The Global OB Fee Trap: How to Find and Fight It

I usually write in this blog about babies and breastfeeding and potty training and other cute and gross and funny and sentimental things. So I apologize in advance for this one. It’s about insurance.

STOP!

Don’t leave. I know insurance is not what anyone wants to talk or read about but please please please, I will sprinkle cute baby pictures throughout if you just hear me out on this one. It’s important. To me and to women everywhere.

See, our healthcare system in the US is pretty much fucked. And as much as I’d like to go all Erin Brockovich on this one and change the system it just ain’t. gonna. happen.

BUT there is one thing I might be able to change. And it starts with getting the word out since I’m willing to bet most people who have an infant at home just pay their medical bills and get on with it and don’t actually check to see if their insurance company is paying their fair share (spoiler alert: they’re not).

I know the last thing new moms have time for it fighting their insurance companies. I really, really know.

But do it anyway.

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Do it anyway so the next generation of moms doesn’t have to.


So here’s the deal.

This whole battle started out over $590. Yet another bill for Lucy’s birth on top of the thousands I had already paid that I didn’t expect and couldn’t afford. My insurance company should have paid it, and yet again they were deferring the cost to me. My dad implored me to fight it, and I told him “I have a 2 year old and a 2 month old. some days I don’t have time to brush my teeth, how do you expect me to find time to fight a billion dollar insurance company?” But I didn’t have the money to pay, so I fought it anyway. I fought and fought and fought and finally, I won. I won the battle (they paid my bill) but not the war (they still aren’t paying other women’s bills).

In the beginning I said, I can’t be the first person to figure this out. I can’t be the first person who’s pissed. There are hundreds of new mothers across the country who are lawyers, lawmakers, legislators. Surely one of them has already tried and failed to defeat this. But that’s a dangerous way of thinking. Because if that’s what we all say, well, that’s how we end up here.

So I’m not a lawyer, I’m not a legislator, I’m not anything special but I am a mother and let me tell you, motherhood makes you fierce.

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Ok, so here’s what’s going on.

Back in the day insurance companies billed for each OB appointment separately. Each prenatal appointment was a separate bill, then the delivery, the postpartum checkup, etc.

Then the affordable care act was signed into law and insurance companies were suddenly subject to a whole new set of mandates including one that required them to pay for all preventative care (i.e. prenatal visits) in full, without any member cost sharing. (In case you don’t speak insurance, that means they pay for the whole thing and the patient shouldn’t receive any bill whatsoever.)

But anyone that has been to the doctor since the affordable care act was passed knows that this pretty much never happens. They always find some way to charge you something – whether it’s covering the vaccine but not the actual giving of the shot (yup, that happened to me), or having a service covered but not available anywhere in your state (again, been there). All of their little workarounds piss me off, but this one really put me over the edge.

Now, they’ve come up with a way to avoid paying for prenatal preventative care.

Basically what they do is instead of billing each OB appointment separately, they bill the entire pregnancy in one “Global OB Fee” after the delivery of the baby. So they lump the prenatal visits, delivery and postpartum checkup into one bill – with one code.

And therein lies the rub.

Since all the appointments are lumped together into one bill, they code the entire thing as diagnostic care and apply it to the member’s deductible or cost sharing. Even though a large portion (arguably the majority) of the cost of that Global OB Fee is for prenatal visits, which are preventative and should be paid in full by the insurance company.

But instead of paying them, they combine it with the diagnostic service (delivery) and pass the cost on to the patient.

Hellz to the NO.

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Because I’m cheap smart broke I go ever every bill with a fine tooth comb before paying it – and when I got a bill from my doctor after Lucy was born, I noticed something was off. NOTE: The bill you receive isn’t called a “Global OB Fee,” and you probably won’t see that phrase anywhere on it. That’s just how providers refer to this type of global procedure coding. The bill will simply look like a bill from your OB or midwife. Since the bill comes after the baby is delivered, most people mistakenly think it’s a bill for their doctor’s delivery fee, but in reality, all of the prenatal charges are lumped in there too. The only way to find out exactly what was included in the bill is to ask your doctor, or ask your insurance company how it was coded (there are 5 different global OB codes). In general, if the amount billed to insurance (remember, the amount that you actually owe is likely less) is over 1000 dollars, then it is probably a global OB fee, and not just a delivery charge. Also note that this fee is separate from the charges you will likely receive from the hospital and/or anesthesiologist. The global OB charge is specific to services performed by your doctor.

