Tuesday, August 31, 2010

3rd Party Reimbursement for Doulas ~ The A, B, C's

Welcome Guest Blogger April Kline!  She shares with us how to unravel the mystery of 3rd Party Reimbursement!

Earlier today, I had a conversation with a friend who is a hypnobirthing professional. She isn’t a doula, but she was telling me about a birth she recently attended for a woman who did not have a doula. My friend commented that she could not believe the amount of love and energy it requires to be truly with a woman in her pregnancy and birth. She said she had a new respect for doulas and the work they do.

I don’t think any of us would argue that the work of a doula is necessary and important. All doulas can surely agree that this work is a labor of love, with many hours and untold amounts of energy poured into one woman’s pregnancy and birth. But what we do not always agree upon is whether there is a monetary amount that should be attached to the work we do. Doula fees vary widely from region to region, but even within a geographic area, prices vary from free to the top amount a given market will bear. Some doulas seem to think affixing a price to their services somehow lessens the sacredness of what we do. Others are much more practical and won’t even entertain the idea of working with a client who cannot pay their fee.

I believe an educated and experienced doula’s services are priceless. Since priceless is not an amount most clients can afford, I believe that we, as doulas, need to set our fees within the market of our region and in keeping with our education and experience. If we consistently charge anything less, we are only encouraging the belief that we are not professionals and that what we do is not valuable.

That said, there are several options we can offer clients that may make paying our fees a bit easier. The most common of these is to offer a sliding scale according to need. Most doulas offer some variation of this. Another option is to incorporate a specified number of free births you are willing to offer per year. It may be possible to write at least portions of these free births off as charitable work under some special circumstances, so check with your accountant if you are planning to incorporate this into your practice.

The other option is not so common, but is a growing trend. Over twenty insurance companies have begun paying for doula services and, now that there is a CPT code covering doula services, this is more of a possibility than ever before. (CPT stands for Current Procedural Terminology, and is a copyright of the American Medical Association.) The CPT code commonly used to claim doula services is 99499 for Evaluation and Management Services/Labor Support.

The fact that their insurance company might reimburse at least some portion of the fee for your services might make you attractive to a group of potential clients who might not have been interested before. Getting reimbursement for doula services requires patience and persistence, but it can be done. If you are going to offer this as a possibility for your clients, you will also need to be willing to offer some guidance and, most likely, a fair amount of support, as they attempt to get reimbursed.

The following is a partial list of insurance companies have reimbursed in whole or in part for doula services.

Aetna Healthcare
Baylor Health Care System/WEB TPA
Blue Cross/Blue Shield
Blue Cross/ Blue Shield PPO
Degussa, a German Chemical Company
Elmcare, LLC, C/O North American Medical Management
Foundation for Medical Care
Fortis Insurance
Glencare Managed Health Inc.
Great-West Life & Annuity Ins. Co.
HNTB (Peoria, IL)
Houston New England Financial, Employee Benefits (Fort Scott, KS)
Humana Employers Health
Lutheran General Physician's Organization
Maritime Life
Medical Mutual
Oschner HMO, Louisiana
Professional Benefits Administrators
Prudential Healthcare
Summit Management Services, Inc
United HealthCare of Georgia (San Antonio, TX)
United Health POS
Wausau Benefits, Inc

So, you say you want to help your clients get insurance reimbursement. How do you go about making this happen? Let’s get down to the nitty-gritty.

Step 1:
Before you offer to help clients get insurance reimbursements, you will want to get your own National Provider Identification (NPI) number. In October of 2009, a new taxonomy code for doulas was approved by the National Uniform Claim Committee. This code allows certified birth and postpartum doulas to register for their own NPI number which makes it possible to submit to Medicaid and third-party insurance companies for reimbursement. According to the International Childbirth Education Association (ICEA), the new taxonomy code is 374J00000X and is called Doula under the heading of Nursing Service Related Providers Type. ICEA goes on to state, “While the term Doula is listed under the Nursing heading, RN or LPN licensure are not required to obtain the NPI number. The description includes the services of antepartum, labor doulas, and postpartum doulas.”

