REIMBURSEMENT CONSIDERATIONS

Adding medication and/or aspiration abortion and EPL management into your practice should not cost you money in the long term. In time, all costs should be recoverable through proper billing and appropriate fee setting.

There are three main components of financial analysis for integration of EPL and abortion services: cost, revenue, and profit or loss. In addition, there are also many intangible benefits of integrating these services, including improved continuity of care, patient retention, and enhanced relationships with your patients.

1. Cost

For aspiration procedures, there are several one-time expenses including equipment and supplies and a possible ultrasound machine. As a result, you may not be able to show a profit in the first year of service, especially if you are seeing a low volume of patients. However, over time – 2 to 3 years – the variable supply costs should be very low, especially if you take advantage of group purchasing programs (for example through NAF membership, Afaxys, or HRSA 340b pricing for contraceptive supplies). Some sites may need to purchase liability insurance to cover abortion services.

Facilities that receive federal funding, such as Title X or Section 330 funding (Federally Qualified Health Centers), are prohibited from using federal funds for abortion care.  These facilities need to establish clear financial and administrative systems to ensure that abortion expenses and revenues are properly segregated from their federally funded services. The following administrative guide outlines the key administrative and financial issues that federally funded facilities must take into account as they integrate abortion services. Sites that were purchased or renovated with federal funding may have additional restrictions that need to be explored before abortion services can be provided on site.

When incorporating medication abortion services (either in person and via telehealth) there will be little upfront cost to the organization. Expenses may include purchase of mifepristone and optional cost of an ultrasound machine. Based on where you practice, ultrasound may already be readily available on site or through the radiology department. 

2. Revenue

Knowing how much you can expect to be paid for EPL and abortion services is another important step in developing your budget. EPL services should be reimbursed by all payers, including Medicaid. In some states, state-based Medicaid and private insurance plans will reimburse for abortion services while in other states, patients will have to pay out of pocket. The Guttmacher State Policy Guide is helpful in determining the insurance coverage in your state.

If your patients have insurance, it will be beneficial to research if and how much those insurance plans will reimburse for EPL and abortion services. If you encounter plans that will not reimburse, consider negotiating contracts with those insurance companies with which you already have relationships. Be prepared to dedicate staff time to identifying and establishing new contracts. See FP Insurance Letter to use as a blueprint for contacting an insurance company.

With respect to abortion services, while some of your patients may be insured, it is important to note that approximately 40% of patients who have insurance decline to use it for abortion services for privacy reasons. 

3. Billing

When billing Medicaid or private insurance, use of proper billing codes is very important to getting accurate reimbursement.  A list of the most common ICD-10 codes used for diagnosing and billing for early pregnancy loss, manual vacuum aspiration for abortion and medication abortion can be found here. 

4. Fee Setting

There are three key considerations when setting your fee for patients:

• What are your actual costs?
• What are your competitors charging?
• What is the value placed on it by patients?

In setting your fees, make sure to consider including the following:

• Lab tests (if using)
• Pain medications (for aspiration procedures)
• Ultrasound (if using)
• Birth control (if provided at the same visit)

The staff making the appointment should be able to articulate all the services in the visit. Consider additional services provided at the same visit including: contraceptive counseling and provision, pap test, STI screening, even flu, COVID and HPV vaccination. Some practices offering medication abortion will choose to bill for the medications for the abortion and part of the provider time as the abortion part of the visit, and bill the rest as they would any primary care visit.

Fee differences between an aspiration abortion, medication abortion, and telehealth visit may impact a patient’s choice or make the preferred procedure inaccessible. It is advised to consider setting the same fee for all abortion services.

5. Helping Patients Pay For Their Abortion

Paying for abortion services can be a financial challenge for some patients. Patients who may be paying out of pocket include those who do not have insurance, patients who have insurance in a state that limits coverage for abortion services, and patients who are keeping the visit confidential from those on the same insurance plan. With bans and state-based restrictions, patients are now increasingly traveling out of state for abortion care. This increases the costs to the patient to include travel, overnight accommodations, time off from work, and childcare.

Providers can connect with local and national abortion funds to help patients pay for their abortion care. The National Network of Abortion Funds maintains a complete listing of state-based abortion funds. Your staff can become familiar with helping patients access supportive services such as travel support (i.e. brigidalliance.org). Patients can also reach out to Planned Parenthood and National Abortion Federation for financial support to help cover abortion-related costs. 

6. Professional Liability Insurance

Obtaining affordable liability coverage is currently a challenge for clinicians in every area of medicine, and abortion services in particular. Although the financial risk to the insurer for abortion services is approximately one third that of obstetric services, insurance companies often “bundle” abortion with general Ob-Gyn coverage, despite much lower complication rates (Dehlendorf 2008). ACOG released a committee opinion that early pregnancy care (including early EPL and abortion care) should fall under the scope of gynecologic care and as such, individuals may choose not to carry professional liability coverage for obstetrics. Many insurance companies do not yet recognize abortion as a service that falls safely within the scope of practice of primary care providers, despite significant safety and efficacy data.

Providers who do not have coverage for EPL and abortion services under their instiutions’ professional liability insurance, can obtain supplemental malpractice insurance. Providers working at FQHCs will need to obtain this supplemental insurance as the Federal Tort Claims Act excludes abortion related services.

Advocacy for improved insurance industry regulation could help ensure that clinicians trained and willing to provide services to their patients are not limited by the decisions of liability insurers.

The Access Delivered toolkit has a useful table on liability insurance. The graph below provides information on different malpractice insurance options. States differ on which insurers they consider to be legitimate. If you plan to purchase individual insurance, check with your state insurance commissioner that your carrier is on the approved list. Whichever option you choose, assure the coverage is adequate for your services.