested an internal appeal stating that since my wife had a non-grandfathered plan, her prenatal care was a preventative service required to be covered with no cost-sharing. We included copies of the HRSA Guidelines and the HHS ACA FAQ’s clarifying prenatal care is included in a “well-woman visit.” Anthem obviously upheld their decision, not really explaining why. We then requested an external appeal with the state. We live in Ohio, and apparently the state doesn’t have the authority to make a medical judgement on the case. so they had to send it to an IRO to determine if the care my wife received was maternity or preventive. The IRO returned upholding Anthem’s decision stating that since prenatal wasn’t specifically listed under the preventive care section in our contract, it’s not covered by the preventive benefit. For lack of a better word, that response was bull…, because we never were requesting a review based on our policy, but based on federal guidelines (and for the record prenatal care isn’t specifically listed under Maternity either in my wife’s certificate). We filed a complaint with the Department of Insurance to look into the claim, however since they cannot make a medical judgement by law, and the IRO findings said the service wasn’t preventive, there was nothing they could do. I called HHS and was sent to the CIIO department who enforces the ACA. I was told they can’t do anything because legally Ohio is the one who enforces the law. Therefore it seems our only option now is to get a lawyer and sue, which doesn’t seem feasible. Honestly I think the insurance purposely designed the system this way. The total cost of care was expensive, but not quite expensive to warrant a lawsuit. So it seems Anthem successfully has found a scheme to skirt the law because we don’t know what else to do at this point.
Wow. I am SO sorry to hear about everything you’ve been through. That is truly despicable. But you’re right – the insurance companies know the law and have armies of lawyers to help them get around it. The only advice I think I can give you at this point is to take it to the court of public opinion. When I got to the end of my rope with Harvard Pilgrim, I called my state senator and had a meeting with her. She took my complaints to the state attorney general who pressured Harvard Pilgrim to change their billing policy, and actually refund hundreds of people across the state of Maine. If they didn’t make the change (they did) I was ready to go to the local newspaper with my story. I would try contacting a state senator or other representative and explaining your story and all your evidence about the insurance company skirting the law by writing a policy that violates it. If you can’t get them to take action, go to a reporter with your story – they usually love a good scandal. Hopefully we can bring enough attention to this issue that insurance companies are pressured to come into compliance. They have armies of lawyers but if public opinion and local politicians start calling them out they will eventually make changes. Thank you for taking your case through all the avenues that you already have – it’s people like you that will eventually force their hand and create change for the next group of mothers/families.
Does this still apply as of August 2019? I am concerned that some of the ACA has been repealed since this post. I am experiencing the same frustration with Florida Blue not understanding my maternity coverage coupled with my OB office collecting up front, by my 20th week of pregnancy my global maternity fee of $768. Florida Blue does have physical offices to inquire about coverage issues, etc. Am I better off taking this issue up in person vs telephone to get 40% of my global fee reimbursed? Thank you for your help. We need to change this!
Hi Candice, to my knowledge this does still apply. The part of the ACA that was repealed was the individual mandate, not the preventative care coverage. However, it can be complicated depending on how your healthcare plan is worded. The first thing you need to do is confirm that your plan covers prenatal visits as preventative well checks. If they don’t they are in violation of the ACA but you may need the state insurance commission to help you fight them on that one because it comes down to how they interpret the wording of the law. If they DO cover prenatal visits as well checks, than you can use some of the wording and resources in my post to help explain to them that the “well-check” portion of your global OB fee needs to be paid as preventative (i.e with no cost sharing). The 40% is just an estimate, they will give you their own number, but it should be somewhere in that realm. You may have more success going into the physical office, but I’m not sure, I never had that option. Also, its worth noting that you would still need to pay your doctor upfront – most OBs require that to protect themselves, and typically they are only asking you to pay the portion that they expect will be remaining after insurance pays their part. If insurance reimburses them more than anticipated, they should refund that money to you. Feel free to message me on instagram if you have other questions!
Thanks for sharing these steps! I am finding navigating the health care system to be extremely frustrating. I, unfortunately, had to switch health insurance companies partway into my pregnancy due to being laid off.
If you have any articles on being able to get short-term disability while pregnant please share. I lost my short term disability because my company had a corporate policy that I could not extend. My new short term disability does not cover me because I was pregnant before I qualified for benefits.
Hi Heather, it can definitely be really frustrating trying to navigate our super complicated healthcare system – sorry you’re going through that. Unfortunately I don’t know much about short term disability, although I do know those policies are not regulated the same way health insurance policies are so the “rules” would really depend on your specific policy. For mine, there were all kinds of waiting periods, etc and I only ended up getting paid a pretty small amount during my maternity leave. It is definitely possible that your new policy has a pre-existing condition exclusion, and pregnancy would be considered a pre-existing condition so, that’s a bummer. But maybe since you were continuously covered they would make an exception? It’s worth taking a look at the fine print of your policy or talking to someone in the HR department at your new job about that. I hope you’re able to figure something out – let me know if there is anything else I can do to help!
Thanks for your feedback, it’s greatly appreciated!
Hello. Im still in the middle or my prenatal care ..have not delivered yet. My doc office said my insurance covers 85% of their global bill so i pay 15% upfront. After viewing my insurance plan, I saw that under maternity care it said 0 copay office visits and $5 for specialist. Even get free ultrasounds. And then 15% is my portion for hospital delivery. At first i thought my doc office was trying to rip me off. Iij nhad them look into it she talked to my insurance again and explained its bc of the “global billing 5400 code ” its the way they bill and that i pay 15% according to my ins. So then i called my ins. And they told me ya some doctors bill that way. In advance witb a global fee. You might just have to find another doc if ur not ok with that. Some do that global fee and some bill per visit she said. Hmm. So i got curious ab ok ut this ghb lobal billing and started googling..read up on the explanation of it ans then found your article which was mind blowing. Now im even more mad. Lol. So basicall does this mean i have no choice but to wait til im billed after to deliver to see what im charged and then fight anything?
