Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
Sorry Suzy, I just saw it. My EOBs do not have the codes on them, just descriptions. One is HOSPITAL MISC (3400), one is BIRTHING CTR (1200), one is SURGERY (4500), and another for BIRTHING CTR (5800). I am especially stumped by the one marked surgery since nothing even remotely close to a surgery happened. The first of those four has my son listed as the patient, and the other three have me listed as the patient.
Really weird.
Providers of medical services communicate with insurance companies using two sets of codes, ICD 9 (for the hospital) and CPT (for outpatient).
So a normal delivery would be coded by the hospital: 650 Normal full term delivery and V27.0, live newborn, for delivery in a hospital (the birthing center counts).
The obstetrician would code 59400 for routine prenatal care, delivery, and postpartum care.
If mom had an epidural, the anesthesiologist would code 01960 for providing anesthesia for a normal vaginal birth.
Additional codes are used for additional diagnoses and procedures and the codes change depending on who does what. For example, if a family practitioner provided prenatal care but referred the mom to an obstetrician because the baby was breech and the OB did a Cesarean, there are codes for just prenatal care for the FP and codes for the Cesarean and postpartum care for the OB.
The baby has his own set of codes, also. The pediatrician uses those and the hospital has a set, too.
So what you need is copies of the claims sent to the insurance company. Your best bet would be to walk in and ask for them. Get me the codes and we can figure out what the insurance company paid for. There is no reason for the birthing center to deny those to you, either.
One thing that is not clear to me is how your obstetrician or midwife and pediatrician billed and how they were paid. Is that included in what we have been discussing or did you pay that separately? Did you have the services of an anesthesiologist?
I am assuming the "surgery" was the delivery. That would correspond to what you expected for the original quote you received.
I have a hard time seeing how a birthing center could justify that much money for normal newborn care. The other two charges for you could be charges for the facility and for anesthesia if you had it. But if that is true they should have told you ahead of time.
Thanks for the responses. I do have the paperwork and it states that the birth is $4500. Claims were submitted to the insurance company in the amount of $15, 380. Close to $12000 of that was paid out. At this point I am not sure if the center realizes that so many claims were filed and that they have gotten so much money from one birth - only 4 people work there total and I think they are very overwhelmed. I became close with all the employees and it absolutely sickens to me to think that this could be on purpose.
I feel like at this point I need to physically go to the center with all my paperwork and point out what is happening and hopefully they will realize that something HAD to be misfiled. Golfgal, if they still don't seem to think something is amiss and then try to fix it, I will definitely go back to the insurance company and see what to do next.
That being said, on the one and only claim that is actually for $4500, the part that my insurance says I am responsible for is less than what I actually paid them out of pocket. So just looking at that one, that should mean that they DO owe me a refund for what I paid, correct?
This is NOT the way to deal with this. CALL your insurance company, talk to someone in the fraud division and let THEM investigate. If you take this to the birth center they are just going to say they made a mistake and not do anything about it. You may get your money back, which you SHOULD no matter what but these people know what they did. PLEASE, PLEASE, PLEASE call your insurance company, say you suspect fraud and they will get you to the right people. I work in the industry, we see this ALL the time with "specialty" clinics like this and other areas (Chiropractic especially). This is exactly how they commit fraud-they get the patient to pay a nominal up front fee, they don't expect the insurance company to change how they pay, then they bill for 3 or 4 times the expected cost and now instead of $4500 they have made over $13,000.
This is NOT the way to deal with this. CALL your insurance company, talk to someone in the fraud division and let THEM investigate. If you take this to the birth center they are just going to say they made a mistake and not do anything about it. You may get your money back, which you SHOULD no matter what but these people know what they did. PLEASE, PLEASE, PLEASE call your insurance company, say you suspect fraud and they will get you to the right people. I work in the industry, we see this ALL the time with "specialty" clinics like this and other areas (Chiropractic especially). This is exactly how they commit fraud-they get the patient to pay a nominal up front fee, they don't expect the insurance company to change how they pay, then they bill for 3 or 4 times the expected cost and now instead of $4500 they have made over $13,000.
Until we know what the charges were for it is premature to cry fraud.
Fraud would be billing for something that was not done. The charge for actual services provided is up to the facility. The actual payment is whatever the facility and the insurance company agree to.
"For patients not covered by health insurance, the typical cost of a vaginal delivery without complications ranges from about $9,000 to $17,000 or more, depending on geographic location .."
So that is what the insurance company would be billed, but not necessarily what it would pay, depending on negotiated discounts.
So a normal delivery would be coded by the hospital: 650 Normal full term delivery and V27.0, live newborn, for delivery in a hospital (the birthing center counts).
The obstetrician would code 59400 for routine prenatal care, delivery, and postpartum care.
If mom had an epidural, the anesthesiologist would code 01960 for providing anesthesia for a normal vaginal birth.
Additional codes are used for additional diagnoses and procedures and the codes change depending on who does what. For example, if a family practitioner provided prenatal care but referred the mom to an obstetrician because the baby was breech and the OB did a Cesarean, there are codes for just prenatal care for the FP and codes for the Cesarean and postpartum care for the OB.