A definition of doula work is included on the National Uniform Claim Committee website: “Doulas work in a variety of settings and have been trained to provide physical, emotional, and information support to a mother before, during, and just after birth and/or provide emotional and practical support to a mother during the postpartum period.”

Applying for your own NPI number is simple and will only take you a few minutes online if you follow these instructions.
  1. Log on to the National Plan & Provider Enumeration System website at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions
  2. Read over the required information and follow the links for applying for an NPI number
  3. Complete the online application
  4. Wait a few minutes, and an email will come to you with your very own NPI number

Yes, it really is that simple. And yes, it will make insurance companies and even Medicaid take you much more seriously.

Step 2:
Make an information sheet for your clients outlining the steps they should take to make reimbursement most likely. Note that it is best to have your clients pay you directly in full, and then attempt to get reimbursement from the insurance company for themselves. I strongly advise against offering to wait for payment until the insurance company pays your client. I even more strongly advise you against dealing with your client’s insurance companies directly – it is no fun and can leave you unpaid in the end.

The following is a thorough and easy-to-follow sample outline you can share with your clients. This outline describes the steps they can take to help them get reimbursed by their insurance companies for your doula services.

How to Request Insurance Reimbursement for Doula Services
___     Pay your doula in full.
___     Get an invoice from her which includes the following information:
a. The doula's name and address
b. Her social security number/taxpayer ID number or NPI number
c. The date and location services were provided
d. The CPT code for the services provided
e. A diagnosis code
f. The doula's signature
___     Submit the invoice with a claim form to your insurance company.
___     Within four weeks, expect a letter telling you either that
a. They need more information before they can process your claim.
b. This is not a covered expense.
___     Ask your Doula to send you the following:
a. A copy of her certification (if she is certified)
b. Other credentials or relevant training
c. A letter detailing her training and experience and what she did for you
___     If possible, ask your obstetrician or midwife for a letter explaining why a doula helped you, was necessary, or saved the insurance company money. (Did you have a high-risk pregnancy? Did the doula's suggestions appear to prevent complications or help your labor to progress more quickly? Did the doula's presence decrease your need for expensive pain medications?)
___     Write a letter explaining why you felt the need for a doula and how you believe the doula was beneficial to your health.
___     Submit to your insurance company: the doula's letter and credentials the letter from the doctor your cover letter
___     If they refuse it, write a letter to Health Services requesting that they review the claim, as you feel it was a cost-cutting measure and they should cover the cost.
___     Follow up by telephone if necessary.
___      If they refuse, write a letter to the CEO explaining why you feel that doula care should be a covered expense. They may not pay your claim, but they will consider it for the future. (Kelli Way, ICCE, CD(DONA) 1998. Reprinted with permission.)

Step 3:

Write a sample letter upon which your clients can base their own letters to their insurance companies. The following is an example of the letter that I have used with success.

To Whom It May Concern,

[Client's name], who is insured through your company, has retained my services to assist in the birth of her [number of birth] baby. [Client’s name] has hired me because she [include detailed information about the benefit your client was looking for: fewer interventions, expertise with VBACs, special assistance avoiding a particular procedure, etc.]. [Include other pertinent details here that might be persuasive to the insurance company including: how many hours you spent with your client in prenatals, at the birth and postpartum, exact services you provided, etc.]

Eleven controlled medical studies have shown that women who give birth with consistent doula support undergo fewer interventions including epidurals, forceps and vacuum-assisted deliveries, and c-sections, often have shorter labors, typically have shorter hospital stays, and overwhelmingly rate their labors and births with higher levels of satisfaction than women who do not have this support. Babies of mothers who are supported by doulas often experience less interventions and spend less time in the nursery or neonatal intensive care unit than babies born without doulas.

As a certified doula through [name of certifying organization] since [year of certification], I am uniquely qualified to provide the services [client name] was seeking. The CPT code for the services I provided is [CPT code]. My doula license number is [license number] and my NPI number is [NPI number].

