In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN office when she was asked to pay $960, the total the office estimated she would have to pay after delivery. .
Clarke, 39, was surprised that she was asked to pay this much amount during this second prenatal visit. Typically, patients receive a bill after the insurance portion has been paid, and for pregnant women this usually occurs only after the pregnancy has ended. It would take several months for the office to file a claim with his health insurer.
Clark said she felt trapped. The Cleveland, Tennessee, maternity practice was affiliated with a birthing center where she wanted to deliver. Also, she and her husband had wanted a child for a long time. And Clark was emotional, because his mother had died just a few weeks earlier.
“You're standing there at the window, and there are people all around, and you're really trying to be nice,” Clark recalled, crying. “So, I paid it.”
on online baby message board and others social media platformPregnant women say they are being asked by their providers to pay fees out of their own pockets earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for advance payment ensures that they receive compensation for their services.
It's hard to track how often this happens because it's considered a private transaction between the provider and the patient. Therefore, payments are not recorded in insurance claims data and are not studied by researchers.
Patients, medical billing experts and patient advocates say billing practices cause unexpected anxiety at a time of already increased stress and financial pressure. Estimates can sometimes exceed the amount owed to a patient and can force people to fight for a refund if they have an abortion or if the amount paid exceeds the final bill.
Upfront payment also creates barriers for women who want to change providers if they are unhappy with their care. In some cases, they may deprive women of prenatal care altogether, especially in places where few other maternity care options exist.
“It's holding their treatment hostage,” said Caitlin Donovan, a senior director of the Centers for Disease Control and Prevention. Patient Advocate Foundation,
Medical billing and women's health experts believe that OB-GYN offices have adopted this practice to manage the high cost of obstetric care and the way it is billed in the US.
When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. The practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy. American College of Obstetricians and GynecologistsBut such bundled billing is outdated, he said.
Previously, pregnant patients had to pay for each prenatal visit, which may have caused them to skip important appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Additionally, it has become common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery – especially in rural areas where patient transfers are common.
Some providers say prepayment allows them to spread lump sum payment To ensure that they are compensated for the care they provide during pregnancy, even if they do not ultimately give birth to the child.
“Unfortunately, you have people who are not getting paid for their work,” said Pamela Boatner, who works as a midwife at a hospital in Georgia.
Although she believes women should get pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill is not ignored after the baby is born. Boatner said new parents may be burdened with hospital bills and the costs of caring for a new baby, and they may lack income if the parent is not working.
Having a child in America can be expensive. According to the , people who get health insurance through large employers pay an average of about $3,000 out of pocket for pregnancy, delivery, and postpartum care. Peterson-KFF Health System TrackerAdditionally, many people are opting for high-deductible health insurance plans, leaving them bearing a larger share of the cost. of 100 million american people With health care debt, 12% owe at least some of it to maternity care 2022 kff poll,
She said families need time to save money for the high costs of pregnancy, delivery and child care, especially if they lack paid maternity leave. joey burkhardCEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepayment “is another serious blow,” he said. “What if you don’t have the money? Do you put it on a credit card and hope your credit card goes through?”
Calculating the final cost of childbirth depends on many factors, such as pregnancy timePlan benefits, and health complications, said erin duffyA health policy researcher at the Schaefer Center for Health Policy and Economics at the University of Southern California. He said the final bill for the patient is unclear until a health plan decides how much of the claim it will cover.
But sometimes the option to wait for the insurer is taken away.
During Jamie Dr.'s first pregnancy in 2020, her OB-GYN refused to pay in advance because Dr. wanted to see the final bill. But in 2023, during her second pregnancy, a private midwife practice in New York told her that since she had a high-deductible plan, it was mandatory to pay the $2,000 monthly copayment.
Dow, a health policy researcher at Columbia University, said delivery was due in September 2023 and received a $640 refund check in November to cover the difference between the estimate and the final bill.
“I study health insurance,” she said. “But, as most of us know, it's very complicated when you're actually living it.”
While the Affordable Care Act requires insurers to cover some prenatal services, it doesn't prevent providers from sending patients their final bills early. It would be a challenge politically and practically, he said, for state and federal governments to attempt to regulate the timing of payment requests. Sabrina CorlettCo-director of the Center for Health Insurance Reform at Georgetown University. Medical lobbying groups are powerful and the contracts between insurers and medical providers are proprietary.
Due to legal gray area, lacey marshallAn insurance broker at Rapha Health & Life in Texas advises customers to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring upfront payment.
If the insurer says they can refuse to pay upfront, Marshall said, she tells clients to get established with a practice before refusing to pay, so the provider can't deny treatment.
Clark said she met the insurance deductible after paying for genetic testing, additional ultrasounds and other services from her health care flexible spending account. Then she called her obstetrician-gynecologist's office and asked for a refund.
“I got my spine back,” said Clark, who previously worked at a health insurer and a medical office. She received an initial check for about half the $960 she was originally paid.
In August, Clark was sent to the hospital after his blood pressure increased. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.
Only after settling most of the delivery bills did she receive her remaining refund from another OB-GYN practice.
This final checkup took place in October, just days after Clark brought Peter home from the hospital, and after calling the office several times. He said all this has added further stress to an already stressful period.
“Why do I, as a patient, have to pay this price?” He said. “I'm just trying to have a baby.”
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