Understanding Insurance Billing For Lactation Services: A Guide For Healthcare Providers

Breastfeeding can be challenging, and many new parents experience difficulties. Working with a lactation consultant can help overcome these challenges and set parents up for success. In the United States, the Affordable Care Act (ACA) mandates that health insurance plans cover breastfeeding support, counselling, and equipment for the duration of breastfeeding. However, the specific coverage provided may vary depending on the type of insurance plan. For example, some older grandfathered plans are exempt from these regulations. To determine coverage, individuals should contact their insurance provider and ask specific questions about their plan's coverage, such as whether lactation support is covered, if there is a copay or coinsurance, and if there are any network restrictions. It is also important to be aware of potential challenges, such as insurance companies not having enough in-network lactation professionals. By understanding their insurance coverage and knowing the right questions to ask, new parents can access the support they need to keep themselves and their babies happy and healthy.

Check if your insurance plan covers lactation consultations

Checking if your insurance plan covers lactation consultations can be done in several ways. Firstly, you can refer to the Affordable Care Act (ACA), which mandates that health insurance plans cover breastfeeding support, counselling, and equipment for the duration of breastfeeding. This means that many insurance companies are required to cover preventative lactation services without additional costs or copays. However, it's important to note that this may vary depending on the type of insurance plan you have, as some older "grandfathered" plans are exempt from these regulations.

To check your specific insurance plan, you can start by contacting your insurance company directly. They will be able to provide you with detailed information about your plan's coverage for lactation consultations. Ask them if they require referral documentation from your physician and what specific codes they cover for lactation services. Some commonly used codes include:

• HCPCS Code S9443 for a face-to-face lactation class
• CPT Code 99404 for preventive medicine counselling
• CPT Codes 99341-99350 for a home visit
• CPT Code modifier 95 for "synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system"
• ICD Code Z39.1 for the "encounter for care and exam of a lactating mother"

Additionally, you can utilise online tools such as the National Women's Law Center's Breastfeeding Toolkit, which helps determine whether your plan is required to cover services like lactation consultants. This toolkit also provides guidance on how to call your insurance company and demand these services.

It's worth noting that some insurance companies may not have enough in-network lactation professionals to serve their customers. In such cases, you can request an Out-of-Network Exception or a Geographic Gap Exception, which allows you to seek care from an out-of-network provider with potential reimbursement from your insurance company.

Lastly, your workplace may offer its own healthcare solutions or postpartum care programs that include lactation consultation coverage. It's worth checking with your employer about any lactation benefits they may provide.

How to request a lactation consultation

Lactation consultations are usually covered by insurance. The Affordable Care Act (ACA) mandates that health insurance plans cover breastfeeding support, counselling, and equipment for the duration of breastfeeding. However, the type of insurance plan you have may affect the level of coverage you receive.

Check Your Coverage

First, check your insurance coverage by contacting your insurance provider. You can also fill out a "Request a Lactation Consultation" form, which will ask for your name, contact information, address, and supplemental information, including your preferred type of visit (in-home, in-office, or telehealth), the urgency of your visit, and whether you already have a lactation consultant in mind.

Contact a Lactation Consultant

If you don't already have a lactation consultant, you can contact one directly. International Board Certified Lactation Consultants (IBCLCs) are considered the gold standard in lactation care. They can help you set feeding goals, pick a pump that works for you, and overcome feeding challenges such as latching, milk supply, and clogged ducts.

Schedule a Consultation

Once you've confirmed your coverage and chosen a lactation consultant, schedule a consultation. During this initial appointment, the IBCLC will take a detailed account of your health history, discuss and set breastfeeding goals, and answer any questions or concerns you may have.

Follow-Up Appointments

Ongoing, expert lactation care is important, and you may require multiple lactation consultations throughout your breastfeeding journey. As your baby grows and new challenges or questions arise, you can reach out to your IBCLC for support.

Get Reimbursed

If your insurance plan does not cover lactation consultations, you may still be able to get reimbursed for the cost. You can submit a superbill, which is an itemized form used by healthcare providers to detail the services provided, to your insurance company for reimbursement. However, this may require additional steps, such as getting pre-authorization from your doctor and providing the required documentation.

In-network vs out-of-network providers

When it comes to insurance coverage for lactation services, it's important to understand the difference between in-network and out-of-network providers to ensure you know how much you'll pay out of pocket. Here's a detailed overview:

In-Network Providers:

In-network providers have a contract with your health insurance company and have agreed to provide healthcare services at a pre-negotiated or discounted rate. This means that when you receive services from an in-network provider, you pay a lower cost, as the insurance company has negotiated a lower rate on your behalf.

To be considered in-network, healthcare providers must meet certain credentialing requirements and agree to the discounted rates set by the insurance company. These discounted rates help control healthcare costs and ensure better affordability for patients.

Out-of-Network Providers:

Out-of-network providers, on the other hand, do not have a contract with your health insurance plan. They haven't agreed to any discounted rates, so their charges are typically higher. If you use an out-of-network provider, you may have to pay the full price for their services, and your insurance plan may not cover any of these costs.

