Info picked up at ILCA in Acapulco:  There is a health ins co, I believe in
Calif, that is smacking down a home health service.  The ILCA attendee is an
IBCLC who was doing first week home visits with a PNP.  The agency was
billing the visits under the Service's provider # or the PNP's provider #.
I don't remember which.  The IBCLC does not have a provider # but her
services were part of the Home Health Service's care program.  The health
ins co declared that: (1) It's illegal - i.e. insurance fraud -  to bill for
the services of one person - the IBCLC - under the provider # of another
entity - the HHS that employs the IBCLC, or the PNP who was the licensed
care provider going to the patient's home.  The provider # used must be that
of the person who actually provided the care, not the employer of the person
or the licensed colleague who was leading that health care visit.  The ins
co. is reviewing all billings by that HHS submitted over the past several
years to look for more such billings.  (2) Only LICENSED personnel are to
make home visits.  So far, IBCLCs in the US are not licensed unless they are
also members of another licensed profession.

If I don't have my facts exactly right - someone who was there at ILCA's
pre-conference Track I, session 4, please post your corrections.  This is
from my memory.

My understanding of conclusions:  All IBCLCs must apply for individual
provider #s if they or their employers want reimbursement for the IBCLC's
services.  I believe a very great many medical practices do bill for health
care services under their business provider # and include the services of
allied health professionals who also saw that patient during a given visit.
At least one health insurance co is alleging insurance fraud based on this.
I don't know if they intend to take the allegation to court or if they are
just trying to cut costs by eliminating as many allied health care providers
as possible from the patient's billing.

Maybe this is another reason to pursue Registration of IBCLCs in our various
states (in the US) following Karen Zeretsky's lead in Louisiana.  Her
version of Registration requires NO expense on the part of her state's
IBCLCs to be legally Registered as health professionals.  The expense of
Licensing and a Licensing Board, and the effort needed to PROVE the need for
such an expense to our Legislatures scares me.  I have nightmares of health
ins co's and ABM co's and all their $$ lobbying against such Licensing.  Or
am I just being paranoid?

After JCAHO is finished with us (eom Sept), I and my IBCLC colleagues are
going to pursue getting our own individual provider #s for our local
Medicare program.  Only one of us is an RN.  Let's see if she is the only
one who can get one.  If that happens, the ins co's will be effectively
forcing hospitals to hire only RN/IBCLCs if the hospital wants
reimbursements for their LC program.  Again, maybe I'm being paranoid in
advance of actual facts.  Of course, after we get our provider #s, then we
have to work out contracts with each of the 6 individual ins co's
participating in the Medicare program.  ...  I need an aspirin...

Phyllis Adamson, IBCLC
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