06/08/2022
THE PROMISE OF FREE LACTATION COVERAGE
“Isn’t lactation covered by my health insurance because it is preventative care?”
I have seen this question come up a lot among my clients and colleagues over the years and I want to shed a little light on it that healthcare consumers may not know.
YOUR INSURANCE COMPANY HAS WAYS TO GET OUT OF PAYING FOR YOUR LACTATION VISIT.
Let me repeat that: YOUR insurance company has ways to get out of paying for YOUR lactation care.
“They told me it was covered 100%.” They only cover a PORTION at 100%, the rest of the visit fee may be assigned cost-sharing with the patient (you).
“I thought it was guaranteed by the Affordable Care Act (ACA).” Most insurance companies have developed workarounds to limit how much they pay under the ACA rule. The organization that manages billing codes for the U.S. healthcare system has created ONE lactation code – a CLASS code. This means the insurance companies can assign payment under this code at patient education rates. Payments to IBCLCs vary from $9-71, no matter if they spent 30 minutes or 2 hours with you. Any other medical billing codes that are relevant to your situation may not be coded in their system to apply to this provision of the ACA.
Surprised by a bill from your IBCLC? We have to send those because the contract we sign to be in-network providers requires us to collect the portion they determine is your responsibility. WE didn’t say it’s your responsibility – your insurance company did.
“Why can’t you use different codes to help me get it covered?” As healthcare providers, we code based on a combination of factors: what the insurers allow for our credential; the time spent on your visit; the location of your visit; the medical conditions affecting your situation, etc. One insurance company tells their subscribers to tell us to use a certain code that is sure to get denied because our credential doesn’t qualify to use that code. Another insurance company promises to pay 100% and then reimburses us $9 for the code they told the subscriber. Earn $9 for a 1.5 hour visit and anyone will go out of business.
“Why do you bill for both mom and baby? My insurance paid on me but wants to charge me for the baby.” Lactation consultations usually involve two patients (or three with twins). Mom has her own health history, medical conditions, and treatment needs that are different from the baby’s health history, medical conditions and treatment needs. It is very rare that everything is PERFECT with one and the whole entire problem is with the other. Occasionally we will see mom only for a pumping visit or infant loss. Most of the time, we are helping both mom and baby to coordinate improved feeding.
“Lactation appointments are so expensive!” The cost of doing business is expensive. In the office, we have the costs of running a brick-and-mortar business. Doing home visits, we have the expense of driving all day, sometimes 50 miles between client homes (and OMG the price of gas right now is killing home visitors). We have the expenses of our supplies, our specialized scales and pumps, liability insurance, taxes, phone/computer/EHR, fax services (yes, medical offices still uses fax due to HIPAA restrictions on electronic transmissions), etc. And that’s BEFORE payroll. We charge what we need to keep our business running so we can help families like YOU.
“So how do we get covered?” Please pay your invoice and then send the receipt to your insurance company with a strongly worded letter of appeal to demand they reimburse you under the provisions of the ACA. Insist that they cover ALL codes submitted by the IBCLC under a lactation “umbrella.” If they refuse, appeal up the chain of command, contact the State Insurance Commissioner and file a complaint, or contact an attorney.
The alternatives? We stop taking insurance and you pay the fees out of pocket. Lots of medical providers are doing this.
“I have AHCCCS/Marketplace insurance – they said they cover lactation visits.” They do, under VERY limited conditions. The State of Arizona and WIC have an exclusive contract for lactation support. THEY WILL NOT PAY PRIVATE PRACTICE IBCLCS. They won’t, they just won’t, even if they told you they will. They won’t. WIC is contracted at the state level. You can get help from a local WIC office, or pay a private IBCLC. Most lactation consultants will offer reduced fee services to families enrolled in WIC. Don’t have WIC because you make too much but you have marketplace insurance? Call a private practice IBCLC and work out a payment plan. When it comes down to it, the insurance will NOT pay even if they told you they would.
“I saw another lactation consultant and the insurance paid in full.” Chances are they had either: a.) another credential (like RN) that provided additional coverage; b.) they had a biller file a successful appeal on your behalf; or c.) they accepted being underpaid. Usually it’s c.
We need YOU, the consumer, to advocate with your insurance companies for full coverage. We as IBCLCs have fought from our side and each year the insurance companies rewrite their codes to decrease reimbursements. To remain in-network, we are forced to agree to reimbursement discounts, and then they take more codes away from us to reduce payments more and divert responsibility to you. Some IBCLCs have additional credentials, so they may get reimbursed differently according to their contract terms. But please know we want your bill to be paid 100% by the insurance – it’s just that if they don’t, our hands are tied.