In my case, the total amount billed to insurance by my doctor was $2,950 dollars. That included prenatal visits, vaginal delivery and a postpartum checkup (I know because my doctor informed me of this upfront). My insurance company processed the bill as diagnostic care, and since I had already met my deductible (because for some reason an uncomplicated vaginal delivery + 24 hour hospital stay costs 15k dollars) they applied the entire amount to my member cost sharing. They paid 80% and left me with a bill for the remaining 20%…$590 bucks.

Hold up though.

A large portion of the $2950 that my doctor billed the insurance company under the Global OB code was for my prenatal checkups, which, according the ACA (and my insurance company’s benefits handbook) are considered preventative care. So according to the law, the cost of those appointments should be paid in full by the insurance company. The remainder (i.e. the delivery/diagnostic portion of the bill) should then be applied to my member cost sharing. This would have brought the bill down to somewhere between $200-300 bucks.

But instead, they billed the entire Global OB fee to my member cost sharing. NOT LEGAL.

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To make a long story (sort of) short:

To make a very, very long story short, I decided to fight them. I did incredible amounts of research on the exact language of the Affordable Care Act, the benefits included in my specific healthcare plan, and how other insurance companies process and pay claims billed with Global OB codes. What I discovered is what I already knew – that these Global OB codes have created a conundrum for payers (insurance companies) in that they combine both preventative and diagnostic care under one code – and the insurance company’s software doesn’t know how to divide up the bill and pay it accordingly (full coverage for preventative, cost sharing for diagnostic). Whether this is an unfortunate outcome of a new system (yeah right), or an intentional workaround to avoid paying for preventative care (more likely) – it is ILLEGAL.

Some healthcare companies have already made changes.

I discovered that at least one major health insurance company (United Healthcare) has already implemented a percentage system in which they assume 44% of the Global OB bill is preventative care and 56% is diagnostic – and pay out the claims accordingly (i.e. insurance pays 44% and the remaining 56% is applied to member cost sharing). The following quote is from the United Healthcare benefits handbook, further reinforcing my assertion that applying an entire Global OB bill to member cost sharing is not legal.

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The other (legal) option is for them to separate the bill into individual appointments and pay out each claim individually (like they used to do back in the day) – but this takes significantly more time for both the insurance company and the doctor, and in my case, Harvard Pilgrim’s own Provider Handbook states in no uncertain terms that doctors may not bill appointments separately (as described above), and instead that they MUST bill using the Global OB codes, or they won’t be paid.

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I fought my way through three member services representatives and one supervisor before finally getting word that Harvard Pilgrim had agreed to reprocess my claim – and ended up paying the entire thing (not just the preventative portion) – more than they legally had to.

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Why would they do that?

They paid my entire bill (instead of just the preventative portion) for two reasons. The first is that their processing software has only two choices for how to pay out a bill with just one code – preventative (pay in full) or diagnostic (apply to cost sharing). Since their own software wouldn’t let them divide up the global bill they either had to pay all of it, or apply the entire thing to cost sharing.

They opted to pay the entire thing because they realized it was cheaper for them to pay my bill then battle it out in court, and because if I took them to court and they lost, they would have to change the way they bill for everyone. A very expensive proposition.

The battle is won but the war continues.

