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Renuka Rayasam | (TNS) KFF Health News In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN’s office when she was asked to pay $960, the total the office estimated she would owe after she delivered. Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that’s usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer. Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died. “You’re standing there at the window, and there’s people all around, and you’re trying to be really nice,” recalled Clark, through tears. “So, I paid it.” On online baby message boards and other social media forums , pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services. How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers. Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill. Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo 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 at the Patient Advocate Foundation . Medical billing and women’s health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S. When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists . But such bundled billing has become outdated, she said. Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it’s become more 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 prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don’t ultimately deliver the baby. “You have people who, unfortunately, are not getting paid for the work that they do,” said Pamela Boatner, who works as a midwife in a Georgia hospital. While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn’t ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn’t working, Boatner said. In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker . In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll . Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard , CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay “is another gut punch,” she said. “What if you don’t have the money? Do you put it on credit cards and hope your credit card goes through?” Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy , plan benefits, and health complications, said Erin Duffy , a health policy researcher at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said. But sometimes the option to wait for the insurer is taken away. During Jamie Daw’s first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments. Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 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 so complicated when you’re really living it.” While the Affordable Care Act requires insurers to cover some prenatal services, it doesn’t prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette , a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary. Because of the legal gray area, Lacy Marshall , an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front. If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can’t refuse treatment. Related Articles Which health insurance plan may be right for you? California case is the first confirmed bird flu infection in a US child What’s up with that brown haze across Colorado’s Front Range when it’s not summer ozone season? Your cool black kitchenware could be slowly poisoning you, study says. Here’s what to do Does fluoride cause cancer, IQ loss, and more? Fact-checking Robert F. Kennedy Jr.’s claims Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN’s office and asked for a refund. “I got my spine back,” said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid. In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks. It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice. This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period. “Why am I having to pay the price as a patient?” she said. “I’m just trying to have a baby.” ©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.SEOUL, South Korea — North Korean leader Kim Jong Un vowed to implement the “toughest” anti-U.S. policy, state media reported Sunday, less than a month before Donald Trump takes office as U.S. president. Trump’s return to the White House raises prospects for high-profile diplomacy with North Korea. During his first term, Trump met Kim three times for talks on the North's nuclear program. Many experts however say a quick resumption of Kim-Trump summitry is unlikely as Trump would first focus on conflicts in Ukraine and the Middle East. North Korea's support for Russia's war against Ukraine also poses a challenge to efforts to revive diplomacy, experts say. During a five-day plenary meeting of the ruling Workers’ Party that ended Friday, Kim called the U.S. “the most reactionary state that regards anti-communism as its invariable state policy.” Kim said that the U.S.-South Korea-Japan security partnership is expanding into “a nuclear military bloc for aggression." “This reality clearly shows to which direction we should advance and what we should do and how,” Kim said, according to the official Korean Central News Agency. It said Kim's speech “clarified the strategy for the toughest anti-U.S. counteraction to be launched aggressively” by North Korea for its long-term national interests and security. KCNA didn't elaborate on the anti-U.S. strategy. But it said Kim set forth tasks to bolster military capability through defense technology advancements and stressed the need to improve the mental toughness of North Korean soldiers. The previous meetings between Trump and Kim had not only put an end to their exchanges of fiery rhetoric and threats of destruction, but they developed personal connections. Trump once famously said he and Kim “fell in love.” But their talks eventually collapsed in 2019, as they wrangled over U.S.-led sanctions on the North. North Korea has since sharply increased the pace of its weapons testing activities to build more reliable nuclear missiles targeting the U.S. and its allies. The U.S. and South Korea have responded by expanding their military bilateral drills and also trilateral ones involving Japan, drawing strong rebukes from the North, which views such U.S.-led exercises as invasion rehearsals. Further complicating efforts to convince North Korea to abandon its nuclear weapons in return for economic and political benefits is its deepening military cooperation with Russia. According to U.S., Ukrainian and South Korean assessments, North Korea has sent more than 10,000 troops and conventional weapons systems to support Moscow's war against Ukraine. There are concerns that Russia could give North Korea advanced weapons technology in return, including help to build more powerful nuclear missiles. Ukrainian President Volodymyr Zelenskyy said last week that 3,000 North Korean troops have been killed and wounded in the fighting in Russia's Kursk region. It was the first significant estimate by Ukraine of North Korean casualties since the North Korean troop deployment to Russia began in October. Russia and China, locked in separate disputes with the U.S., have repeatedly blocked U.S.-led pushes to levy more U.N. sanctions on North Korea despite its repeated missile tests in defiance of U.N. Security Council resolutions. Last month, Kim said that his past negotiations with the United States only confirmed Washington’s “unchangeable” hostility toward his country and described his nuclear buildup as the only way to counter external threats.
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