Navigating and Negotiating a U.S. Hospital Bill for International Intended Parents
The U.S. healthcare and insurance system is not like any other in the world. It’s complicated, vague, and challenging, even for Americans. Although IVF and surrogacy are at the forefront in the U.S. and there are many reasons international intended parents (IPs) would embark on a journey in America, it does come with the challenge of navigating the insurance and cost of care for their newborn.
In the U.S. there are two sets of insurance that all IPs need to have: Coverage for the gestational carrier (GC) for her prenatal, delivery, and postpartum care, and coverage for their newborn. The insurance for the GC is non-negotiable, and if it is not already included in the GCs current insurance coverage, additional coverage can be purchased for her through Open Enrollment in the Health Insurance Marketplace (www.healthcare.gov).
For American IPs, the newborn would automatically fall under their insurance. Simple. For international IPs who do not have American health insurance, they are left with the option to either buy expensive newborn coverage or pay out of pocket.
If there are any complications with the delivery or if the newborn requires an extended hospital or neonatal intensive care stay, international IPs do have the option of buying insurance retroactively to cover some of these costs. However, the goal for international IPs is a ‘routine’ delivery and newborn care and then to pay the hospital bill in cash. However, navigating and negotiating this bill requires knowledge of the following:
What is included in routine newborn care in a U.S. hospital?
How much should IPs expect to pay?
How can IPs navigate and negotiate their hospital bill?
Are there any resources to help IPs negotiate their hospital bill?
These bullets are the areas I plan to cover in this article, in order to help international IPs feel more comfortable with what they can expect to receive for newborn care, about how much this should cost, and how to approach negotiating their bill.
What is included in routine newborn care in a U.S. hospital?
Routine newborn care includes the initial physical examination and treatment immediately after birth and then additional testing and screening in the 24 to 48 hours that the newborn will be in the hospital.
Immediately after birth, the following will occur (1, 2, 3):
Suctioning of throat and/or nose if extra fluid is present from the lungs (crying will be a good indication this is all clear).
APGAR scoring: Activity (muscle tone), Pulse (heart rate), Grimace (response to stimulation), Appearance (skin color) Respiration (breathing rate and volume, screaming is best). Each area is scored from 0 to 2 and anything above 7 is normal.
Cleaned (sometimes delayed until after bonding), weighed, and measured.
Bonding and skin-to-skin contact: This has been shown to improve the baby’s temperature regulation, stabilize their heart rate and breathing, and increase blood oxygen levels.
Vitamin K injection: Newborns are born with low vitamin K levels, so this is given to help with blood clotting.
Antibiotic eye ointment: This is to prevent infection from the vaginal canal.
For the remainder of the 24 to 48 hours, the following will occur prior to discharge (3, 4):
Required newborn screening when the baby turns 24 hours old: This includes a heel prick for 5 drops of blood to test for over 20 different diseases (such as congenital hypothyroidism, phenylketonuria (PKU), cystic fibrosis, sickle cell anemia). Often parents will be asked if they want to donate extra samples for future research.
Hearing test: To identify any possible early hearing issues, and this can be repeated one week after discharge from the hospital, if needed.
Bilirubin test: Monitor placed on the forehead to detect liver abnormalities and risk for jaundice (yellowing of the skin).
Blood sugar test: More often for babies born to GCs with gestational diabetes, but could be for any newborn who is considered large for gestational age (LGA), or greater than the 90% percentile or about 8 pounds 13 ounces (4,000 grams).
If the GC is breastfeeding, lactation consultation is available throughout the hospital stay.
For the vast majority of IPs, this will be their path through the first 24 to 48 hours of being parents. Next, the bill will arrive.
How much should IPs expect to pay for routine newborn care?
Childbirth without insurance is rare in the U.S. as in 2017 only 4% of hospital births were self-paid (5). Also, there are a variety of factors that can influence a hospital bill, including but not limited to the providers, hospital, and location. This means that no two IPs — unless they deliver in the exact same hospital at the exact same time — will have the same bill.
There is a publically available service that IPs can use to estimate their hospital costs. The service is called FAIR Health Consumer (https://www.fairhealthconsumer.org/en), and their mission is to help people understand healthcare costs and health coverage and to bring transparency to healthcare costs and insurance. FAIR Health is an independent, national, nonprofit organization known for providing fair and neutral information through compilation of more than 43 billion health claim records.