So my battle with Harvard Pilgrim is over, but the war is not. They paid my claim, but they still aren’t correctly processing Global OB bills for many other women. And in order to get them to make a systemic change in the way they pay for obstetrical care we need to CONTINUE to put the pressure on them. And there are a couple ways we can do that:

  1. If you had a baby recently (or are having one soon), fight your insurance company AND FIGHT HARD to force them to pay their fair share of your Global OB bill. Even if it only saves you a few hundred bucks – it saves women collectively millions. Millions that belong in our pockets for diapers and daycare – not private jets for insurance company executives. (Here are Some Tips for How to Fight Your Global OB Insurance Bill)
  2. Contact your state legislator and ask them to hold insurance companies responsible for covering preventative obstetrical care as required by law. I’m meeting with one of my state legislators next week to discuss this very issue.
  3. Share this post to bring attention to insurance companies that are circumventing health care laws and get it in the hands of influencers like the media, legislators, lawyers, etc.

Get in touch.

If you have questions about an obstetrical bill from your insurance company, you’d like help fighting your Global OB Fee claim, or you know someone who you think could help bring attention to or enact legislation to create change, feel free to contact me directly!

I know this probably seems like an itty bitty bandaid on an incredibly broken healthcare system. But I can’t change our healthcare system overnight. I might be able to change this.

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10 thoughts on “The Global OB Fee Trap: How to Find and Fight It

  1. Pingback: How to Fight Your Global OB Fee Bill | Oh Baby Richards

  2. Good job! This stuff is so complicated and bull shit. Global payments make a lot of sense, but we aren’t doing it right in this country. The ACA was a step in the right direction, but our politicians really need to have the balls to move to a more simplified (ahem socialized) approach. Cover everyone for all preventative and emergency care (deliveries included) and then we can buy insurance for the extras.

  3. YOU GO GIRL! Kudos to you for taking the time to inform your peers of this issue and not assuming that a little battle won does not contribute to fighting the war! Aunt Annie

  4. Good for you for standing up for your rights! I just got a letter saying that the global code procedure was accepted, yet I got a bill for previous services. Already, I am dealing with contradictions. My insurance at first told me I had a co pay when I see the co pay each time, but further details say if it’s preventive it’s zero co pay..they put me on hold, and come back and say yes, every visit is zero copay. I asked about ultrasounds..they said co pay wasa like 30 or something, i asked what if it’s in office and the ob wants to do it during the prenatal visit, and since u are seeing the ob for preventive, wouldn’t that be preventive since he ordered it? and they said yes, so zero copay in that case. Now, I get a bill of 30 and I will continue getting it every time I go to them. The billing lady said my insruance told her it’s 30 a visit and I said that’s because it’s generic and if they dig deeper, they will find out its not bc of preventive etc..she said well what u got done isn’t preventive. I’m like what?? I said according to ACA, prenatal visits are well woman visits and well woman visits are preventive. Shes like we don’t consider them well woman visits, just regular visits. And she said besides that, when you do your first visit, it’s not prenatal it’s first time established patient, and besides that, ultrasounds are not preventive and you would get charged anyways for that. I told her what my insurance said and she said, well if they send us a fax saying it’s zero co pay for all the ob visitis, then we will put that in the file so u don’t keep getting charged. I spoke to claims and she claled up my plan and said they told her same thing, preventive prenatal care visits are zero copay, but to what is censidered preventive is basic in what they told her. ie they didn’t even tell her urine tests and bloodwork etc. So, she is going to call the billing to see what they are saying etc.. I told her that it sounds like the woman is not coding it as well woman nor preventive and not wanting to code it correctly. She didn’t seem concerned about what i said about aca etc. I’m thinking, well, I didn’t ask for hte ultrasound, the dr ordered it so I would think that’s preventive as he saw it necessary to do it?? My first visit at ten weeks they ordered a transvag and ultrasound and the 2nd one at 12 weeks an ultrasound..but i saw a procedure code for the nuchal something and he ordered bloodwork each visit i went and did all the blood pressure urine test fetal heart uterus measuring etc. What’s odd is hte bill they sent me doesn’t show global coding nor the nuchal one for the ultra sound..it just shows the codes 99203 (new pt interm ov), 76856 (pelvic ultrasound) a, 76830 (utz transvaginal), 99214 estab pt interm ov and 76801 (ultrasound ob 1st tr)…but yet i got an authorization approval from my insurance for codes 76813 (ob us nuchal measure 1 gest) same day as my 2nd visit, andm 59400 (two times two different days of referral and two different referral numbers for same two codes) for routinge ob care inc atempartum care , vag delivery and post partum care. does that mean as well that if i need a c section it wont be covered?? i know in my plan it says zero co pay for c section. and 600 co pay per hospital admission. so i am curious if you have ot pay for your ultrasounds including ones for nuchal and first visit? and what u recommend i do?

