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From:
Desiree Allison <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Fri, 22 Mar 2013 17:06:11 -0700
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Hi Judy,

We have lived off one income for many years, so my situation is a little
different, as I'm not used to two incomes.  We have moved 10+ times state
to state in that time, so not conducive to a career for me during those
years.  LLLL fills in my employment gaps.  I started my pp in January and
after talking to an accountant, decided part of my start up expenses would
be the wait time for the insurance payments.  To be honest, had I known
what I was doing, I would have set all this up and had it going within a
few weeks, but it's been a task to fit it in where I had available time.
 In the short term, it does mean money is tight, but I'm looking at the
long term perspective of starting up a practice, where I hope to have
additional IBCLCs on staff and I think this will have the best business
opportunity for the long term.  I've worked on my forms and found Liz
Brooks' HIPAA cd of forms quite helpful.

 I know there must be others who are struggling similarly.
Small business  loan? I have talked about working cooperatively with other
IBCLCs but nothing  has worked out ( yet anyway.) I suppose if I were
actually
charging 150-300 per  hour my overall intake would be very different.

I've thought about working with other IBCLCs as well, but I don't know if I
want to risk friendships and professional relationships with financial
entaglements.  I am nervous about the SBA loan, but it is a good idea, as
you know how much money you already make from your business.  I was nervous
because I didn't know what my revenue would be to be able to pay it back.
 In the Pheonix metro area it's about $75-150/hr for cash LC services.  IF
you give a mom a superbill with your NPI and EIN on it and a receipt she
can pay you and request reimbursement from her insurance company.  She then
has the incentive to follow through on the claim.  I have the insurance
claim check sent to me.  Eventually, I'll have electronic funds transfer
and won't have to worry about the checks.  My long term plan is to have a
practice like my friend's pt practice where I can hire IBCLCs and the
framework will be in place for insurance reimbursement.  Until then, I take
the reduced pay as I get it all up and running.  Most businesses run in the
red for a few months as they go through start up.

My first client signed an agreement that if insurance didn't pay, she
would. So I wasn't out the money and she wrote a check for services.  She
knew up front that she would be my guinea pig so to speak and I didn't take
insurance for a few visits after that as I figured out how to process
claims.

In your situation, before even mentioning you can do this for a client,
 I'd contact the major insurers in your area and register as an out of
network provider.  You'll need an NPI for yourself and an EIN, unless you
want to use your social, plus whatever business licensing is required for
your city/county/state.  It was fairly inexpensive in AZ to set up an LLC
($60+), city transaction privilige license is ($65)/yr.  Look into Aetna's
website for electronic processing vendors-
http://www.aetna.com/healthcare-professionals/claims-administration/clearinghouse.html.
 I use Office Ally's practice mate, which is free, but they do have paid
services as well.

Once you are registered with the insurance company, you will have to go
through Credentialling- that is like a verification service. I like how
helpful and "quick" Aetna was in getting that process rolling.  Quick is
10-15 business days...  Then finish the credentialling process with CAQH.
 If you don't hear back from them, call the insurance companies and ask
them to direct you to who you need to speak with and don't give up.  If you
are humble, they are usually friendly and helpful.  They are also shocked
to speak with the actual "provider"  and don't want to mess up.  Call for
help filling out the forms as IBCLC and Lactation Consultant are rarely on
them...

As an out of network provider of lactation services, if you are registered
with the insurance company, you can do a precertification/preauthorization
for lactation services/ office visit as an out of network provider and have
the in network requirement waived, if there are no other in network
providers for the mother to contact, but you have to call prior to the
appt.  You would know you could submit and receive payment.  You'll need a
client you would be willing to do that groundwork for as practice for you.
 Then once you feel comfortable with the process you can begin to offer it
to other mothers.  I am also pursuing in network status with insurers, as
there is less red tape involved with claims and better opportunity for
reimbursement without needing appeals (read- wasted time).

*"My question is how do you
 live while waiting 12-16 weeks to get paid? Since we live week to week
here,  basically check to check, I can't figure out how to make this
transition
and  still be able to buy food and pay bills which will not wait 12-16
weeks to be  paid."*

I gave mother's the long lead time, in part for the insurance companies to
enter in my data (based on their estimates) and on my schedule w/ 3 kids,
visiting with clients, etc.  From submission to correcting my mistakes to
reimbursemnt for my client it was actually 3 weeks.  When I am comfortable
with the process, I'd like to hire someone for about $10/ hr to enter and
submit claims.  Then I can use my time for reports or seeing clients (which
would earn more than $10/hr).  I just can't afford that help yet.  I'd also
love a data pkg and small laptop/ tablet to take with me, but that is a
pipe dream for this year.  It would make me much more efficient though...

