Sometimes change comes via legislation or mandate and sometimes it comes via
changes in custom.  By that I mean:  no one makes a sweeping definitive
rule, stuff just sort of creeps in and takes root and becomes "normal
operating procedure."  It seems to me that it can be difficult (because of
threats to the status quo) to attempt change via the former, so while I
participate in efforts to legislate change, I tend to be a big proponant of
making oneself indispensible and achieving change via alteration of custom.
In my own situation,  I learned that each HMO negotiates contracts with
providers of various services.  I had a long-term professional relationship
with a doctor who became chief of peds of a local HMO.  We spoke about me
becoming a preferred provider with the group.  It took a lot of convincing
from him to get the medical director to even consider the idea (perhaps
because I am not a nurse) but ultimately they arranged to have a site visit
to my clinic.  They inspected my files (to see how my charts were
organized -- they were esp. pleased to see all papers stapled into the
chart)  they wanted to look at my books and my certification paperwork and
my fire extinguisher and exit notices over the door.  They wanted to know if
TB tests were current, and how our sterilization protocols were assured (I
have an autoclave).  We passed all the inspection criteria and signed a
contract.  Now, if a doctor in the system has a client who needs a lactation
consult, they fax me an authorization number.  I contact the client or they
contact me and we arrange a visit.   I collect a co-pay from the client.   I
fax the doctor a  1page report containing my assessment  (never more than
1-2 paragraphs) and my suggested plan for remediation.  I submit a copy of
the UCLA form using the MDs diagnosis (gen. Infant Feeding Problem) along
with an invoice I created in Quickbooks to the HMO billing company. When
they are good and ready they send me the rest of my fee.  The cash flow is a
problem because I never know when to expect a check, but the service is
great for doctor and patient.

My suggestion is find out who the chief of peds is for your local HMOs and
go in with a suit on and offer your services as a preferred provider.  But
be prepared to present yourself and your services in the most professional
way you can.  Offer to do some work on a trial basis.  Keep your reports
very short.  I think a lot of LCs think more detail will wow the docs.
Anything longer than 1-2 reasonable paragraphs will not be read.  The more
you can negotiate with local people to bring you into the 3rd party
reimbursement system the more accepted the custom of paying for LC services
will be and the less you'll have to deal directly with insur. industry types
(who have a vested interest in NOT adding coverage to existing plans).  Then
when ILCA or your state bfg coalitions go in with guns blazing to get the
services mandated, there is precedent and people can say:  Look, this is
already happening all over the place, let's just standardize it.
Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.jump.net/~bwc/lactnews.html

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