Insurance

Congratulations!! You took a pregnancy test and it came out positive. Then you scheduled a consult and tour at our birth center. And while you visited us, we put together an estimate for your insurance coverage. Most people really don't understand how their insurance plans actually work. I mean, they understand that they have insurance but they often don't understand why they have to pay anything out of pocket or a how we come up with the estimate, so we thought we would help break this down for you. 

But first: there are different ways people obtain insurance plans. Some employers include insurance plans are a benefit to working with their company. Employers will contract with different insurance companies and each employer might offer different plans to different employees, so just because you have Cigna, as an example, it doesn't mean all Cigna plans are the same. Also, some people purchase their own insurance plans directly from insurance companies or from the Marketplace (public government contracts).

 Medicaid is NOT commercial insurance. 

So lets use a typical plan as an example. A typical insurance plan will have a deductible, a co insurance, and sometimes a copay. We will break these down for you. 

A deductible is the amount that is your responsibility to pay out of pocket before your insurance will start paying on claims. The amount of deductible is assigned by the plan and when you were choosing your plan, you might have been given options. A higher deductible is usually associated with a lower monthly premium payment on your end, or out of your paycheck. A lower deductible amount is usually associated with a  higher monthly payment. Some employers pay all of your insurance as part of your job, others offer a group plan and you pay a weekly, bi weekly, or monthly fee to be in their group. Deductibles range from -0- to $10,000.00, with the typical being $1500-2500.00. 

Deductibles may be required for different services elsewhere and you may have already met some of the deductible amount at several doctors offices. So when we calculate your deductible amount, we look in your insurance portal to see what has been reported or applied  toward this balance. Once the deductible is met, it's met.  Typically, deductibles reset annually. You should be well aware of your deductibles and where you are spending it, like a savings account.You also need to be aware of when your particular plan resets. Some are in January, some are in June, some are on their anniversary date of the start of your insurance, but most reset on January 1st each year. 

A Coinsurance is based on a percentage of overall charges for a service. So for example, if your care was based on a $10,000. claim and you have a 20% coinsurance, your responsibility would be $2000.00 out of your pocket. 

Copays don't usually apply to birth centers, but they are often charged for doctors visits. These are typically a $10-35.00 per visit charge. 

A claim is a bill that is entered and submitted from your provider to your insurance company on your behalf and is processed through your insurance company's system. Claims have code numbers and there are several key factors that must be completed for a "clean claim" to be paid by your insurance company.  Claims can take 30 days to process and can be denied by insurance companies if specific criteria is not met. Before a claim is paid, the deductible, and any co insurance amounts are subtracted from the total sent to the provider. 

Birth Centers that are contracted with particular insurance companies have agreed to a certain rate for care (a contracted rate) so the fees are basically set. Some services are not included in the contract and might be patient responsibility, such as use of Nitrous Oxide, or childbirth classes as an example, and these are typically on our estimate. 

So let's look at a very basic birth center estimate! 

Karen has a plan with Astro insurance company. Our birth center is contracted with Astro Insurance Company at a rate of $8000.00 and Karen has a $2000.00 deductible, along with a 20% coinsurance as her responsibility. She has no copayments for visits with us. We add the deductible of $2000.00 plus the calculated 20% of the total of the original contracted claim amount of $1600.00 for a total estimate of $3600.00 that would be her out of pocket responsibility to pay to her provider.  This amount will be deducted automatically from her insurance company when her provider submits a final claim for services provided. Birth Centers cannot bill an insurance company until all services have been completed (meaning the baby has been delivered or the patient transfers care to another provider). 

Once a claim has been submitted on your behalf and your insurance company processes it, the check is sent electronically to your care provider (us in this example). After that, an Explanation of Benefits (or EOB) is sent to you. This is basically a receipt for your care. On this, you can see the claim number and amount that your care provider has submitted for a particular date of service. You will see if the insurance company applied any deductible or coinsurance and you will see the total amount that your insurance company has paid to your provider. All of this is also available on your insurance company's portal and you have access to all of this information in our billing system as well. You should keep track of thees receipts, as they show you how much you have paid toward your deductible, coinsurance and copays. 

A few last words about billing your claims: Although our office submits your insurance claims on your behalf as a courtesy, if claims are denied for lapse of coverage or other issues, the total due is ultimately the responsibility of the patient. 

Call Kat Joiner today at Heart 2 Heart Birth Center for a complete estimate for your particular claim. She will take the time with you to help you understand how your insurance works to get you the most accurate information