As an LC in practice (both private and hospital-based) for eleven years now, I have quite a bit of experience with the issues surrounding re-imbursement.

To summarize--it's a semi-nightmare, even when you live somewhere that has rules making re-imbursement legal!

You can mail me privately for more details, but here's the bottom line: it depends on which state you live in, what laws govern health care provider practice and how strong your state insurance commissioner's office is + support from your institution/agency/clinic (assuming you are working in one).

In WA state, LC's who are RN's are very, very lucky, as we have a Nurse Practice Act that essentially mandates our being paid for nursing services that a patient chooses to get from us.  If the insurance company would pay an MD for the same service and if the RN has training that allows him/her to provide the service, then the insurance company must pay.  There are a few exceptions and loopholes, but in general re-imbursement is good.

The process of dealing w/ insurance companies is, well, frustrating and not revenue-enhancing for a small business.  The foot-dragging and "lost" claims excuses on timely payment means that you might have receivables out for 6 months or more.

However, I'm rambling on a bit.  The above info applies to outpatient services (and, to a limited extent in our state, home follow-up services for lactation).  For inpatient, it depends on the standard of care in your community.  Where I live, "ancillary" services are not all billed separately by the hospital and lactation is one that is not.  I' sure it's different in different places.  If the LC is a staff nurse, I don't know about policies governing that.

Let me know if you need specifics.  Am I glad I closed my private practice and now do outpatient visits through the hospital?  Yes, yes when it comes to re-imbursement and billing. I can focus on patient care instead of time-wasting on the phone with insurance companies. (Even though I still must do some of that for "pre-authorization and for pre-approval for some pump rentals.)

Jeanne Brotherton, RNC, IBCLC
Bellingham, WA

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