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In April, just 12 weeks into her pregnancy, Kathleen Clark stood at the receptionist window of her obstetrician-gynecologist’s office when she was asked to pay $960, the total the office estimated she should after giving birth.

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 share, and for pregnant women, it’s usually not until the end of the pregnancy. It would be months before the office filed the claim with its health insurer.

Clark said she felt stuck. The obstetrics practice in Cleveland, Tennessee, was affiliated with a birth center where she wanted to give birth. Additionally, she and her husband had wanted to have a baby for a long time. And Clark was emotional, because a few weeks earlier, her mother had died.

“You’re there by the window, and there’s people all around, and you’re trying to be really nice,” Clark recalled through tears. “So, I paid for it.”

Online electronic message boards for babies and others social media forumsPregnant women report that their providers ask them to pay fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers say requesting payment up front ensures they will be paid for their services.

It is difficult to track how often this occurs because it is a private transaction between the provider and patient. Therefore, 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 in a time of already increased stress and financial pressure. Estimates can sometimes be more than a patient might ultimately owe and force people to fight for reimbursement if they miscarry or if the amount paid is more than the final bill.

Upfront payments also create barriers for women who might want to change providers if they are unhappy with their care. In some cases, they can lead women to forgo prenatal care altogether, particularly in places where few other maternity care options exist.

This “holds their treatment hostage,” said Caitlin Donovan, senior director of Patient Advocate Foundation.

Experts in medical billing and women’s health believe that OB-GYN practices have adopted the practice to manage the high cost of maternity care and the way it is billed in the United States.

At the end of a pregnancy, obstetrician-gynecologists typically file a single insurance claim for routine prenatal care, labor, delivery and, often, postpartum care. This practice of lumping all maternity care into a single billing code began three decades ago, said Lisa Satterfield, senior director of health policy and payment at American College of Obstetricians and Gynecologists. But this bulk billing has become obsolete, she said.

Previously, pregnant patients were subject to a co-pay for each prenatal visit, which could 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. Additionally, it is increasingly common for pregnant women to switch providers or for different providers to handle prenatal care, labor, and delivery, particularly in rural areas where patient transfers are common.

Some providers claim that prepayments allow them to spread out one-off payments throughout the pregnancy to ensure that they are paid for the care they provide, even if they do not ultimately give birth.

“There are people who, unfortunately, don’t get paid for the work that they do,” said Pamela Boatner, who works as a midwife at a Georgia hospital.

While she believes women should receive pregnancy care regardless of their financial ability, she also understands that some providers want to make sure their bill isn’t ignored after giving birth. New parents may be burdened with hospital bills and the cost of caring for a new child, and they may lack income if one parent isn’t working, Boatner said.

In the United States, having a baby can be expensive. People who get health insurance from 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 Monitoring. Additionally, many people opt for high-deductible health insurance plans, allowing them to cover more of the costs. From the 100 million Americans With health care debt, 12% attribute at least part of it to maternity care, according to a KFF 2022 survey.

Families need time to save money to meet the high costs of pregnancy, childbirth and child care, especially if they don’t have paid maternity leave, said Joy BurkhardCEO of the Policy Center for Maternal Mental Health, a policy think tank based in Los Angeles. Asking them to pay up front “is another gut punch,” she said. “What if you don’t have money?” Do you put it on your credit cards and hope your credit card gets accepted? »

Calculating the final cost of childbirth depends on several factors, such as time of pregnancyplan benefits and health complications, said Erin Duffyhealth policy researcher at the Schaeffer Center for Health Policy and Economics at the University of Southern California. The patient’s final bill isn’t clear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option of waiting for the insurer is removed.

During Jamie Daw’s first pregnancy in 2020, her obstetrician-gynecologist accepted her refusal to pay up front because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwife’s office in New York told her that because she was on a high-deductible plan, she was required to pay $2,000 in monthly installments.

Daw, a health policy researcher at Columbia University, gave birth in September 2023 and got a reimbursement check in November for $640 to cover the difference between the estimate and the final bill.

“I’m studying health insurance,” she said. “But, as most of us know, it’s so complicated when you actually experience it.”

Although the Affordable Care Act requires insurers to cover certain prenatal services, it does not prohibit providers from sending patients their final bill early. It would be a political and practical challenge for state and federal governments to try to regulate the timing of requesting payment, said Sabrina Corletteco-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobby groups are powerful and contracts between insurers and medical providers are exclusive.

Due to the legal gray area, Marshall Lacean insurance broker with Rapha Health and Life in Texas, advises his clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring an upfront payment.

If the insurer says it can refuse to pay up front, Marshall said, she tells clients to establish themselves in a practice before refusing to pay, so the provider can’t refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, additional ultrasounds and other services through her healthcare flexible spending account. Then she called her obstetrician-gynecologist’s office and asked for a refund.

“I got my backbone back,” said Clark, who previously worked in health insurance and a doctor’s office. She received an initial check for about half of the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure increased. A high-risk pregnancy specialist – not her original practice in obstetrics and gynecology – delivered her son, Peter, prematurely by emergency cesarean section at 30 weeks.

Only after paying most of the bills for the delivery did she receive the remainder of her reimbursement from the other OB-GYN practice.

That final check came in October, just days after Clark brought Peter home from the hospital and after several calls to the office. She said it all added stress to an already stressful time.

“Why do I have to pay the price as a patient? » she said. “I’m just trying to have a baby.”

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the primary operating programs of KFF, an independent source of health policy research, polling and journalism. Learn more about KFF.