    • Hi Melissa, thanks for reading and I’m sorry you are going through all this! Insurance is so complicated :/ While I am definitely not an expert and all insurance plans are different – I’ll tell you what I know from my own experience and time spent sifting through various ACA regulations.

      It sounds like you are currently pregnant and haven’t delivered yet. In that case you likely have not received a global OB bill yet. That will come AFTER your delivery. Included in that code/bill is typically all of your prenatal appointments (note that it is just the appointment fee – any tests or ultrasounds you receive at those appointments will be billed separately) as well as your delivery fee. You will be billed separately for your hospital stay (if applicable) as well as anesthesia or any other drugs you receive in the hospital. The Global OB fee is just for the prenatal appointments and delivery services provided by your OB. The thing to look out for when you receive that bill is to make sure that at least 40% of the global OB fee is paid for by insurance BEFORE they apply it to cost sharing. At least 40% of the global OB fee should be considered preventative, and therefore not subject to cost sharing. For example if your global OB bill total was $2000, at least $800 (40%) of it should be paid by insurance, and only $1200 (60%) should be subject to copay, deductible or coinsurance.

      You asked about the global OB code including vaginal delivery but not c-section – that is just because the doctor has to choose one global OB code to use (there are different codes for vaginal delivery, c-section, twins, etc) and he or she is anticipating that you will have a vaginal delivery. If you need a c-section they will simply change the global OB code to one that specifies a c-section. Both vaginal and c-section deliveries are considered diagnostic (not preventative) care so you will be subject to cost sharing for those services. However, if your insurance plan specifies no copay for c-section than you should not be charged for it. The $600 copay for hospital admission will be billed separately by the hospital.

      As far as the ultrasounds – ultrasounds are not considered part of a well-woman prenatal visit. So the actual visit with your doctor (checking blood pressure, measuring your belly, listening to the fetal heart rate, etc.) is considered preventative and would not have a copay – but diagnostic services you receive during those appointments (for example urine tests, blood tests, ultrasounds, etc.) are all considered diagnostic and WOULD BE subject to your copay. That is probably why you are seeing those charges. That said, all doctors code those services differently. My first baby my OB coded the ultrasounds as preventative and so I wasn’t charged. My second baby I had a different doctor and he billed them as diagnostic so I did get charged. You can ask your doctor to change how they code it – but according to the law they don’t HAVE to bill ultrasounds as preventative. The ACA only specifies that the actual appointment is preventative. There are certain services like STD testing, gestational diabetes testing and routine urine protein testing that ARE included in the ACA as preventative care for pregnant women, so you should not be charged a copay for those services, and if you are I would absolutely appeal the charges with your insurance company. However things like blood tests and ultrasounds (even though they are routinely ordered by your doctor) are not considered preventative under the ACA. You can see what tests are specifically covered as preventative here: https://www.healthcare.gov/preventive-care-women/. If you have been billed for any of the services listed there, I would show that list to your insurance company and ask them to reprocess the charges.

      Again I know this is super complicated and SO frustrating. You are smart to be looking closely at all the charges and keeping track – I know it is time consuming!!! If you have any other specific questions I am happy to help you research them and appeal the charges with your insurance company if necessary. Good luck and congratulations on the new baby – let me know if you have any questions once you get the post-delivery bills 🙂