If you need any additional information to pay this claim, please feel free to contact me at [your phone and/or email address].


[Your name]

And there you go! Now you know how to offer assistance with insurance reimbursement to your clients. This can be helpful not only to your clients, but also to you as you grow your doula business.

Thursday, August 12, 2010

MOMS for the 21st Century Act ~ Have you heard????????

On July 21st, 2010, Congresswoman Lucille Roybal-Allard (CA-D) introduced the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act on July 21st in the House of Representatives. This legislation proposed by Congresswoman Roybal-Allard of California is designed to improve maternal and infant outcomes in the US.

If passed in its current form, House Bill 5807 could change the face of maternity care in the United States!  It will not only address the health and well-being of mothers and babies, but in the process save thousands of dollars now being spent for unnecessary interventions in all aspects of maternity care.  Thus the intent of this House Bill is to make the passion and dream of many a midwife, nurse, childbirth educator and doula come true: make evidence based maternity care a reality.

Particularly thrilling is the promotion of a Consumer Education Campaign (Section 103, page 17 line 22.) which "highlights the importance of protecting, promoting, and supporting the innate capacities of childbearing women and their newborns for childbirth, breastfeeding and attachment PLUS promoting the understanding of the importance of using obstetric interventions only when supported by strong, high quality evidence".  Later  in the same section, the Bill speaks of utilizing "non-invasive maternity practices....that are significantly underused in the United States, including...continuous labor support."  Clearly the writers of this Bill have done their homework and have spoken to the right people, as the verbage is heavy towards consumer education.

Title III (page 28, line 17) and other portions of the Bill addresses the need for more geographical and ethnic diversity.  The Bill incentivizes entering obstetrical care by providing financial support for physicians (OB and family physicians), and midwives (CPM and CNMs) as well as grants to professional organizations to increase diversity in maternity care professionals.  Additionally, the Bill addresses the disparities of maternity care of women/care of newborns along racial and ethnic lines.  In spite of tremendous strides in innovative technology, our statistics in the world as far as maternal morbidity/mortality and infant morbidity/mortality is bleak.  Many hospitals in this country are either updating NICUs or building newer/bigger NICUs for the influx of near-term infants, many of whom are the result of inductions too early.

As it reads now, the bill will create a Center for Excellence on Optimal Maternity Outcomes to oversee many of the above projects.  As long as the sponsors of this bill (currently 24 and referred to the House Energy and Commerce subcommittee and the House Ways and Means subcommittee), stay true to the verbage of this version of the bill, great things will happen for women and children in the United States.

Where to take it from here?  Not sure?

Here are some easy steps!  And this is what I am doing!

1) Find out who your US Congressperson is ~ not sure?  click here  If you are close to several districts, make sure you energize others in those districts to make appointments NOW with the Rep.  They will very soon be on a six week summer break!  Most likely, the bill will be reintroduced after the first of the new year.  

2) Take some information with you as evidence of why you are supporting this bill!  First read the bill yourself and highlight the points you want to make with your Rep.  You may not have much time to meet with them.  Not sure what to take?  I have put together a packet of information for my own visits.  I will gladly send one to you for the cost of copying and postage.  Contact me for additional information on this packet at info@birthsource.com

3) After you have met with your Congressperson, let me others know what you did and what the reaction was!  Email me and I'll be posting the responses on the my Facebook page!

Wednesday, August 04, 2010

Sorting Out All of The Recent Flood of Research!

There is NO doubt about it ~ there has been a flood recently of information, data, research and press releases regarding maternity care.  One of the two most fascinating pieces of information is the newest ACOG (American College of Obstetricians and Gynecologists) Practice Bulletin on VBAC (#115).  I recently blogged about this very Practice Bulletin.

Now, in a great PDF by Childbirth Connection, you can print off the "Comparison of American College of Obstetricians and Gynecologists VBAC Practice Bulletin 115 (2010) with VBAC Practice Bulletin 54 (2004) and Induction of Labor for VBAC Committee Opinion 342 (2006).

