Regardless of whether you agree or disagree with the politics of the Affordable Care Act, the truth is that there are some things in it that are very encouraging. Among them is a section that talks about insurance companies being required to cover for breastfeeding services.
For a pediatric practice, looking to incorporate lactation consultants, this is a good thing.
To give us a better understanding of how this part of the ACA works, and what it could potentially mean to us as small private practices, I’ve asked Susanne Madden to write a post that explains all this ACA stuff.
Susanne is one of the smartest people I know in the business of healthcare. I highly value her opinion and expertise. When Susanne talks, I listen.
You should too… or read, rather… unless she is speaking, of course… oh, you know what I mean.
Most pediatricians I speak with say that they support breastfeeding Moms one way or another. It could be when the Mom presents at a newborn’s well visit and needs some advice or it may be when she is experiencing nursing problems. However, unless you have a dedicated lactation consultant or provider in your practice that is well versed in these issues, you may just be covering the basics.
But there are many benefits inherent in fully supporting breastfeeding, not least of which is a mother’s opportunity to continue nursing rather switching to formula because she was unable to access the help she needed, when she needed it. However, just covering the basics now means that you are overlooking a significant opportunity to provide services that finally pay!
In the past, providing services has presented difficulties in terms of getting paid for those services.
Lactation consulting is often time-consuming and, even if you knew how to code appropriately, it rarely paid well enough to invest the time to do it. Additionally, only licensed providers such as physicians and nurse practitioners were eligible for payment.
However, thanks to a section in the Affordable Care Act, as of August 1, 2012, insurers must cover, without cost (no copay, co-insurance or deductible) to the patient, “Breastfeeding support, supplies, and counseling”. The HHS guideline further states this as covering “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” (Click here for more details)
“Okay” you might say “but I still don’t get what’s the big deal?”
Well, there are a couple of excellent opportunities emerging for pediatricians:
First insurance companies are now recognizing “trained providers” which means not just MDs, DOs, NPs etc but also IBCLCs (those that have been certified by the International Board of Lactation Consultants), regardless of licensure.
This opens the door for you to employ or contract with an IBCLC to provide services to your patients that will, in fact, be payable by insurance. So rather than spending an hour of YOUR time with a nursing Mom, a less expensive resource can do so instead and earn your practice revenue.
Second insurers are now paying for classes.
That’s right – if you hold a class on breastfeeding, you can bill and get paid for it. This is a little different than, say, just hosting a support group (which isn’t payable).
The idea here is that you are providing ‘group counseling’ and as such, it is a payable service. You would now bill using group counseling codes for each person that attends. Rates are anywhere from $50-$100 per hour. If you have 10 Moms in a class . . . well, you do the math!
You can also bill individual problem-focused visits and even consults (that is, using consult codes) if a Mom is referred to you. And make sure that you bill for both mother and child in appropriate instances, such as for a feeding problem, where you examine both the baby and the mother.
Services rendered to the baby get billed to the baby’s insurance, and you will need to create a new chart for the Mom and bill those services to the Mom’s insurance (yes, you can do this!)
Now, different insurers are going to require different billing criteria and pay in different ways.
For example, United Healthcare will not pay 99411 (preventive counseling) when done during a well visit, but will pay it as a separately identifiable service when billed on its own or with a modifier (-25) attached to an E & M code.
Also be aware that in many cases IBCLCs must be contracted with a given insurer before services are covered. Many insurers do not yet credential IBCLCs (as lactation consultants only, that is, with no ‘license’ under another credential), but will ‘contract’ with them so that services can be rendered in-network. For example, Aetna credentials and contracts IBCLCs, United Healthcare contracts but does not yet credential. So check with the insurance companies in which you participate to see what each one’s policies may be.
Here are the National Breastfeeding Center we are in the process of compiling policies from more than 200 insurers and will have those available on our website soon. We will be ranking those with the best, and worst, breastfeeding policies.
It’s early days and most insurers have not yet worked out all the ‘bugs’. Some have rushed to meet the August 1 deadline in terms of policy only to find that the rest of their organizations have not coordinated an intake process for credentialing, or provided adequate information on contracting.
So even though an insurer may have a policy on coverage, there may be few details in that policy about how to credential and contract your lactation consultant resources. Therefore, I recommend contacting the medical director at each of your plans to ask for specific details about how each company’s process works.
However these policies shape up, one thing is certain. You can now get adequately paid for providing breastfeeding services in your practice.
If you need more information, please contact me at the National Breastfeeding Center at firstname.lastname@example.org. You can also follow their Facebook page by visiting this link.
Susanne Madden is a co-founder and COO of NBfC. Her work includes running The Verden Group, a practice management consulting firm, and she is a proud new mother nursing a 6 month old baby boy. To her, breastfeeding services are an essential ingredient to ensuring long term population health and she is inspired to be part of an organization that is centered on delivering innovative breastfeeding services to the businesses that support nursing moms.