The baby has his own set of codes, also. The pediatrician uses those and the hospital has a set, too.
So what you need is copies of the claims sent to the insurance company. Your best bet would be to walk in and ask for them. Get me the codes and we can figure out what the insurance company paid for. There is no reason for the birthing center to deny those to you, either.
One thing that is not clear to me is how your obstetrician or midwife and pediatrician billed and how they were paid. Is that included in what we have been discussing or did you pay that separately? Did you have the services of an anesthesiologist?
I am assuming the "surgery" was the delivery. That would correspond to what you expected for the original quote you received.
I have a hard time seeing how a birthing center could justify that much money for normal newborn care. The other two charges for you could be charges for the facility and for anesthesia if you had it. But if that is true they should have told you ahead of time.
Thanks Suzy. There are not (or at least not that I am aware of) separate charges for the midwife and the birthing center. The midwife owns the BC and there is one other midwife who works there. They both were present at my birth, but only one of them was really in charge of it. I had no IV, no anesthesia, no stitches, no drugs of any sort. There was no pediatrician - the midwife also performed the well-baby checks and the immediate after-birth care of baby. We left the birth center less than 4 hours after the baby was born. Any literature they provide and all papers I have signed indicates that $4500 is the end-all fee for everything.
My EOBs have a space for the codes, but it is blank. I looked at some other EOBs for trips to allergist, pediatrician, etc., and none of them have codes either so I guess that is just how my insurance does their EOBs.
This is NOT the way to deal with this. CALL your insurance company, talk to someone in the fraud division and let THEM investigate. If you take this to the birth center they are just going to say they made a mistake and not do anything about it. You may get your money back, which you SHOULD no matter what but these people know what they did. PLEASE, PLEASE, PLEASE call your insurance company, say you suspect fraud and they will get you to the right people. I work in the industry, we see this ALL the time with "specialty" clinics like this and other areas (Chiropractic especially). This is exactly how they commit fraud-they get the patient to pay a nominal up front fee, they don't expect the insurance company to change how they pay, then they bill for 3 or 4 times the expected cost and now instead of $4500 they have made over $13,000.
Hi golfgal - at this point I don't feel like that's what I should do. I have personal relationships with these employees and so far they have been completely cooperative and answering my questions thoroughly and are still checking into things. Until they come back to me and say that the claims are correct and that's the end of it, I think it would be jumping the gun to try and claim that they are committing fraud. Especially considering that I do want to have more children at this center, I would like to maintain my good relationship with them. It is making me physically ill to think that these claims are purposefully fraudulent BUT I promise you that if they do come back and say that these are accurate - even if they do give me my money back - that I will be calling the insurance company and starting an investigation, especially into the one coded as surgery. But at this point I feel as though I owe it to them to discuss it with them, show them my EOBs and get an explanation. This is a tiny business that has literally exploded and I think they are overwhelmed, new at this and I do think there is a good chance that this was a mistake.
Thanks Suzy. There are not (or at least not that I am aware of) separate charges for the midwife and the birthing center. The midwife owns the BC and there is one other midwife who works there. They both were present at my birth, but only one of them was really in charge of it. I had no IV, no anesthesia, no stitches, no drugs of any sort. There was no pediatrician - the midwife also performed the well-baby checks and the immediate after-birth care of baby. We left the birth center less than 4 hours after the baby was born. Any literature they provide and all papers I have signed indicates that $4500 is the end-all fee for everything.
My EOBs have a space for the codes, but it is blank. I looked at some other EOBs for trips to allergist, pediatrician, etc., and none of them have codes either so I guess that is just how my insurance does their EOBs.
The codes would be on the paperwork that the birthing center filed with the insurance company. You should ask them for a copy. They have document what they are charging for. The insurance company should be able to provide the codes also.
$4500 sounds reasonable for the services you received. The center needs to justify the additional charges.
What surprises me is that the insurance company paid those addtional charges.
Edited to add: If the center is new, whoever is doing the coding may not know what s/he's doing. I still think it is a coding issue, not deliberate fraud.
Until we know what the charges were for it is premature to cry fraud.
Fraud would be billing for something that was not done. The charge for actual services provided is up to the facility. The actual payment is whatever the facility and the insurance company agree to.
"For patients not covered by health insurance, the typical cost of a vaginal delivery without complications ranges from about $9,000 to $17,000 or more, depending on geographic location .."
So that is what the insurance company would be billed, but not necessarily what it would pay, depending on negotiated discounts.
She gave birth at a birthing center which typically have fixed costs for a birth. Unless she neglected to mention major complications during the birth, she was given a cost of $4500, which is pretty typical cost. The $15,000+ bill they sent to the insurance company is NOT typical for an uncomplicated birth at a birthing center. Fraud very much can be overcharging for services, not just billing for services not done. Again, PLEASE call your insurance company and have them investigate, PLEASE. If you don't, and someone else does, YOU can be in trouble too, just so you know that. You have this on the internet now, the information you have typed is forever on your computer, you have been TOLD that this may be fraud and if you choose to let it slide and someone else reports it later, you could be in legal trouble too. PLEASE, PLEASE call your insurance company, MONDAY!!!
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