You will be able to see side-by-side comparisons of the three articles/Practice Bulletins including "What resources are recommended for offering labor after cesarean", "Who is a candidate?", "What Kind of Care is Appropriate for labor after Cesarean" PLUS whether the recommendations are Level A ~ based on good and consistent scientific evidence, Level B ~ based on limited or inconsistent scientific evidence or Level C ~ recommendations are based primarily on consensus and expert opinion.

Great handout for professionals and expectant parents!

Monday, August 02, 2010

2 + 2 Is Still = 4, So Don't Discourage Childbirth Classes

I can remember sometime between junior high and high school, new math was introduced.  It would revolutionize math as we knew it ~ we would be math geniuses, plus run faster and jump higher (insert some sarcasm here).  But alas, 2 + 2 still equalled 4.

For years, (ok perhaps decades), childbirth educators have been discussing, exploring, documenting, investigating, mulling-over, speaking about, shouting about, and jumping up/down about the link between early induction of labor, the rise in the cesarean rate and near term infant births.

Dr. Deborah Ehrenthal of Christiana Care Health System published a study in the July issue of the journal Obstetrics & Gynecology found that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section delivery as those who experienced spontaneous labor.

In today's Time Magazine article  Are C-Sections Overused? Rethinking Induced Labor, author Tiffany O'Callaghan states that "the (high) rate (of induction) is significant because ACOG guidelines, which have been in place since 1982, recommend against elective inductions in the early term, or anytime before 39 weeks."  She hits a home run when she also states that "Despite studies showing VBAC to be safe for most women — ACOG data suggests that 60% to 80% of women who attempt VBAC will succeed — many hospitals have urged women to undergo a repeat cesarean over the past decade, largely to avoid medical risks and malpractice suits."

In discussing the relationship between early induction and the need for cesareans, O'Callaghan reported that researchers found that under the new policy the overall induction rate dropped 33% and the rate of elective inductions fell by roughly the same amount. What's more, the total number of C-sections among first-time mothers who underwent elective induction dropped 60%. The results of the Magee-Womens study were published in April 2009 in the journal Obstetrics & Gynecology.

Near the close of the article, Dr. Ehrenthal advised that patients should be informed and included in the decisionmaking process.  That is something, too, that childbirth educators have been including in their classes for decades.  

However, with the amount of clout that physicians/obstetricians do have with their patients, they must certainly understand that discouraging attendance at childbirth education classes interferes with the amount of birthing information, knowledge of alternatives and exposure to informed consent.  Since we all live in a mobile society, many of us do not have the luxury of learning about birth from the wise women in our families, nor do we have the opportunity to attend the births of our aunts or siblings.  Hence, we read books (some questionable at best), view birth related television shows (now those are factual, aren't they ~ oops, sarcasm again), or surf the internet. I think it would be fair to say that perhaps none of the above 3 information gathering techniques (books, tv or the internet) would lead to definitively lead a pregnant women to the Healthy Care Practices from the World Health Organization or those crafted by Lamaze International.

As Mary Kroeger stated in the book Impact of Birthing Practices on Breastfeeding, "Solid scientific evidence shows that returning to birthing practices that preserve normalcy can accomplish many things: faster, easier births; healthier, more active and alert mothers and newborns; and mother-baby pairs physiologically and optimally ready to breastfeed."

The information in the ACOG revision and the Time Magazine article (plus thousands of other media publications) regarding inductions/cesareans/VBACs is not new.  2 + 2 still = 4.  If physicians would be willing to work together with childbirth educators to achieve Dr. Ehrenthal's suggestion (and that of Healthy People 2010) that patients should be informed and included in the decisionmaking process, then we just would not only lower the U.S. cesarean rate, but also impact the health of newborns with fewer admissions to the NICU, higher breastfeeding rates, AND maternal morbidity/mortality rates that are better than some third world countries.