Are upfront payments to Obstetrician allowable for reimbursement?

[Guest okiedokie]

A participant is going to have a baby. She is making upfront payments to the obstetrician as part of a payment plan agreement. Although no actual service is being preformed, would the payments that have already been made, qualify to be reimbursed through the FSA. (payments made are not for reqular office visits) My thinking is that this would not qualify to be reimbursed, because she is actually paying for a "provided service" that hasn't taken place yet. I hate to see someone "SOL" so I thought I'd get a second opinion, just to make sure I'm on the right track.

[GBurns]

I would say that it is not reimburseable because the service has not yet been rendered, so the expense has not yet been incurred although pre-payment has been made.

Also the arrangement has a chance of not being completed. What would happen if, heaven forbid, she had a miscarriage and so never uses the OB? She would get her money back from the OB and would also have been reimbursed by the FSA.

Some service should at the least be rendered for even pro rated or partial reimbursement.

[Guest JerseyGirl]

Hope everyone is sitting down for this one, because I agree with GBurns! However, once the birth takes place these fees become eligible expenses, regardless of when the payments were made (last year, this year) because at that point, the service will have been provided.

[GBurns]

Accidents do happen.

[david rigby]

Perhaps I am misreading something. Are you (both) saying that no services are "performed" until the birth occurs?

[oriecat]

Yeah, aren't there any pre-natal visits? Or are those charged and paid for separately.

[GBurns]

The OP made a point of stating that "no actual service is being preformed" and that "the payments that have already been made".

Normal prenatal visits would be covered under any health plan, since pregnancy is treated as any other illness. Other payments other than simple co-pay for office visits, that would be significant enough to need installment payments, would be related to either the delivery or infant care and if there is no maternity coverage or limited coverage would create the situation described.

[Mary C]

This is similar to reimbursment of ortho expenses where one fee is charged event though services are spread out over a period of time.

We've dealt with this situation with an employee enrolled in a PPO plan with a $500 deductible and 70%/30% copay when the OB was out of network. We asked the doc to provide a breakdown for the cost of a pre-natal visit, the sonogram, the blood tests, delivery, etc. then calculated the reimbursement based on that less what the plan would reimburse. And yes, prenatal visits should be considered services eligible for reimbursement when incurred if you have a breakout of the cost.

[mbozek]

OK-It is highly unlikely that no services would be rendered to the employee before birth because medical ethics and malpractice issues would require periodic examination of the pregnancy prior to birth. Hospitals require that docs certify that a minimal level of care has been given in order for admission for a delivery. My own recollection is that monthly examinations are required in addition to various pre natal tests which are part of the overall fee for delivery.

[GBurns]

Pre natal treatment is a separate issue from delivery. In fact the pre natal is covered under pregnancy which is treated as any other illness, whereas, delivery falls under maternity benefits which might not even be covered by the health plan.

[Guest JerseyGirl]

The approach used by Mary C is one that I would try as well. Further probing could reveal the use of an out-of-network obstetrician, no maternity coverage, insufficient coverage, any number of reasons that this delivery requires a payment plan.

However, we must still consider the facts as stated by okiedokie: 1) upfront payments are being made; 2) no actual service is being performed; 3) payments are not for regular office visits. Should all of these details prove after further investigation to be accurate and correct, the only recourse is to reimburse the total after the service (delivery) has been rendered.