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 *********************************************** Archives: http://community.lsoft.com/archives/LACTNET.html To reach list owners: [log in to unmask] Mail all list management commands to: [log in to unmask] COMMANDS: 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. 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