Insurance fraud is any act made to deceive an insurance procedure. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due. It is also a deliberate deception perpetrated against or by an insurance company or agent for the purpose of financial gain. Fraud may be committed at different points by applicants, policyholders, third-party claimants, or professionals who provide services to claimants. Insurance agents and company employees may also commit insurance fraud. Common frauds include “padding,” or inflating claims; misrepresenting facts on an insurance application; submitting claims for injuries or damage that never occurred; and staging accidents.
People who commit insurance fraud include:
Common types of healthcare and insurance fraud
1. Fraud Committed by Medical Providers
2. Fraud Committed by Patients and Other Individuals
3. Fraud Involving Prescriptions
How to Prevent Insurance Fraud?
The Affordable Care Act of 2010 included fraud-fighting efforts, such as allowing the U.S. Department of Health and Human Services (HHS) to exclude providers who lie on their applications from enrolling in Medicare and Medicaid and the Improper Payments Elimination and Recovery Act, which requires agencies to conduct recovery audits for programs every three years and develop corrective action plans for preventing future fraud and waste.
Other efforts included:
Additionally, in 2012, HHS and the Department of Justice formed the National Fraud Prevention Partnership to combat health care fraud. The group also consists of private and public groups such as health care companies and their organizations, the National Association of Insurance Commissioners, the National Insurance Crime Bureau and the National Health Care Anti-Fraud Association. The groups will share information on claims from Medicare, Medicaid. and private insurance to be administered by a third-
Fraudulent acts have no escape with the law. Whether you’re a healthcare provider trying to slip away money from your clients, or a client who doesn’t one to compensate the services provided to you. Either way, one must be vigilant enough to take part in protecting his/her right and preventing these things to happen. Keep all your records intact and avoid providing your information to anyone asking for it. Always verify, verify, verify!
Background on: Insurance fraud. III. (n.d.). Retrieved June 18, 2022, from https://www.iii.org/article/background-on-insurance-fraud
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/
One significant role of a midwife is providing mothers with quality of health services. It is our duty to provide them with proper care and comfort making sure that their pregnancy journey will be a memorable one. There are many more maternal billing and coding challenges that you may encounter much especially during this pandemic. You’ve got to figure out a way to provide prenatal checkups, physical exams, annual well checks, and vaccinations because both your patient’s health and your practice’s revenue are at stake.
Global maternity care includes pregnancy-related antepartum care, admission for labor and delivery care, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. When billing for maternity care, it is crucial to understand the Global Obstetrical Package. Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.) All services must be provided by a provider with all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care.
Global Billing with CPT Code 59400-59618 Includes These Services
The Global OB package covers patient care during the entire pregnancy — the antepartum period, delivery, and postpartum. Providers get paid a flat rate for the services rendered under these CPT global obstetric codes:
When billing with the global OB codes, front desk staff, coders and billers need to be aware of visits and services that aren’t part of routine maternity care. This allows schedulers to provide accurate information on possible patient costs and billers to charge separately. Proper global package code selection is essential to receive the maximum allowed reimbursement. There are times when one code might be paid but using the correct code will bring higher insurance payment. For example, if a patient has a cesarean delivery after an unsuccessful attempt at a vaginal delivery, code 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, 67.00 relative value units) is in order.
However, if this same scenario transpires after a prior cesarean delivery, 59618 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery, 67.88 RVUs) is the proper code to use.
CPT Code 59400 Includes Only Uncomplicated Services
It’s important to note, global maternity billing covers services under normal, uncomplicated conditions. Global maternity billing does not cover:
Insurers Vary on CPT Code 59400 Billing, Payment Schedule, Duration
Global billing for maternity care is beneficial to both patient and provider when the pregnancy follows an uncomplicated course. Some variables, however, can complicate matters for the provider’s revenue cycle. Considering the global maternity billing package spans a nine-month period, that’s a big window to wait for reimbursement. Variables to consider with insurance companies when billing for global maternity services are:
CPT Code 59400 Doesn’t Always Apply
The CPT OB bundles are billed for and reimbursed when all services are rendered by a single providers or multiple providers from the same group. There are some situations that complicate global maternity billing and require the provider to bill the delivery, antepartum, and postpartum separately. These include when a:
Global Maternity Care Code Quick Reference Guide
1, P. O. (2022, April 1). CPT code 59400 Global Maternity Billing You Need To Know. Healthcare Training Leader. Retrieved May 30, 2022, from https://healthcare.trainingleader.com/2019/10/cpt-code-59400/
Billing is a function that is critical for the financial cycle of all health care providers including midwives. It requires attention to detail and experience with the electronic and paper systems used in billing healthcare services. It is clear that understanding billing procedure is important to you as a midwife. While you may see a lot of billing courses online and in some institutions, billing for your own practice is crucial and time consuming that may affect your practice as well.
