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Insurance 101

Insurance is a tricky topic due to the vast array of plans and coverage options. For instance, BlueCross Blue Shield may have multiple different plans and coverage criteria within the same company. With the new healthcare laws coming into effect in 2014, an individual’s specific coverage will be difficult to explain fully, but we will give a broad overview.

Every insurance policy has inclusions and exclusions. For example, some policies of small businesses will specifically exclude any healthcare expenses resulting from a pregnancy. Many of these policies will cover “complications of pregnancy.” However, your insurance company and you may disagree on what a “complication” entails.

Many insurance policies have recently excluded all “obstetrical complications” which would include preterm labor, twins, triplets, pre-eclampsia, gestational diabetes and breech babies requiring Cesarean sections. These policies likely will not cover any prenatal care, labs, ultrasounds, consultations, delivery or postpartum care, which will all be “out of pocket” expenses. However, they will cover your broken leg, car wreck or appendicitis while you are pregnant.

Deductible and co-pay expenses vary widely. If, for example, you have a $1,000 deductible and a $40 co-pay and have met none of your deductible for the plan year, you could pay several hundred dollars out of pocket for an ultrasound and a consultation.

At Austin Perinatal, we will frequently see patients for a radiologic procedure (ultrasound) and a consultation. Your insurance will dictate what is covered without a deductible or co-pay or a specific amount or percentage that applies to both radiology procedures and office visits/consultations.

You will be responsible for paying these fees at the time of your visit. Just as a dermatologist may have multiple complexities of office visits and biopsy fees, consultation and ultrasound charges at Austin Perinatal depend upon which complexity of service that we perform.

For example, a quick check for a baby heart rate at 6 weeks would be different from a complete anatomic survey at 18 – 20 weeks which would be different from a “biophysical profile” which looks for fetal well-being near term. You may even have multiple ultrasound procedures done at the same time (growth scan plus a biophysical profile, or an early fetal scan plus a nuchal translucency). Also, abdominal ultrasound examinations are charged at different rates from vaginal ultrasounds.

A common occurrence that many patients may not understand regards the potential double paying of their annual deductible amount. Some patients may have paid the generalist obstetrician their yearly deductible amount on one of their first visits. Under a global plan, the obstetrician cannot file the claim with your insurance for your pregnancy until after you have delivered. When we here at Austin Perinatal call your insurance to find out amount of your deductible met, they will have no record of your payment to your Ob’s office. This may lead to you “double-paying” your deductible, only to receive a refund from your obstetrician after delivery.

We do not offer payment plans at Austin Perinatal, but we do offer the option of Care Credit, a quick line of credit designed to help you with these expenses should the need arise. Our insurance specialists and office manager are always happy to help you in any way possible. If, at any time, you do not understand the billing, insurance or collection procedures of Austin Perinatal Associates, please ask anyone in our office and you will be directed to the right member of our staff.

Dr. David L. Berry

A 4th generation physician and Austinite since 1978, Dr. Berry is board certified by the American Board of Obstetrics and Gynecology both in OB/GYN and maternal-fetal medicine.

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The APA Staff

Courteous, friendly, and experienced, the Austin Perinatal Associates staff is second to none. We staff genetic counselors, sonographers, nurse practitioners, and more.

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