I am not a lawyer and have not gone over the actual law with a fine tooth
comb, but my reading of it is- no cost sharing is an insurance term that
applies to how insurance companies cover preventive services not how
providers bill.  It determines whether preventive services are "free" to
the patient if they go to an insurance contracted provider or if the
services apply to the deductible or co pay (cost sharing) before insurance
benefits kick in.  Does that mean a provider ought to pad profits by
passing on exorbitant fees billed to the client (double dipping)?  No,  I
have a set fee and submit to insurance on behalf of mothers (still a small
private practice, not too busy yet).  I bill for mom and baby, since I
eval, assess, offer interventions as needed to both and offer counseling to
the mother.  (Our field straddles medical and mental health CPT codes due
to the counseling part of our practices).  You would select Medical
provider when prompted by insurance company phone systems though.  If
insurance only covers 60%, I can pass the difference on to the mother and
suggest she appeal to her insurance co for the claim difference, I can
choose to write it off, or she can pay the difference.  The big "UNLESS"
though is some insurance companies will require you to sign something
accepting the lower payment amount and request that you write off the
difference- not charging the mom, if you want to receive payment for the
claim.  Read the fine print carefully.

The no cost sharing for lactation services is similar to a situation when a
mom chooses where to give birth- in network/out of network and pays the
difference to the provider that insurance doesn't cover depending on the
contract the provider has with insurance company.  When I have submitted
claims- I have to submit as an out of network provider and request a waiver
or a  precertification to cover services on an in network basis, otherwise
I get less from the insurance company as an out of network provider.  I can
appeal the claim or I could pass that along to my client or give her the
HCFA  form to appeal and be reimbursed the amount an in network provider
would receive for the same services.  Does that make sense?

In the Phoenix Metro area, to the best of my knowledge we do not have
private practice ibclc's contracted with the major insurance companies and
until I make it through the contracting process, I have to submit as out of
network- as will most of you if you choose to go through the process of
credentialling and contracting.

It is important to know the law if you are requesting reimbursement, as you
will often hear from the insurance representatives that they don't contract
with IBCLCs (CIGNA, Golden Rule, and AHCCCS- state medicaid).  In a way
this is almost a back door way to avoid compliance with the law- if they
don't allow IBCLCs to contract, who provides the *"**Comprehensive
lactation support and counseling, by a trained provider during pregnancy
and/or in the postpartum period"?*  Many assume it is the OBGYN, Midwife,
or Ped. and are surprised that they refer to an IBCLC.  If there are no
IBCLCs contracted then the insurance company can force a mother to use out
of network benefits for the services w/o receiving the no-cost sharing
benefit.  UNLESS- either the mother or the IBCLC are willing to go through
the precertification process (which is 3-7 days and may require more hoops
than it ought to because most insurance companies are unsure of how to
comply with the ACA) or the claim can be appealed after service for a
waiver or exemption to receive in network benefits (which is not
a guarantee of payment.....  It has been a frustrating process, but now I
am so irritated and upset by the process, I'm following up regularly with
insurance companies out of sheer stubbornness and motivation to help
mothers.

This is the website I've been using to communicate the information to the
insurance companies I've talked to so far, as very few know about this part
of the law- aside from pumps.    http://www.hrsa.gov/womensguidelines/  -
see part of the excerpted webpage below
*"Women's Preventive Services: Required Health Plan Coverage Guidelines
Supported by the Health Resources and Services Administration*

*Under the Affordable Care Act, women’s preventive health care – such as
mammograms, screenings for cervical cancer, prenatal care, and other
services – is covered with no cost sharing for new health plans. However,
the law recognizes and HHS understands the need to take into account the
unique health needs of women throughout their lifespan. *

*The HRSA-supported health plan coverage guidelines, developed by the
Institute of Medicine (IOM), will help ensure that women receive a
comprehensive set of preventive services without having to pay a
co-payment, co-insurance or a deductible.  HHS commissioned an IOM study to
review what preventive services are necessary for women’s health and
well-being and should be considered in the development of comprehensive
guidelines for preventive services for women.  HRSA is supporting the IOM’s
recommendations on preventive services that address health needs specific
to women and fill gaps in existing guidelines.*
*Health Resources and Services Administration Supported Women's Preventive
Services: Required Health Plan Coverage Guidelines*

*Non-grandfathered plans and issuers are required to provide coverage
without cost sharing consistent with these guidelines in the first plan
year (in the individual market, policy year) that begins on or after August
1, 2012.  "*

Please correct me if I'm reading this wrong.  It's all new to me and the
insurance companies...

Warmly-

Desiree Allison IBCLC

Date:    Wed, 3 Apr 2013 16:04:16 -0400
From:    Mandy Schaub <[log in to unmask]>
Subject: Insurance Reimbursement

In reading the posts on insurance reimbursement I had a concern.  I am by
no means an expert, but I beleive if you are being reimbursed under the
Affordable Care Act (ACA) you are not allowed to charge the patient
anything.  My understanding is the coverage is at no cost share.  It is not
a reimbursable expense to the patient and if you agree to take insuance's
money I don't think you can make up the difference or loss by charging the
patient.  Maybe I misunderstood.  I'm in a hospital OP center, so I
understand my bottom line is not impacted the way someone's in pp would be,
but I believe the rules apply to all ACA payments.  If it is non-ACA
coverage, then it is probably not a problem.

-Mandy Schaub, MS, RD, IBCLC

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