Hiring a biller company could be an option that you can consider for your midwifery practice. If you will hire a biller company you can avoid doing everything on your practice like submitting timely medical claims to insurance companies and payers such as Medicare and Medicaid, preparing, reviewing, and transmitting claims using billing software, including electronic and paper claim processing, setting up patient payment plans and work collection accounts, updating billing software with rate changes, updating cash spreadsheets, and running collection reports and so many grueling tasks that will greatly affect your services.
However, after you reached into the decision of hiring a biller company, the next consideration you should deliberate is asking “who will you hire?” Do you have any specific criteria based on your needs? Background checking with their previous clients, did they encounter previous issues and how they were able to overcome those issues. To help you with that, here are some questions that you can ask a biller company before hiring them for your midwifery practice.
1. What will it cost?
This is always the main thing on everyone’s mind. The rate should be under 8% of collected charges. A percentage is a better option than a flat rate—the percentage usually goes down as your collections go up. Also ask about start-up fees, termination fees, data conversion fees, and any other additional costs. Some companies charge extra for patient collections follow up and other services.
2. Can they provide references?
Have they worked with practices that are similar to yours in size, scope, and/or specialty? Do they have testimonials, or can you call someone directly for a reference?
3. Who owns your billing data?
Your billing data should belong to you, and you should be able to take it with you if you choose to change services or bring your billing in-house.
4. What kind of training does the staff have?
Are they certified? What type of ongoing training do they receive? Are they using the most up-to-date resources and guidebooks (i.e., CPT, HCPCS, etc.)?
5. Do they have any professional affiliations?
Does the service, or its employees, maintain any professional affiliations such as HBMA?
6. Do they have a compliance plan in place?
Are they HIPAA compliant? What are their security protocols?
7. Who will actually be working on your account?
Can you meet (on the phone or in person) the actual people who will be working on your account?
8. Can you get a guarantee of transparency?
How often will you receive reports showing the financial state of your business and the billing service’s progress? How will they communicate with you and how involved will you be in the billing processes?
9. Are most of their services electronic?
In this day and age, most of the processes should be electronic from eligibility verification to remittances. They should also offer credit card processing and online bill pay for patients.
10. Are there billing follow up items that they don’t handle?
Don’t assume that a billing service will do everything or that everything is included in your rate. Ask up front and be sure you know if there are services that they don’t offer.
There are a lot of choices out there. You may have some questions that are specific to your needs, but the following ten questions should apply to any practice. Ask them to each service you speak with and then compare the answers. Use these questions to help guide your decision when selecting a medical billing service. It’s worth it to take your time evaluating your options so that you get the best service possible from the start.
Lea Chatham Lea writes educational articles to help medical practices improve their businesses. In addition to Kareo. (2013, February 26). 10 questions to ask before hiring a medical billing service. Kareo. Retrieved May 13, 2022, from https://www.kareo.com/blog/article/10-questions-ask-hiring-medical-billing-service
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!
When we talk about matters pertaining to your client’s insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by different healthcare provider including midwives. But what do these terms actually mean, and more importantly what do they mean for you as a midwife? How will these affect your practice and you be able to apply these terms to your midwifery practice?
What does in-network mean?
In-network refers to midwives that have direct contract with the health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, clients pay a lower cost-sharing when they receive services from an in-network midwife.
What does out-of-network mean?
Out-of-network refers to midwives who does not have a contract with the health insurance plan. If a client uses an out-of-network provider, health care services could cost more since midwives don’t have a pre-negotiated rate with the client’s health plan. Or, depending on the health plan, the health care services may not be covered at all.
