Nikki writes: 
"Maybe we in the US need to make lactation a clinical speciality?"


I think from a reimbursement standpoint this may be true, but that requires
a specific training/education program, a well recognized certification and
generally a clinical (nursing or other clinician is implied) background.
(And all of this has been the topic of much discussion) While I whole
heartedly agree that lay counselors who become IBCLC's are invaluable and
their training and experience unmatched, it can be a difficult case to
present to a reimbursing party. (One more reason why insurance carriers and
employers need to know the value of IBCLC and we need to work to have the
credential recognized as the standard)

The problem with the way maternity services are billed is that hospitals are
paid a set lump sum amount for a c-section, a set amount for a vaginal
delivery etc. All of the associated costs are not really billed separately.
It is package pricing which is negotiated between the insurance carrier and
the facility or health system based on DRG's and regional going rates.
Having to break out costs and bill them separately would mean the hospital
had to take the time and bear the expense of doing that - and most insurers
wouldn't pay it anyway. 

DRG's are applied in other illnesses too - a fellow who is admitted for a
heart attack for instance is billed by the hospital for the heart attack -
if he falls and breaks his leg or develops pneumonia while in the hospital,
the hospital doesn't get paid more for that - they still get paid the going
rate for the heart attack. For the guy who is discharged in 3 days they make
money, the one who develops long term sequelae and complications costs the
hospital money. Sort of a weak example I know - it's actually somewhat more
complicated than that. Does the Respiratory Therapist and Diabetic Educator
and physical therapist get paid separately? That depends on what kind of
"package" the facility and insurance carrier have negotiated and how the
billing is handled for individual carriers. It can vary within a facility
between carriers because it can be contract dependant. 

In order to obtain reimbursement for IBCLC services in the hospital, that
would have to be something the facility negotiated out with the carrier. In
many cases it's a "gimme" because the consumer demands the service, but the
carrier is not willing to pay for it and the hospital (or entire health
system corporation) uses this sort of thing as a negotiating point. 

Would a hospital stand to make money on revenue producing Lactation
departments? Maybe - but by the time all the wash is done, it might not be
worth billing for. Since the hospital negotiates discounted package rates,
they only get paid the package amount regardless of what's actually billed. 

That's about as basal of an understanding I have about the whole concept.
These are questions I have asked and these were the answers I was given. I
hope this helps. 


Michelle Meeks, RN

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