I usually write in this blog about babies and breastfeeding and potty training and other cute and gross and funny and sentimental things. So I apologize in advance for this one. It’s about insurance.
Don’t leave. I know insurance is not what anyone wants to talk or read about but please please please, I will sprinkle cute baby pictures throughout if you just hear me out on this one. It’s important. To me and to women everywhere.
See, our healthcare system in the US is pretty much fucked. And as much as I’d like to go all Erin Brockovich on this one and change the system it just ain’t. gonna. happen.
BUT there is one thing I might be able to change. And it starts with getting the word out since I’m willing to bet most people who have an infant at home just pay their medical bills and get on with it and don’t actually check to see if their insurance company is paying their fair share (spoiler alert: they’re not).
I know the last thing new moms have time for it fighting their insurance companies. I really, really know.
But do it anyway.
Do it anyway so the next generation of moms doesn’t have to.
So here’s the deal.
This whole battle started out over $590. Yet another bill for Lucy’s birth on top of the thousands I had already paid that I didn’t expect and couldn’t afford. My insurance company should have paid it, and yet again they were deferring the cost to me. My dad implored me to fight it, and I told him “I have a 2 year old and a 2 month old. some days I don’t have time to brush my teeth, how do you expect me to find time to fight a billion dollar insurance company?” But I didn’t have the money to pay, so I fought it anyway. I fought and fought and fought and finally, I won. I won the battle (they paid my bill) but not the war (they still aren’t paying other women’s bills).
In the beginning I said, I can’t be the first person to figure this out. I can’t be the first person who’s pissed. There are hundreds of new mothers across the country who are lawyers, lawmakers, legislators. Surely one of them has already tried and failed to defeat this. But that’s a dangerous way of thinking. Because if that’s what we all say, well, that’s how we end up here.
So I’m not a lawyer, I’m not a legislator, I’m not anything special but I am a mother and let me tell you, motherhood makes you fierce.
Ok, so here’s what’s going on.
Back in the day insurance companies billed for each OB appointment separately. Each prenatal appointment was a separate bill, then the delivery, the postpartum checkup, etc.
Then the affordable care act was signed into law and insurance companies were suddenly subject to a whole new set of mandates including one that required them to pay for all preventative care (i.e. prenatal visits) in full, without any member cost sharing. (In case you don’t speak insurance, that means they pay for the whole thing and the patient shouldn’t receive any bill whatsoever.)
But anyone that has been to the doctor since the affordable care act was passed knows that this pretty much never happens. They always find some way to charge you something – whether it’s covering the vaccine but not the actual giving of the shot (yup, that happened to me), or having a service covered but not available anywhere in your state (again, been there). All of their little workarounds piss me off, but this one really put me over the edge.
Now, they’ve come up with a way to avoid paying for prenatal preventative care.
Basically what they do is instead of billing each OB appointment separately, they bill the entire pregnancy in one “Global OB Fee” after the delivery of the baby. So they lump the prenatal visits, delivery and postpartum checkup into one bill – with one code.
And therein lies the rub.
Since all the appointments are lumped together into one bill, they code the entire thing as diagnostic care and apply it to the member’s deductible or cost sharing. Even though a large portion (arguably the majority) of the cost of that Global OB Fee is for prenatal visits, which are preventative and should be paid in full by the insurance company.
But instead of paying them, they combine it with the diagnostic service (delivery) and pass the cost on to the patient.
Hellz to the NO.
cheap smart broke I go ever every bill with a fine tooth comb before paying it – and when I got a bill from my doctor after Lucy was born, I noticed something was off. NOTE: The bill you receive isn’t called a “Global OB Fee,” and you probably won’t see that phrase anywhere on it. That’s just how providers refer to this type of global procedure coding. The bill will simply look like a bill from your OB or midwife. Since the bill comes after the baby is delivered, most people mistakenly think it’s a bill for their doctor’s delivery fee, but in reality, all of the prenatal charges are lumped in there too. The only way to find out exactly what was included in the bill is to ask your doctor, or ask your insurance company how it was coded (there are 5 different global OB codes). In general, if the amount billed to insurance (remember, the amount that you actually owe is likely less) is over 1000 dollars, then it is probably a global OB fee, and not just a delivery charge. Also note that this fee is separate from the charges you will likely receive from the hospital and/or anesthesiologist. The global OB charge is specific to services performed by your doctor.