 *It's  amazing to me that an insurance company that received a**
bill for IBCLC services  for something like 300-450-600 dollars for one
visit ( initial visit of 1  1/2 -2 hours), would pay all but 5 dollars of
that.
They rarely reimburse for  the usual lower rate of $225.  Or are your visit
lengths different?*

I have spent many hours on the phone, educations the customer service reps,
filling out forms, etc, The claims were not something dropped out of the
blue as a surprise, so register and call first.  ;-)  You don't have to
disclose your fees to the rep, but you do want to verify coverage.  It
helps to remind them of the afordable care act and compliance with the law.
 I was so excited to be reimbursed because of what it meant, not the actual
amt this time around.  Admittedly the amount reimbursed for my client was
less than $100/  as it was the baby's portion of the appt.  I break the
appointment in to the amount of time spent with mom and baby and file 2
claims- usually for each appointment. The baby at this appointment was
assessed and evaluated for 1/2 hr.  The mother's portion and counseling was
1.5 hours.  It varies by encounter.  I am still waiting on the mother's
larger claim to be reimbursed, as I made a mistake and they had to
reprocess.  My avg time with mothers is 1- 2 hrs depending on complexity
and level of coordination and counseling required.  I am trying to reduce
my time on reports away from patients and finish it shortly after our
visit, instead of my overly long reports, I started with.  If your claim is
rejected, call back and ask why it was rejected.  They will often reprocess
it or tell you how to appeal it.
*
*
*"I have so many clients who no  matter what we do, never get paid. I have
concerns,
since for them it is one  bill in a year, but for me that could mean many
fees never paid."*
*
*
I have the checks sent to me.  For the time being, I will reimburse
mother's any balance that I owe them after insurance pays (like a DR's
office sign that says "payment is due at time of service"  and I will file
the claim as a courtesy to them on their behalf).  If I have to go back to
the insurance co and contest a payment, I'll discuss that a PT or OT
charges 150-300/hr and that a counselor charges well over $100/hr and that
given the scope of what I am doing it is reasonable amount to request,
especially given the long term outcomes.  Partial supplementation with
Alimentum(sp?) for 1 year will cost the insurance co $2500 for one of my
clients pumping and supplementing what she can't make at the moment.  It's
a complicated case and we are working to increase her supply.  When you
take that into perspective, LC services are a bargain at $400-$600.  There
is a lot of education to be done about what we do and why it is important.
 How we set our rates and submit to insurance helps them to see what is a
"reasonable" fee for service and they like to be able to compare catagories
of service.  If we sell ourselves short, then we harm not only ourselves,
but also other IBCLCs who have done their research on how much to charge
for services and submit to insurance at higher rates.  I don't think this
is a way to make money quickly or easily, we work hard and with each claim
we submit, data is collected for future use.

For a little perspective:  In Phoenix a PA visit for 10min is $55 x
6=$330/hr, an allergist is $500/hr, Developmental Pediatrician is
$350-600/hr, SLP assessment of my son was $500/hr (insurance covered it).
 Teeth cleaning at a DDS with the hygenist is $125-150/ 30-45 min with a
3-5 min dds consult.  Insurance companies understand healthcare
professionals also have overhead expenses to consider and the hourly rate
includes those fees as well as the providers salary.  More perspectiv:  To
have a gardner is $90-150/hr for 3 people, pool service is $50/hr at least,
and to deliver appliances across town is $80.  I think we need to keep in
perspective when talking to the insurance companies of what our services
are worth and how much our educational counterparts charge for services/hr.
  Even if insurance only reimburses $300/hr at %50, you'll know that and be
able to account for that.  Sending in a few test claims will help you get a
feel for what your insurers will reimburse and it has given me the
confidence to keep calling them.  When you are comfortable you can begin to
offer it to all moms.

I hope this helps.

Has anyone else received CAQH credentialling or had any luck with CIGNA?

HTH
Desiree Allison IBCLC, LLLL, Arizona

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