      • diseases, genetic,etc or maybe because I’m 35, so the dr said like the genetic testing ones etc. are covered because of my age. The reason I am being charged 30 is because of the billing lady is coding it as new patient visit and established patient visit instead of i dont know what they would code it as, but for the well woman prenatal preventive. I even typed in teh codes online and thats what they came up as normal visits. My friend works at an ob office and said I shouldn’t be charged for every single visit. but the billing lady said she would charge me for every single visit of 30 until she gets something from my insurance saying what i told her they told me. She told me they told her my maternity plan is 30 for prental visits and i said, yes, but it also says for NON preventive services..and shes ike, well these are not preventive visits and not well woman we charge are normal etc. There’s a helpful website I came across the breaks down what is included in a well woman prenatal visit or examples. http://www.healthlaw.org/issues/reproductive-health/well-women-visits-prenatal-care-under-the-acas-womens-health-amendment#.WKdzHfkrLIW.
        So with global coding, u are saying I should only have to pay one co pay and not for every single visit? My insurance works with copays not co insurance. and i wnoder how that works since the dr visiting me at the hopsital is zero copay, surgeons, anestheologists etc are zero copay, but hospital including maternity is 600 co pay. Update: I tried to speak to 2 different women with insurance and one lady finally saw what i saw saying she “said” and was going to call up the billing lady with me, but they were closed..and yet she noted that i “think” i should have to pay zero co pay when i told her they can listen to the phone call and told me that is what it should be lol. and she referred to the 30 co pay lol. My hubby was like, what??? that’s unprofessional. the other lady i spent over an hour with arguing with her, and pointed out that it even says preventive services for pregnancy are zero co pay, and she told me those are for birth control etc and i’m like, no that’s a different section all together and thats not what the other reps said. Let alone it says well woman is preventive and shes like thats your yearly and i told her according to law, prenatal visits are well woman. shes like well your policy doesn’t go by that lol, but yet, if you look it says they go by aca and hrsa lol. so i asked to speak to a supervisor but i dont know if she was lying or not but she said he was at lunch adn would call me when hes back or today. and she said she understands my frustation and shes just hte middle man but almost said it like i was wrong though i told her thats what the reps told me 2 x. but yet the insurance companny puts basic notes down is client asked about prenatal care 30 copay and left out the part they said zero co pay for preventive services lol. i’m like u can listen to the phone call and hear them! and i told her yes its frustrating etc and she hung up.

  5. ahh sorry it cut off the first half of it lol. Thanks for all of your help 🙂 That’s the thing is the insurance flat out told me ultra sounds were covered for pregnancy stuff ie not like normal ones and the first one he did because at 10 weeks taht’s the only way he can measure the uterus and hear the fetal heart beat and getstational age etc. and the 2nd one, was for nuchal US, which goes with the genetic testing , but i did read somewhere i wanna say that bloodwork is preventive such as blood group RH and diseases etc, but maybe because of my age is why.

  6. I’m so sorry, Melissa that is so frustrating. If your insurance states that you should have zero copay for a service, then definitely do not pay the bill until you have worked it out with your insurance company. Once you pay it is hard to get your money back so I would withhold payment until a resolution is determined – that will incentivize your doctor’s office to work it out with insurance so that they can collect their money.

    It sounds like you are doing all the right things to fight this. You definitely should not have to pay a copay for regular prenatal checkups. Those checkups are included in the global OB fee and under the ACA are required to be completely free (no copay). Other services provided at the appointment might have a copay, but not the visit itself.

    As far as the ultrasounds go they are not required to be covered as preventative (no copay) by the ACA, BUT if your specific insurance plan says that they are covered with zero copay then you should not have to pay one. As you move forward fighting your insurance company/doctor’s office on this issue I would ask for everything from your insurance company in writing so that you have written documentation of what they are telling you, and then submit that to your doctor’s office. You can also request a 3-way phone call between you, your doctor’s billing representative, and an insurance representative – that might help with the miscommunication.

    Lastly, the insurance company’s most effective tactic with stuff like this is making it drag on for so long that people just give up and pay the bill. They never call back when they say they will, and it feels like each representative you talk to is starting from square one. I recommend asking for each representative you talk to to give you their name and direct phone number so you can talk to the same person each time. When they know they can be identified they also tend to be a little more helpful. At some point if they continue to stall and not help you, you can tell them you will be submitting a claim to the state insurance board – that usually kicks them into high gear since they don’t want to deal with the insurance board.

    Good luck and let me know how it goes!

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