Savannah Midwifery, LLC
GeorgAnna Wiley, CNM (Certified Nurse Midwife), BSN, WHNP, MSN, RN, CPM
1127 Washington Avenue, Savannah, GA 31404 | (912) 344 – 5066
http://www.savannahmidwife.net | [email protected]
financial agreement | insurance info
This financial agreement outlines the fees for midwifery services provided by GeorgAnna Wiley, CNM, BSN, WHNP,
MSN, RN, CPM, and Lauren O. Bibin, CNM, MSN, MS, APRN.
Home birth midwives work irregular hours, are unable to pursue a 9-5 job, and often miss holidays, birthdays, important
family events, and may drive over 2 hours each way in inclement weather. This financial agreement reflects your
midwife’s level of commitment to you and the extensive training, which requires significant annual maintenance
expenses.
For uninsured clients, a discounted fee of $4300 is required by 36 weeks gestation. For clients with health insurance,
GeorgAnna Wiley collects a $4000 deposit towards patient responsibility of insurance payment. When insurance pays
Savannah Midwifery, LLC, the client will be reimbursed up to $3600 ($4300 less Larsen Billing Company’s 8%
processing fee, any deductibles or co-pays that may apply, and a $100 administrative processing fee). When insurance is
billed, the itemized charges may total to more than $4300. As per insurance regulations, any payments from the insurance
company over what the client paid is retained by the provider. The client will not be responsible for more than $4300. The
out of pocket amount may be paid in full or in installments. A $500 fully refundable deposit is due at the first visit. The
midwife will not go “on-call” until the balance is paid unless prior arrangements have been made. Larsen Billing may
handle collection of payments, unless other arrangements are requested.
I/We agree to cooperate with Larsen Billing Service and/or GeorgAnna Wiley to accomplish payment and reimbursement.
This may involve applying for exemptions or appeals. I will complete a Patient Registration Form with Larsen Billing
Service, which includes a Verification of Benefits with my insurance company at a cost of $20 to be paid directly to
Larsen Billing (not included in the fee for services).
The fee includes:
 Any prenatal appointments with your midwife at her office
 Any childbirth education taken with your midwife
 Use of an Aquadoula tub
 At least one prenatal visit at the client’s home in the last 6 weeks of pregnancy
 On-call time for the delivery beginning at 37 weeks gestation
 Birth services at home
 Newborn examination and care
 One visit in your home between 24 and 72 hours postpartum
 One postpartum office visit at 4-6 weeks
It does not include doctor or other health care provider visits, blood draws, lab work, ultrasound, or any other doctor or
midwife ordered testing, medications, vitamins, herbs, birth supplies, transportation by ambulance, any hospital fees, or
lactation consultation beyond that given by the midwife.
Your fee may be reduced based on the following things:
1. Financial need/sliding scale for those with real need (at midwife’s discretion).
2. Bartering/trade agreements at midwife’s discretion.
If care is terminated at any point during pregnancy prior to start of labor, money will be refunded based on the amount of
prenatal care given ($250 per prenatal, $300 per home prenatal, $500 for initial intake visit, and number of days the
midwife has been on call ($50 per day starting at 37 weeks of pregnancy). In the event of transport to the hospital during
labor or the postpartum period, no refund will be granted.
It is rare, but occasionally a midwife will miss a birth, sometimes by a few minutes, sometimes by more. Money will or
will not be refunded in such a situation at the midwife’s discretion, based on the circumstances.
To provide optimal care for clients, there is a limit to how many clients are accepted each month. Therefore, a $500
refundable deposit is required. Delayed and extended payment plans are essentially a form of loaning money, and
difficulties often arise upon collection. Therefore, GeorgAnna is able to accept PayPal, credit cards, checks (postdated are
acceptable as long as they do not extend beyond 3 months of your due date), Health Savings Account payments, and cash.
Unless other arrangements have been made, the full amount is to be paid by 36 weeks gestation, or the midwife reserves
the right not to attend your birth and no refund shall be given.
