Dear Judy and Lactnetters:

As Chair of the USLCA Licensure and Reimbursement Committee, I am responding
to your concerns about insurance reimbursement and licensure in line below. 

I am now getting calls from moms looking for lactation consultants in
network, but their insurance company cannot provide them with any names
actually in their network. The mom also said that the insurance company told
her all lactation consultants are nurses, so she should get the lactation
consultant to bill as a nurse doing a post-partum visit, and/or  many are
working in pediatric offices so they can get a private consultation in
their pediatrician's office and that would be covered.

I have had a number of similar reports from others. These are likely
statements coming from the uninformed customer service representative who
has no knowledge of lactation issues. It is my understanding that Aetna did
provide education to their customer service and claims personnel when they
implemented lactation counseling policies. However, I can't be sure all
these personnel actually attended meetings or read their updates. Aetna's
coverage policy for their in-network providers specifies which codes should
be used and does not include codes for nurse visits which are meant to be
5-10 min visits and yield reimbursement of <$20. I suggest not using the
nurse code (99211) regardless of whether you work in-network or out of
network due to this problem. 

It does seem that for better or worse, the era of the solo practitioner may
be coming to an end. 

This is what USLCA is working to prevent. As a solo practitioner, you are
free to continue your practice without participating in insurance
reimbursement at all, as you may have always been doing. 

The Affordable Care Act has mandated insurers who offer non-grandfathered
plans to provide lactation services coverage as preventive health care. The
Affordable Care Act does NOT specify who should provide lactation care.
These insurers have notified their clients that lactation services coverage
is part of their plan benefits. This notification, unfortunately, does not
automatically enroll IBCLCs into their plans as providers. In fact, some of
the insurers will not enroll IBCLCs as providers at all. This will sadly,
leave mothers with the only option for care that is "covered" by insurance
to seek care from other kinds of health care practitioners who are already
licensed and credentialed with insurance companies, regardless of their
knowledge or training or level of expertise in lactation. USLCA was not a
part of developing or passing this legislation. It happened without our
involvement at all. 

IN response to this new law, USLCA is trying to help IBCLCs become
credentialed providers and this is an arduous process with thousands of
insurers in the US. Additionally, the fact that IBCLCs do not have a license
in any state makes the issue even more complex, particularly with Medicaid
plans because of federal regulations prohibiting reimbursement to unlicensed
providers. 

Aetna's webinar stated that patients would be expected to be seen within 24
hours

Aetna is the first and only national insurer to "credential" IBCLCs to
provide lactation counseling services. Your above statement is a
misunderstanding of the provider policy, Aetna said, "Provider must be able
to initiate a therapy within three (3) hours of the referral call for urgent
services and within twenty-four (24) hours of the referral call for routine
services." 

I have spoken to Aetna about this and was told that this means, it would be
best to have access to your phone messages and return the client's call
within the 3 hour window to arrange an appointment - this is what is meant
by "initiate therapy". 

 

 but I can't see how most of us who are solo practitioners in full-time
practice, without other work like agency, office, hospital, or paid speaking
or teaching work, could do this alone.

 

For those IBCLCs who wish to provide lactation consultations which are
reimbursed by third party payers, there is a lot to learn. You will need to
learn about the health care provider credentialing processes and billing and
coding, filing claims appropriately and receiving payments electronically
within 30 days among other things. You may need the professional services of
some one experienced in these areas routinely or at least to set up your
processes, which are changing to accept insurance, or you may need to spend
time to learn it for your self. Anyone offering any kind of medical care who
participates in the health care system must put the appropriate policies and
practices in place as a business. It is just new territory for IBCLCs.  

I so want mothers to all have access to the lactation support they and they
babies  need, but I see how things are already being delayed as moms make
multiple phone calls to their insurers, and IBCLCs would have to somehow
make sure they would be reimbursed for their work, before ever setting foot
in the home 

Ultimately, this is a step forward in recognizing the importance, of
breastfeeding in general, and of breastfeeding support as a necessary health
care benefit for mothers. It is also a step that should improve access to
payment for lactation services (at least for all people with private,
non-grandfathered health insurance plans) in the long-term. In the past, no
one had access to lactation services from their insurance so they didn't
bother looking for it. Now at least there is a positive written policy, even
though the process for getting care is not well in place yet. The mothers
are seeking care and it is usually the consumer that drives improvements in
health care so this is positive as well. 

I hope this information is helpful to you. USLCA has kept IBCLCs informed of
this issue as each development occurs. We have also provided as much
guidance as possible for making practice changes on our website and in the
USLCA eNews for our members. 

Stay tuned for more changes and more information. As we learn we will share
with you

Judy Gutowski, BA, IBCLC





 


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