Depending on the coverage the client has purchased, the plan has established deals with a wide range of midwives and other specialists. These are the health care providers that the insurance company considers in your client’s “network.” The insurer has identified a group of providers who are “in-network” and has contracted with these providers on the client’s behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that your client receives this negotiated or discounted rate for your services, and the insurance provider generally picks up a larger portion of the bill than with an out-of-network provider.
This means that as a midwife, once you’re in an agreement with the insurance company to accept your client’s plans and contracted rate as payment for your full services. This contracted rate that was negotiated by your client and its insurance company includes both the insurer’s share of the cost, and the part that your client will be responsible for paying. The part that your client’s responsibility for paying may be in the form of a co-payment, co-insurance or deductible depending on their negotiation.
Simply speaking, as a midwife, when you accept your client’s health insurance plan we say you’re in network. You will also be called as “participating providers.” When you don’t take your client’s plan, we say you’re out of network. The two main differences between them are cost and whether the plan helps you receive enough value for the care you provide as out-of-network provider.
Healthcare is an important aspect of our daily lives. As a healthcare provider, we are expected to give the best services to our clients and in order for our practice to keep on growing we must receive proper compensation out of that service. Remind your clients that they can avoid unexpected medical bills by knowing how their plan works. Certain choices they make can affect what they'll pay out-of-pocket. Know the difference between in-network and out-of-network care to help them save on health care expenses.
Outreach & Education. CMS.gov Centers for Medicare & Medicaid Services Health Insurance. (n.d.). Retrieved May 13, 2022, from https://marketplace.cms.gov/outreach-and-education
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!
Becoming a business owner while doing what you love is everyone’s pie in the sky. Not everyone can achieve it and only few have enough courage to do it. If you’re employed, it takes enough courage to be out of the shadows of big hospitals and other health companies. Starting your own practice is never an easy task as it takes plenty of groundwork. It needs your expertise in midwifery but that’s not all. You must learn proper ways to introduce and market your practice, maintain good leadership and management talents within your chosen team, manage your finances which is vital for your practice to cultivate and continue operating, and many aspects that you must learn first-hand so you can avoid relying to other people’s expertise making your business vulnerable.
Financial revenue and collection are crucial for a midwife business’s long-term success and probability. Collection comes from cash, co-payments, co-insurance, deductibles, non-covered services, and insurance payments. Midwives are valuable assets our health care system — all the quality and personalized care provided needs to be counted for with insurance reimbursement charges. Billing and coding are not part of midwifery education; however, running a successful private midwifery practice in today’s ever-changing environment requires understanding billing and coding.
Billing plays a vital part in your midwifery practice. Midwife billing and coding is defined as the process of determining diagnoses, medical testing, procedures, and treatments found in clinical documentation and then transcribing the patient’s data into standardized codes to bill government and commercial payers for midwife reimbursement. Keeping up with coding standards, knowing specific insurance company rules, following up with claims, and invoices take time.
Lack of proper knowledge how you will bill your patients for the services that you give is a no-no to your practice. Your revenue is your fuel for your business to operate so you must learn how to properly bill your patients. Below are some medical billing tips that is essential and applicable for your practice:
1. Get Paid for Care What Your Services are Worth
Midwives are great at catching babies, but terrible at personally valuing what those services are financially worth. Make sure your fee schedule is accurately representing your time, overhead expenses, emergency accounts, and future expansion opportunities. Many midwives do just collect cash for care, but we do challenge each midwife to work closely with a billing service to get insurance plans to pay for their midwifery care (get paid more while families are obligated to pay less).
2. Establish a Clear Collection Process
All providers need a collections process to ensure the financial health of their practice. Establishing a step-by-step approach clarifies the procedures for all involved, and it can greatly improve revenue cycles by ensuring patients are properly and thoroughly informed of their responsibilities.
3. Manage Claims Properly
Approximately 80% of all medical bills contain errors, and because of how strict insurance companies are about correct medical billing and coding practices, they’ll likely be rejected. The cycle of submission, rejection, editing, and resubmission can take weeks, often resulting in providers waiting for months before receiving payment for their services.
Because of the wasted time and effort involved in editing and resubmitting claims, it’s important that claims are accurate and complete the first time. This involves inputting the information correctly and double-checking claims for any possible errors before submitting them.
