One of the big questions I get asked is... if I hire a doula, will my insurance company cover her fees? And if so, how do I go about it? This is a very good question because as we all know, having a baby is not cheap. Here is some good news.
Insurance companies are finally recognizing that doulas can actually help lower costs thanks to a number of studies. There was a fairly large studyinvolving 15,288 women that found having a doula present at a woman's birth can shorten her labor time as well as lower the risk of costly interventions such as cesarean sections, instrumental usage and epidural anesthesia. Women allocated to continuous support were more likely to have a spontaneous vagin*l birth. They also found it was good for baby too. The study found that the babies were less likely to have low APGAR scores and lower rates of NICU admittance.
What you need to know!
There are twenty+ insurance companies that have begun paying for doula services. You will have to call your insurance company to see if they participate. And if they do you will have to find out if they'll cover all the expense or just part of it.
I found this PDF regarding Doula care for Anthem. It contained all the required Billing codes as well as all the requirements.
Medi-Cal also has new requirements. According to The Department of Health Care Services (DHCS) “As a preventive benefit, doula services require a written recommendation from a physician or other licensed practitioner of the healing arts.”
There is a special CPT code (CPT stands for Current Procedural Terminology, and is a copyright of the American Medical Association) covering doula services. Here is the special CPT code: (Anthem has different codes)
Birth doula (99499) for Evaluation and Management Services/Labor Support.
Postpartum doula services (99501 and/or 99502).
But here's the catch....I am under the impression that only certified doulas will be able to use this code to apply for an NPI number or for reimbursem*nt. However, I was recently told by a doula who is not with any of the following certifying organizations below that she was able to get her NPI number. So please talk with your insurance company to make sure what their requirements are. Does your doula need to be certified or not?
So make sure you hire a certified doula. Here are some doula certifying organizations:
This is important! Your doula must have a NPI (National Provider Identification) numberin order for you to apply for a reimbursem*nt. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign NPI numbers.Here is how to apply for a NPI if you're a doula. It wasn't very hard to apply and didn't take me very long.
The NPI is used in conjunction with the taxonomy code to submit claims forms for reimbursem*nt through third party providers such as Medicaid and other insurance companies.
The new taxonomy code is 374J00000X and is called “Doula” under the heading of “Nursing Service Related Providers Type.” Although it is listed under the “Nursing” heading, it's not required to be an RN or LPN to obtain an NPI number. The description includes the services of labor doulas, postpartum doulas, and antepartum doulas.
How to Request Insurance Reimbursem*nt for Doula Services
1.) Pay your doula in full.
2.) 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.
Birth doula (99499), this is a nonspecific code described as “Evaluation and Management Services” and can be applied to the prenatal, birth and postpartum periods when coupled with the appropriate diagnosis codes.
Postpartum doula services (99501 and/or 99502/and or 59430) According to this "the CPT code 59430 is also an unspecific code described as “General Postpartum Care” and can be applied to the postpartum period when coupled with the appropriate diagnosis code."
e. A diagnosis code.The diagnosis code typically used for prenatal and labor support is V22.2 “Pregnant State Incidental.” The diagnosis code typically used for postpartum is V24.2 “Routine Postpartum Follow Up.”
f. The doula's signature.
3.) Submit the invoice with a claim form to your insurance company. The standard claim form that is usually used is (HCFA-1500). However your provider may have a different form and they should be able to provide you with the necessary form.
4.) 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.
5.) 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 (see example letter I wrote for my client below)
6.) 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?)
7.) Write a letter explaining why you felt the need for a doula and how you believe the doula was beneficial to your health.
8.) Submit to your insurance company: the doula's letter and credentials, the letter from the doctor and your cover letter.
9.) 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.
10.) Follow up by telephone if necessary.
11.) 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.)
For the Doula - Sample letter that I wrote for my client:
(Your Company Name)
(Your name)
(Your Address)
(Date)
(Insurance Company)
To Whom It May Concern:
My client (name) who is insured through your company (name), has retained my services to assist in the birth of her (number of birth) baby. (Client's name) hired me to assist in this birth because she wanted a non-medicated, natural birth, with the least amount of interventions and she felt that she needed the extra support from an experience birth doula to accomplish her goals. By serving her and her husband, (name), as a doula, I have contributed to the successful birth of their baby, (name ).
We have had several meetings, prenatally (total hours), the actual labor (hours labor took) and birth and two postpartum visits (hours spent). I have spent a total of (#) hours with them not to mention all the e-mails and phone calls.
I am a certified childbirth educator (only if you are) (organization) as well as a certified doula (organization). (I have enclosed my certifications). During our prenatal meetings I educated them on the different stages of labor, comfort measures, what to expect if a cesarean birth happens, helped her with her birth plan and helped her with the emotional and physical aspects of childbirth.
The day of labor, I was by (my client's name) side for a total of (total hours), getting her through one contraction at a time and then stayed a (# of hours)after the baby was born.
I have had two postpartum visits. One was to help her with breastfeeding and the other was to process the labor and to make sure she was well, emotionally, physically and mentally.
I have been approved for an NPI # under the new taxonomy code 374J00000X and is called “Doula” under the heading of “Nursing Service Related Providers Type.
My NPI # for (Company Name) is: (NPI number here)
If a new technological breakthrough could provide women in childbirth a shorter labor with fewer complications, less need for pitocin, reduced use of forceps, fewer requests for epidural anesthesia and fewer cesarean births, most hospitals would purchase as many as they could afford. Of course insurance companies would pay for the use of this technology because in the end it would be cost effective. It would benefit women, babies, hospitals and the insurance industry.
You may be surprised to learn that trained doulas can do just that! Medical research shows the positive effect of labor support by doulas in the birth setting. Twenty-two controlled trials have demonstrated the benefits listed above, in addition to a greater satisfaction with childbirth for the mothers, a more positive assessment of their babies and less postpartum depression. Babies born with a doula present have shorter hospital stays and fewer admissions to special care nurseries. They breastfeed more easily and their mothers are more affectionate in the postpartum period. The enclosed literature cites and summarizes the relevant studies.https://www.ncbi.nlm.nih.gov/pubmed/23076901
The word "doula" comes from ancient Greek and now refers to a trained, experienced woman who provides continuous physical, emotional and informational support to mothers before, during and after childbirth. (Add certifying company information here) For example:Doulas of North America (DONA) is the oldest birth doula certifying organization in America. For more information about DONA, see the web page at www.DONA.org or call (888)788- DONA.
Doulas are an under-utilized resource, according to ACOG!
A recent joint statement released on March 2014 from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) set forth new guidelines designed to prevent primary cesareans. Here are a few highlights:
“Increasing women’s access to non-medical interventions during labor, such as continuous labor and delivery support, has been shown to reduce cesarean birth rates.”
“Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”
“… the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery.”
Healthcare Provider: (Doctor or Midwifes name and information)
CPT code for the services that I provided is : 99499
Diagnostic code is: (add number here)
My NPI # for (Company Name)is: (NPI number here)
Taxonomy code 374J00000X and is called “Doula” under the heading of “Nursing Service Related Providers Type
If you need additional information to pay this claim, please contact me at:
(phone number)
(e-mail address)
Respectfully,
(Your name and certification credentials)
GOOD LUCK!!!!!!!