Hi Diane, in my experience the vast majority of doctors DO charge the patient responsibility portion fo the global OB fee upfront. This is normal, because with the global OB code billing, they don’t get paid at all until after you deliver ((+ months later). The thing to look out for is when your insurance company processes the global OB fee, they need to split it up so that you are ONLY paying cost sharing on the delivery (diagnostic) portion of the bill. It’s hard to know the exact amount because the prenatal care and delivery fee are combined into one lump sum – but a general rule of thumb is that the delivery portion should be no more than 40% of the total fee. So you should only be charged cost sharing (depending on your plan your cost sharing could be anywhere from 0-100%) on 40% or less of the total global OB fee. For example – if your global OB fee is 2,000, and you have 20% coinsurance, you should be charged no more than $160 ( 20% of $800 – which is 40% of the 2,000 total). If your insurance ends up paying more than expected, your doctor’s office will refund you the difference that you already paid to them. Let me know if you have any additional questions. It sounds like your insurance company is expecting you to pay 15% of the total fee – the question is whether that 15% is your normal cost sharing (in which case you should only being paying 15% of 40% of the total bill) OR whether they’ve determined that the delivery is 15% of the total global fee and you are required to pay 100% of your diagnostic portion. I’d have to see your insurance benefits summary to know which one it is. Best of luck!
Ok , Wow! I am actually doing these exact steps now! I just sent a comment to your original article on this before reading this one. The only difference for me is that I haven’t started my OB appointments yet. My OB has quoted me $2400 for the lovely global billing fee. My policy (confirmed by 5 insurance reps) covers all maternity care including standard labs & ultrasound 100% deductible & co-pay waived for the first 5 visits ; visits 6+ are a $20 co pay , deductible waived. So this is a lot of money at stake! My doctor will not budge on billing this any differently. Which I realize , he’s not allowed to. So , I had a supervisor from insurance contact me today & is looking into this she says. She is supposed to get back to me by Sept 14. She also said that my plan “really may not allow other options besides global billing”. BS! My plan states prenatal is 100% covered! Of course , I need to start going to my appts. Am I too early in fighting this battle? Or , should I keep on until I get a guarantee from the insurance company or permission from insurance to allow my doctor to bill differently?? I can tell this is going to take a lot of time & effort on my part.
Hi Lauren,
Sorry you’re going through this. What I recommend you ask them to do is cover at least 40% of the global OB fee (40% is an estimate of the percentage of that fee that is for prenatal care – the other 60% is the delivery which is typically coded as diagnostic and therefore applies to your deductible). You probably won’t be able to get them to cover it up front because they can’t pay a claim until your doctor submits the claim, and your doctor can’t submit the claim until after you deliver. Instead, I would ask them to put in writing what percentage of the fee they WILL cover once the claim is submitted, and send that letter to your doctor. Typically your doctor is only going to ask you to pay up front the portion of your global OB fee that insurance isn’t going to pay. So if your insurance puts in writing how much they’ll cover (which should be at least 40%), you should only have to pay the remainder of the fee (up to your deductible amount) up front. The common objection from insurance companies is that they can’t split a claim and process part of it as preventative care (prenatal) and part of it as diagnostic (delivery) – my response to that is that they then have to process the entire thing as preventative and just pay it all because otherwise they are in violation of the ACA which REQUIRES them to pay for prenatal care 100%. If they require the doctor to bill a global fee, and they can’t split that fee – that’s a them problem, not a you problem – so they have to pay it. If they refuse, you’ll probably have to wait until after the claim is processed because you’re unlikely to be able to get the state insurance commission involved until you actually have a claim on file. But once that happens, if your insurance company doesn’t comply, immediately report them to the state insurance board. Usually they’ll just pay it at that point to get you off their back. I know it’s a hassle and it absolutely shouldn’t be this hard but unfortunately most people do have to fight to get it paid correctly. So sorry you’re going through this – and best of luck with your pregnancy!
Thank you for this blog. If it wasn’t for you writing about this I would be lost! UPDATE: Well , to my surprise the supervisor did contact me back. She provided no answer so I demanded to be escalated. I’ve since spoken with 2 different managers. They are clueless. The second manager actually called my doctor’s office & asked the receptionist if a breakdown of charges can be provided to her. I keep explaining the global bill until I’m blue in the face. My husband’s employer plan (which is what we’re on) is self funded & uses a third party administrator. I found out 2 calls ago that the third party administrator uses a third party administrator! So I’m not even speaking directly with the company. The lack of understanding is just making this harder & I think the administrator knows this therefore just forwarding the same scripted answer to the reps to get me to go away. I find it so hard to believe that the plan administrator wouldn’t have a response for global billing.
So – where I’m at today is I put in a call to my husband’s company’s benefits department since the plan is self funded. If anything , the benefits department needs to know how poor the customer service is of their 3rd party administrator’s 3 rd party – make sense?
I’m beyond frustrated. I keep pushing because my doctor’s office has said that if I can provide anything in writing about the insurance portion , then they’ll only collect portion of the global bill. I’m so angry that this is what women go through!!
Ugh, I’m so sorry you’re going through this – but also great job on pushing through and not letting them scare you away. So many people just don’t have the energy to fight and that’s how this continues on and on. I definitely think contacting your husband’s benefits department is a good next step. They can often help you escalate a claim – or may choose to just pay the claim for you if they care about the wellbeing of employees. Good for you for using all your resources. Keep me updated on how it works out!