To minimize billing problems, be sure to double-check claims before submitting them and communicate with the rendering provider if any information is inconsistent, incomplete, or unclear. After submitting the claim, follow up with a representative of the insurance company and keep up-to-date on any errors they may have encountered.
When resubmitting a denied claim, make sure to check the attached Explanation of Benefits (EOB) in addition to the possible errors listed above. It’s possible that an insurance company will return a claim without an EOB or denial code attached, which makes it more difficult to identify and correct any errors. If this occurs, contact a representative of the company to ask if they can clarify which portions of the claim were problematic or if they can send the EOB.
4. Minimize Documentation & Coding Errors
Make sure all the care you are providing is being clearly documented. When an insurance plan requests additional information or audits your chart, many midwives do the care that is being billed out and not really noting it in any of the documentation, thus requiring funds needs to be given back to the insurance plans.
Within a claim, medical coders describe the performed procedures using standardized codes, making the claims easier to decipher and process. These codes can use ICD-10-CM, CPT and HCPCS Level II classification systems.
While this provides a standard method of describing procedures, errors can still occur. The most common errors, such as incorrect, mismatched, or missing codes, are often caught by clearinghouses before they become an issue. However, some common errors are more difficult to catch.
5. Promptly Handle Denied or Rejected Claims
To discuss this topic in detail, it’s important to establish the differences between a rejected claim and a denied claim. A rejected claim is one that hasn’t been processed yet due to the discovery of one or more errors. It’s preventing the insurance company from paying the bill as it’s written. A denied claim, on the other hand, is a claim that the insurance company has processed and has deemed unpayable due to a discovered violation of the payer-patient contract, or some vital error caught after processing. In both of these cases, the payer will return the claim to the biller with an explanation of the problem. A rejected claim can be corrected and resubmitted, but a denied claim must be appealed before resubmission, a much more costly and time-consuming process.
Checking for errors in a claim can minimize the occurrence of rejections and denials, but if they do occur, be sure to handle them as quickly as possible. Keep in touch with a representative of the payer — they can help clarify problems with the original claim and provide information on current claims as they are processed. All of this can help expedite the claim editing process and minimize appeal and resubmission times.
6. Look for Ways to Improve
The midwifery care world is constantly changing, and practices should follow suit if they want to maximize efficiency and revenue. By tracking performance and keeping current on the latest healthcare regulations, practices can identify problem areas and implement new ways of addressing them.
7. Know When to Outsource
Midwife practices must constantly worry about their patients, current trends in medicine and proper staff management. They must also stay current with the most recent rules about coding standards, insurance companies, and billing regulations. With so much to keep up with, details can slip through the cracks, resulting in rejections, denials, and underpayments that cost medical practices time and money.
Despite their best efforts to implement proactive billing practices, many healthcare providers still find themselves lagging behind. This is often due to the costly time and labor involved in tracking down debtors, submitting and editing claims, and staying on top of current regulation — duties often piled on top of the existing responsibilities of medical office staff.
In response to the multiplying rules and regulations and in an effort to cut labor costs, many practices have outsourced their medical billing and coding to third party specialists. For many, letting another party manage their medical billing is an effective way to increase revenue and regain control.
Billing & coding course. MIDWIFERY BUSINESS CONSULTATION. (2022, April 12). Retrieved May 6, 2022, from https://midwiferybusinessconsultation.com/billing-coding-course/
Rakow, D. J. (2022, March 8). 6 proactive medical billing tips to maximize revenue: HAP. Healthcare Administrative Partners. Retrieved May 6, 2022, from https://www.hapusa.com/6-proactive-medical-billing-tips/
There are lots of options out there for midwifery billing: hire small scale solo biller, hiring someone to train internal, or hire a nationally recognized midwifery billing service. With all the rules around billing constantly changing and each payer make up their own specific rules to learn, I would want to hire the best of the best to bring in my practice essential operating funds from care being provided. Why would you hire someone small scale that typically takes on too many clients to serve and your claims fall through the cracks frequently. Why would you take years to train an excellent biller for your practice that has to learn all the unique nuances to billing for midwives? Pay the extra commission rate to hire the best of the best! I promise you will get far more claims process quickly, for higher rates, and less obligation by families to continue to serve for community for years to come. Be a smart business owner and pick a nationally recognized billing service that has been doing it the longest and can handle supporting hundreds of midwives with their team: Midwives Advantage!