With this large dataset of health claim records, FAIR Health has a tool that anyone can use to estimate healthcare costs, based on the insurance status, location, and type of service (https://www.fairhealthconsumer.org/en/medical). This can be used by international IPs even before the birth of their child to estimate what they can expect to pay out of pocket for their newborn care.
How can IPs navigate and negotiate their hospital bill?
Once the hospital bill arrives, the real ‘fun’ begins for international IPs.
The variability and vagueness of U.S. hospital bills is impressive. Here are 3 different bills for routine delivery and newborn care in the U.S.:
Each of these hospital bills are different in how they present the delivery and newborn costs, the level of details they provide, and the costs of various services.
So how should IPs approach their bill?
It is important to know that the Affordable Care Act (ACA) requires all qualified insurance plans to cover certain newborn care at no extra cost. Even if the newborn is uninsured, it is worth asking if these services can be removed from a hospital bill: Gonorrhea preventive medication (antibiotic ointment) for the eyes and newborn genetic screening (6).
Before contacting the hospital billing department, it should give IPs confidence that when it comes to hospital bills, cash is king. A 2022 study from over 2,300 hospitals found that cash prices were likely lower than negotiated rates at nonprofit or government-owned hospitals, where cost can be shifted to insured patients whose negotiated rates are higher than the actual cost(s) of the procedure (7).
There are some questions all IPs should ask the hospital billing department in order to negotiate the best possible outcome for their hospital bill.
Do they offer charity care or an uninsured discount policy? Many hospitals will offer discounts under charity care or an uninsured patient policy. Stanford Hospital is one example that does not take an individual’s immigration status into account for this type of discount (8).
Do they offer self-pay discount rates? Similar to the study referenced above, hospitals are able to charge cash-paying patients less as they can recover costs through the rates negotiated with insured patients.
Do they have a sliding scale? This can lower the cost of treatment based on a person’s income. While this often requires an individual to have filed U.S. taxes, there may be hospitals that can work with international tax returns to estimate income.
Can they set up a payment plan? This can help make the agreed upon payments more manageable for the IPs by spreading them out over a period of time.
In addition to these questions, it is imperative that IPs question every line item and aspect of their bill. As shown above, the bills can be aggravatingly vague. Even as a physician, I cannot tell you exactly what some of the line items in the bills above are referring to. Also, hospitals and billing departments make mistakes, and so it’s important to know that the charges reflect the care that was received.
PBS published a story that U.S. hospitals can artificially inflated the bills of routine deliveries (9). The story focused on a woman who gave birth in Fort Collins, CO, and had an uncomplicated, routine delivery. However, when this woman checked-in to the hospital through the ER, she was charged the highest level of emergency care (level 5) when she was in no acute distress and had a normal physical examination. While this or similar errors in hospital bills could be clerical mistakes rather than intentional overcharging, the important point for IPs is that they have to rigorously review their bill and ask for clarifications of the vagueness of type and level of care in order to ensure they are only paying for what they should.
Are there any resources to help IPs negotiate their hospital bill?
If IPs are overwhelmed or unable to invest the time and persistence to understand and negotiate their bill with a hospital, there is the option to hire a professional to help.
Medical billing advocates, also known as claims assistance professionals (CAP), can be hired to evaluate bills for errors, duplications, or unreasonable charges and then negotiate with the hospital or insurer (https://claims.org/refer.php). Some charge an hourly rate of $100 to $200, and some charge a percentage of savings, typically 15 to 35% of the reduction in the bills they achieve. Importantly, some of these medical billing advocates are also able to work internationally, providing expert guidance for IPs who are from outside the U.S.
In summary, routine newborn care in U.S. hospitals will involve costs for examinations, testing, mandatory screening, and room fees for the hospital. U.S. hospital bills are vague, non-standardized, and can include errors. When paying without insurance, negotiation and attention to detail is absolutely necessary. IPs can utilize the FAIR Health Consumer site to estimate costs for a medical service to have a reference rate. IPs should line item each aspect of the bill and ask for clarifications regarding level of care in order to ensure accuracy of the bill. They can then discuss sliding scales, charity care, and payment plans to minimize costs with the hospital billing department. If needed, IPs can employ a medical billing advocate or claims assistance professional to handle the negotiation.
References:
https://www.verywellfamily.com/what-to-expect-at-hospital-after-giving-birth-5088542
https://www.verywellfamily.com/newborn-baby-hospital-tests-4064718
https://www.verywellfamily.com/what-to-expect-at-hospital-after-giving-birth-5088542
https://www.axios.com/2023/04/04/hospitals-likelier-patients-who-pay-cash