Even if your insurance plan covers a portion of the charges, it's usually a smaller percentage compared to in-network coverage. For example, an in-network coverage might cover 80% of a procedure, while out-of-network coverage might only cover 40%.

How to Determine if a Provider is In-Network or Out-of-Network:

To avoid unexpected bills, always check with your insurance carrier to confirm if a doctor or healthcare provider is in-network or out-of-network. Most insurance companies have provider lookup tools on their websites or customer service hotlines that you can use to verify a provider's network status.

It's important to note that just because a doctor accepts your insurance, it doesn't necessarily mean they are in-network for your specific plan. So, it's always best to check directly with your insurance company.

Tips for Dealing with Out-of-Network Providers:

If you choose to see an out-of-network provider, be prepared for higher costs. You may be responsible for paying the difference between what the provider charges and what your insurance plan covers.

However, if your insurance plan doesn't have any in-network lactation professionals, you can request an Out-of-Network Exception. Federal guidance states that if a plan doesn't have an in-network provider for a particular service, they must cover the cost of an out-of-network provider without imposing additional cost-sharing.

Additionally, if your insurance company has an out-of-network lactation consultant but they can't see you promptly, you can request a Geographic Gap Exception. This allows your insurer to cover care provided by an out-of-network provider at the in-network rate.

While in-network providers generally offer more affordable rates, don't let the lack of in-network providers deter you from seeking lactation support. Familiarize yourself with your insurance plan's specifics, know your rights, and don't hesitate to reach out to your insurance company to clarify coverage and request exceptions if needed.

What to do if your insurance doesn't cover lactation consultants

If your insurance doesn't cover lactation consultants, there are still ways to get access to support. Here are some steps you can take:

• Contact your insurance company directly to understand your coverage options. Ask them specific questions such as:
• Is lactation support covered (virtual and/or in-person)?
• Is this provider covered? If they are not in-network, they may still be covered.
• Do I need pre-authorization?
• Is there a copay/coinsurance?
• Does my deductible apply?
• What is the process for reimbursement?
• Is there a filing deadline for sending in the reimbursement?
• If your insurance company does not have any lactation consultants in-network, you may be able to receive an Out-of-Network Exception. This means that your insurance company may cover services from an out-of-network provider without cost-sharing, and you may be reimbursed.
• If your insurance company has a lactation consultant but they are not available for several days or are located far away, you can request a Geographic Gap Exception. This allows you to receive coverage for care from an out-of-network provider at the in-network rate.
• Check with your employer to see if they offer any healthcare solutions or postpartum care programs that include lactation support.
• Look for other sources of support, such as your local La Leche League or a breastfeeding support group. These groups are often led by lactation consultants and can provide valuable guidance and assistance.
• If your insurance plan is provided through your employer, you may have a benefits administrator who can advocate on your behalf with the insurance company. They may be able to help you navigate the process and increase your chances of receiving reimbursement.
• If you are delivering at a hospital and your insurance covers your hospital stay, you may be covered for a lactation consultant during your stay. Coverage may vary depending on your insurance company and whether the lactation consultant works in conjunction with your doctor or your baby's doctor.
• If you have a private practice lactation consultant, they may provide you with a superbill, which is an itemized form detailing the services provided. You can submit this to your insurance company for potential reimbursement. However, reimbursement is not guaranteed, and you may need to follow up multiple times.
• If your insurance plan is "grandfathered", it may not be subject to the new regulations requiring coverage of preventative services. In this case, you may need to explore other options.

How to get reimbursed for out-of-network lactation consultations

Check your insurance coverage

Before booking a consultation, it's important to check your insurance coverage. You can do this by contacting your insurance provider and asking them specific questions such as:

• Is lactation support covered? (virtual and/or in-person)
• Is this provider covered?
• Do I need a pre-authorization?
• Is there a copay/coinsurance?
• Does my deductible apply?
• What is the process for reimbursement?
• Is there a filing deadline for sending in the reimbursement?

Request a consultation

Once you have confirmed your coverage, you can request a consultation with a lactation consultant. Some insurance companies may require pre-authorization or prior authorization before covering the cost of a lactation consultation.

Pay for the consultation

In most cases, you will need to pay the lactation consultant directly and then submit a claim for reimbursement from your insurance company. This is known as an out-of-network reimbursement. Keep in mind that the reimbursement process can be complicated and may require multiple submissions.

Submit a superbill

To get reimbursed for your out-of-network lactation consultation, you will need to submit a superbill to your insurance company. A superbill is an itemized form that details the services provided during the consultation. It should include the following information:

• National Provider Identification (NPI) number and tax ID (EIN) number
• Code for the type of appointment (CPT code)
• Code for the problem (ICD-10 code)
• The amount you paid
• The date of service
• The IBCLC’s contact information and signature

Follow up with your insurance company

After submitting your superbill, you may need to follow up with your insurance company to ensure that your claim is processed correctly. If your initial claim is denied, don't give up! Call your insurance company again and ask about the appeals process. You may need to submit additional documentation or resubmit your claim under the mother's or baby's name. Remember, insurance companies are required by law to cover lactation consulting as a "Women's Preventative Service".

Frequently asked questions