Payments (to be worked out between client and midwife) will occur within a few days of the following schedule [use this
space to write out your payment plan]:
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Failure to pay according to the above schedule or to renegotiate the fee and/or fee schedule with the midwife can result in
discontinuation of care. While GeorgAnna tries not to exclude any family from experiencing the joys of homebirth based
on their monetary resources, it is important that you follow through with your financial commitments.
I/We have read and understand this Savannah Midwifery Financial Agreement, and have had my/our questions answered
to my/our satisfaction. I/we accept the ultimate responsibility for and agree to pay the fees as outlined above. I/we
understand that GeorgAnna Wiley, CNM, WHNP, MSN, BSN, RN, CPM, does not accept health insurance directly but
can provide a receipt for services and may assist in reimbursement to the client directly from the insurance provider.
Clients are expected to pay for services in advance. Some services may not be eligible for reimbursement. I/we understand
that checks returned for insufficient funds will accrue a charge of $35 per check. I/we also understand that 5% per month
may be added to my/our fee on each monthly bill sent out after the birth of my/our child.
I/we agree that the fee for the maternity and newborn care will be $_______________ based on the fees outlined above.
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Printed name of mother
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Signature of mother
Date
Date
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Signature of midwife
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Signature of witness
Financial Information
The all-inclusive Global Maternity fee is $4300 – this includes all prenatal care, birth, birth supplies (there is no birth kit
to purchase), the heated birthing pool, being on call from 37 weeks, postpartum care, and initial newborn care. So far, all
my clients have found whatever they had to pay out of pocket was well worth it for the amazing opportunity to have what
can often be an empowering, beautiful birth at home. I am open to trade/barter, extended payment plans, discounts as
needed, credit card/paypal payments, health savings account payments, or postdated checks to make homebirth a viable
financial option. I do not accept insurance directly because I am a one-woman business (no secretary, etc), however, I am
authorized and in network for many insurance companies and use Larsen Billing Service for those who would like to use
insurance. If you choose to use insurance, any applicable deductible and co-pays will apply, as well as 2 fees (below).
If you would like to use your insurance, please visit www.LarsenBilling.com and go to Patient Services tab, then
Verification of Benefits and Patient Registration. If you would like to speak to your insurance company directly, here is
my information:
Savannah Midwifery’s provider number for Larsen Billing is 15226
NPI is 1043547367
Tax ID is 27-5247402
Tricare provider ID is 275247402
GA license number RN 161539
CPM number for South Carolina is 13060005, SC license number LMW-0062
I strongly recommend using Larsen Billing to verify coverage and benefits. They are able to apply for GAP exemptions,
appeal claims, and potentially increase your coverage.
Billing Service
The provider number of Savannah Midwifery, LLC, for Larsen Billing is 15226
The billing agent specializes in handling reimbursement of homebirth fees, specifically getting your homebirth expenses
covered by your insurance provider. If I am out of network, they have excellent success rates at filing exemptions on your
behalf so I will be covered as in network for you. They also are the best option for getting as much of the fee covered as
possible because they “speak the language” and are knowledgeable about billing codes, exemptions, etc. that are really
quite complex. There are 2 fees:
$20 Fee Includes:
 Verification of Benefits –finding out what benefits you have and getting this in writing from your insurer
 GAP Request – Requesting the insurance company to cover you under in-network rates (only if you have NO out
of network benefits or you have a very high deductible). They may approve or deny the request.
 Pre-Authorization Request – Any pre-authorization request needed will be made. Some insurance companies
require a pre-authorization before services are rendered, before the birth or after the birth.
 Appeal –a GAP denial can be appealed up to 2 times.
 Emails – You will be sent an email informing you of what your benefits are.
$100 Administrative Fee- non-refundable fee for billing insurance for services rendered (paperwork will be submitted to
your insurance company after your final postpartum visit):
 What is needed to file a claim o Superbill (from your midwife) – this will state what services were rendered, when, and where (including
the location of the birth)
o Invoice (from your midwife) – services and fees from Midwife and what has or has not been paid