In my case, the total amount billed to insurance by my doctor was $2,950 dollars. That included prenatal visits, vaginal delivery and a postpartum checkup (I know because my doctor informed me of this upfront). My insurance company processed the bill as diagnostic care, and since I had already met my deductible (because for some reason an uncomplicated vaginal delivery + 24 hour hospital stay costs 15k dollars) they applied the entire amount to my member cost sharing. They paid 80% and left me with a bill for the remaining 20%…$590 bucks.
Hold up though.
A large portion of the $2950 that my doctor billed the insurance company under the Global OB code was for my prenatal checkups, which, according the ACA (and my insurance company’s benefits handbook) are considered preventative care. So according to the law, the cost of those appointments should be paid in full by the insurance company. The remainder (i.e. the delivery/diagnostic portion of the bill) should then be applied to my member cost sharing. This would have brought the bill down to somewhere between $200-300 bucks.
But instead, they billed the entire Global OB fee to my member cost sharing. NOT LEGAL.
To make a long story (sort of) short:
To make a very, very long story short, I decided to fight them. I did incredible amounts of research on the exact language of the Affordable Care Act, the benefits included in my specific healthcare plan, and how other insurance companies process and pay claims billed with Global OB codes. What I discovered is what I already knew – that these Global OB codes have created a conundrum for payers (insurance companies) in that they combine both preventative and diagnostic care under one code – and the insurance company’s software doesn’t know how to divide up the bill and pay it accordingly (full coverage for preventative, cost sharing for diagnostic). Whether this is an unfortunate outcome of a new system (yeah right), or an intentional workaround to avoid paying for preventative care (more likely) – it is ILLEGAL.
Some healthcare companies have already made changes.
I discovered that at least one major health insurance company (United Healthcare) has already implemented a percentage system in which they assume 44% of the Global OB bill is preventative care and 56% is diagnostic – and pay out the claims accordingly (i.e. insurance pays 44% and the remaining 56% is applied to member cost sharing). The following quote is from the United Healthcare benefits handbook, further reinforcing my assertion that applying an entire Global OB bill to member cost sharing is not legal.
The other (legal) option is for them to separate the bill into individual appointments and pay out each claim individually (like they used to do back in the day) – but this takes significantly more time for both the insurance company and the doctor, and in my case, Harvard Pilgrim’s own Provider Handbook states in no uncertain terms that doctors may not bill appointments separately (as described above), and instead that they MUST bill using the Global OB codes, or they won’t be paid.
I fought my way through three member services representatives and one supervisor before finally getting word that Harvard Pilgrim had agreed to reprocess my claim – and ended up paying the entire thing (not just the preventative portion) – more than they legally had to.
Why would they do that?
They paid my entire bill (instead of just the preventative portion) for two reasons. The first is that their processing software has only two choices for how to pay out a bill with just one code – preventative (pay in full) or diagnostic (apply to cost sharing). Since their own software wouldn’t let them divide up the global bill they either had to pay all of it, or apply the entire thing to cost sharing.
They opted to pay the entire thing because they realized it was cheaper for them to pay my bill then battle it out in court, and because if I took them to court and they lost, they would have to change the way they bill for everyone. A very expensive proposition.
The battle is won but the war continues.
So my battle with Harvard Pilgrim is over, but the war is not. They paid my claim, but they still aren’t correctly processing Global OB bills for many other women. And in order to get them to make a systemic change in the way they pay for obstetrical care we need to CONTINUE to put the pressure on them. And there are a couple ways we can do that:
- If you had a baby recently (or are having one soon), fight your insurance company AND FIGHT HARD to force them to pay their fair share of your Global OB bill. Even if it only saves you a few hundred bucks – it saves women collectively millions. Millions that belong in our pockets for diapers and daycare – not private jets for insurance company executives. (Here are Some Tips for How to Fight Your Global OB Insurance Bill)
- Contact your state legislator and ask them to hold insurance companies responsible for covering preventative obstetrical care as required by law. I’m meeting with one of my state legislators next week to discuss this very issue.
- Share this post to bring attention to insurance companies that are circumventing health care laws and get it in the hands of influencers like the media, legislators, lawyers, etc.
Get in touch.
If you have questions about an obstetrical bill from your insurance company, you’d like help fighting your Global OB Fee claim, or you know someone who you think could help bring attention to or enact legislation to create change, feel free to contact me directly!
I know this probably seems like an itty bitty bandaid on an incredibly broken healthcare system. But I can’t change our healthcare system overnight. I might be able to change this.