Filing a Claim with your Insurance

INSTRUCTIONS for PATIENTS FILING FOR REIMBURSEMENT

You are encouraged to file a claim for third party reimbursement. By filing a claim, you may receive partial or full reimbursement and you help to establish the need for reimbursement of lactation services. You may find it helpful to contact your insurance company first. Some companies have specific forms that they require you to fill out when filing a claim on your own and most companies have a filing time limit.

1. Make at least one copy of the blank form (the superbill you were given at your consultation) —before you fill out the patient information on the top. This will ensure that you have another copy in case you have to appeal, or the insurance company loses the form or if you want to re-send with different patient information. (parent vs baby) It is your responsibility to keep track of this form. Duplicates will incur a charge of $10.00.

2. Complete the upper part (Patient Information portion) of the lactation visit receipt and sign the release of information on the right side directly under the Patient Information section. Be sure that the patient matches the diagnosis code. For example, if the diagnosis is “newborn sucking problem,” the patient is the baby. Some companies will reject claims for babies and some for parents. If you’ve made another copy you can file the claim a different way.

3. Parents should mail a copy of the lactation visit receipt with any other forms their insurance company may require to their insurance company. Include a note that you don’t expect to be reimbursed for mileage or other expenses on the super bill (such as nipples shields, etc). Insurance companies often “kick out” a claim because of other fees.

4. Please be sure to keep a copy of your lactation visit receipt, claim forms, referral scripts, etc. for your records and mark on your calendar when the claim was mailed in.

5. If, after 60 days, you have not heard from your insurance company, call them to check on the status of the claim. If you have not heard anything for 60-90 days, you may want to write a letter to your insurance commissioner in your state and send a copy to the insurance company.

6. The top reasons that claims are denied are because it’s not a covered service or the lactation consultant is not a provider on your plan. If it is because the lactation consultant is not a provider on your plan, ask who the lactation consultant provider is. Most likely they will say that they do not have a lactation consultant provider on their plan. Then, you reply that you had a referral to be seen by this lactation consultant by your physician because you were experiencing such and such a problem. Tell them that the American Academy of Pediatrics recommends that all babies be breastfed for one year and that the AAP recommends mothers and babies be seen by a board certified lactation consultant when breastfeeding difficulties occur. The AAP also recommends that third party insurance reimbursement be made for lactation help.

7. The Affordable Care Act mandates insurance coverage for lactation services. This is the law. It also mandates no co-pays or deductible for lactation services. Know your rights! This post will give you more information about how to talk to your insurance company about this.

8. Don’t stop with NO from the first person you speak to. Request to speak to their supervisor. The squeaky wheel is the wheel that gets oiled. If you want reimbursement, you may have to fight for it. This is how many things that are now covered by third party insurance companies have come to be standard reimbursement.

A formal appeal may be necessary for you to get reimbursed. You will find a sample letter of appeal on my website.  There is also a link there for the Washington State Insurance Commissioner. If you have been denied reimbursement for lactation services, he wants to know about it!

Ten Facts You Must Know about Insurance and Breastfeeding Support

My dear colleague and friend, Joy Funston, recently attended a webinar to understand the rights of the breastfeeding mother under the Affordable Care Act. (In the US) She graciously shared what she learned with her colleagues. We collaborated to write this post and bring this important information to as many mothers and mothers-to-be as possible.Thank you Joy!!

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If you are in the U.S, you have probably heard that the Affordable Care Act (ACA) mandates insurance coverage for lactation support. You are correct! Unfortunately, the details of the law are vague,and that has created loopholes for insurance companies to jump through.

For example,  the law requires that insurance companies develop a network of breastfeeding professionals. The may “say” they have a network of lactation consultants, but on closer inspection, it is found that lactation services will only be a covered expense if they are provided by a licensed medical professional such as an M.D.  As we know, the vast majority of M.D.’s do not provide lactation services.

Another important aspect of the ACA is mandated coverage for breast pumps & supplies. Unfortunately, no details are included. What type of pump?  Who decides?

The National Women’s Law Center in Washington, DC has attempted to be a resource for moms trying to access coverage and to IBCLC’s offering assistance. The following information is from a webinar that they provided. 

Know your rights! If your insurance company has denied lactation services by an IBCLC, here are the points that you can argue with your insurer:

1.The lactation portion of the ACA states that specific benefit are covered “for the duration of breastfeeding.” Insurance companies are not in compliance with the law if they have arbitrary rules for a set number of consultations or certain age of the baby. There are a couple of exceptions: “Grandfathered plans” and some private “self-insured” plans do not always have to follow the ACA.

2- IBCLC’s are ready and available as trained experts in lactation. No other credential comes close. And no other credential is needed. 

3. While not the intent, ineffective breast pumps satisfy the law. The ACA does not specify the quality of a pump.  Note from Renee: Given the law as it is now, I recommend purchasing your own pump if your insurance company will not provide the type that you need. .

4. The ACA does NOT include a requirement of return to work or school for breast pump coverage.

5. Tricare, insurance for military personal, is NOT covered by the ACA. But things are changing. Recently there was a mandate for covered benefits by the armed forces appropriation’s bill.

7. New marketplace plans ARE, in fact, covered by the ACA.

8. The law mandates “no cost sharing” for lactation support services. This means no co-pay, no deductible and no co-insurance cost. Period.

9. Each insurance company is supposed to provide in-network professional lactation support options. If there is no in-network option provided which is geographically accessible, you may go out of network for support. Keep in mind that the vast majority of insurance companies do not allow IBCLC’s to become in-network providers. The insurance company can use this to deny benefits. This is a “Catch 22” situation and needs to be reported.

10. Any complaints about insurance noncompliance should go directly to your state’s insurance commissioner.  Every time. Every mom. Every problem. Note from Renee: Washington state’s insurance commissioner is very responsive! Documentation of insurance noncompliance can also be reported to www.coverher.org.  They hope to continue to compile data & to be a resource.

And finally, part of the ambiguity in the implementation of the ACA is that the insurance companies are not acknowledging who actually is the expert breastfeeding professional. IBCLC is an international recognition– the only professional qualified to step into the role the law envisioned. But IBCLC does not come with a “license” and in the USA, Insurance companies traditionally reimburse the services of licensed professionals only. Please support state licensure of IBCLC’s when you can.

Sadly the law was not precise… But the intent was very clear. Mothers are absolutely entitled to healthcare benefits for lactation support. Consumers need to demand the coverage their premiums are mandated to provide.

Joy Funston, RN, IBCLC. RNC is in private practice in Charlottesville, VA.  She can be reached at www.joyfulstartlc.com.