In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist at her obstetrician’s office when she was asked to pay $960, the amount the office estimated she would owe after giving birth.
Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Typically, patients receive the bill after the insurance company has paid its share, and for pregnant women, this is usually not until the pregnancy ends. It would take months for the office to file the claim with her 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. Moreover, she and her husband had wanted a child for a long time. And Clark was emotional because her mother had died just weeks earlier.
“You’re standing there by the window, and there’s people everywhere, and you’re trying to be really nice,” Clark recalled through tears. “So I paid it.”
On online baby message boards and other social media forums, pregnant women say their health care providers are asking them to pay out-of-pocket costs sooner than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers claim that asking for upfront payment ensures they are compensated for their services.
How often this happens is difficult 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 is causing unexpected anxiety at a time of already increased stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe, forcing people to fight for reimbursement if they miscarry or if the amount paid exceeds the final bill.
Prepayments also create barriers for women who want to switch healthcare providers if they are dissatisfied with care. In some cases, they can lead women to forgo prenatal care altogether, especially in places where few other options for maternity care exist.
It “holds their treatment hostage,” said Caitlin Donovan, senior director at the Patient Advocate Foundation.
Experts in medical billing and women’s health care believe that OB-GYN offices have adopted this practice to control the high cost of maternity care and the way it is billed in the U.S.
When a pregnancy ends, gynecologists 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 started 30 years ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing is outdated, she said.
Previously, pregnant patients had to pay a co-pay for each prenatal visit, allowing them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. In addition, it has become increasingly common for pregnant women to switch providers, or for different providers to manage prenatal care, labor, and delivery, especially in rural areas where patient transfers are common.
Some providers say that upfront payments allow them to spread one-time payments over the course of the pregnancy to ensure they are compensated for the care they do provide, even if they don’t ultimately deliver the baby.
“You have people who unfortunately don’t get paid for the work they do,” said Pamela Boatner, who works as an obstetrician at a hospital in Georgia.
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 the baby is born. New parents can become overburdened 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 US, having a baby can be expensive. According to the Peterson-KFF Health System Tracker, people who buy health insurance through large employers pay an average of nearly $3,000 out of pocket for pregnancy, childbirth and postpartum care. In addition, many people opt for health insurance with a high deductible, which means they have to bear a larger share of the costs. According to a 2022 KFF poll, 12% of the 100 million American people with health care debt attribute at least some of it to maternity care.
Families need time to save money for the high costs of pregnancy, childbirth and child care, especially if they don’t have paid maternity leave, says Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to pay in advance “is another blow,” 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 cost of childbirth depends on multiple factors, such as the timing of the pregnancy, the benefits of the plan and health complications, says Erin Duffy, a health policy researcher at the Schaeffer Center for Health Policy and Economics the University of Southern California. 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 midwife accepted her refusal to pay upfront because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private obstetrics practice in New York told her that since she had a high-deductible plan, she was required to pay $2,000 spread over monthly payments.
Daw, a health policy researcher at Columbia University, delivered in September 2023 and received a $640 refund check in November 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 live it.”
Although the Affordable Care Act requires insurers to cover certain prenatal services, it does not prohibit providers from sending their final bill to patients early. It would be politically and practically challenging for state and federal governments to try to regulate the timing of the payment request, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobby groups are powerful and the contracts between insurers and medical providers are proprietary.
Because of the legal gray area, Lacy Marshall, insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to pay their deductible up front. Some insurance plans prohibit providers in their network from requiring prepayment.
If the insurer says they can refuse to pay up front, Marshall says, she tells clients to set up a practice before refusing to pay so the provider can’t deny treatment.
Clark said she met her insurance deductible after paying for genetic testing, additional ultrasounds and other services from her health care flexible spending account. Then she called her gynecologist’s office and asked for a refund.
“I have my spine back,” said Clark, who previously worked at a health insurance company and a medical 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 rose. A high-risk pregnancy specialist – not her original gynecology practice – prematurely delivered her son Peter via caesarean section at 30 weeks.
Only after she settled most of the childbirth bills did she receive the remainder of her reimbursement from the other gynecology practice.
This last 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 kid.”
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the core operating programs at KFF – an independent source of health policy research, polling and journalism. Learn more about KFF.
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This article first appeared on KFF Health News and is republished here under a Creative Commons license.
