Insurance Coverage for Lactation Consultations

I get asked everyday whether or not Milky Way participates with any insurance companies.  The short answer is “No.”  Although many of my clients get reimbursed for their consultation fees, I am not a preferred provider with any insurance company.

By the end of this year, every new mother’s insurance should cover at least one lactation-related visit.  The Affordable Care Act dictates that all insurance companies must offer this, at no charge to the mother.  This sounds great, but the reality is not so perfect.

Currently, to the best of my knowledge, there are no IBCLC’s (international board certified lactation consultants) in Southern Maryland who participate with any insurance companies.  In fact, there are only a few throughout the country.  The insurance companies have been slow to figure out how to begin credentialing lactation consultants.  In addition, many LC’s, like myself, are hesitant to begin working with the insurance companies.  So far, the rates offered to LCs have been far below what we normally charge.  In addition, the billing is so complicated that even our professional organization has recommended that we will need to hire a billing service.  Finally, no rates have been developed for home visits.

I do not want to cut the level of service I offer clients.  If I begin participating with your insurance,  I will not be able to see you as quickly since I will have to confirm your insurance participation ahead of time.  In addition, I won’t be able to spend as much time with you because I will have to cram more clients into my day to make up for the financial losses and the new fees I must pay a billing service.  Finally, if I participate with your insurance, I will have to limit or discontinue home visits since they are not currently paid at a higher rate even though they take much more time.

I hope that all of these issues can be remedied in a way that helps everyone.  However, that process is likely to take months, if not years.  So what do you do if you need a lactation consultation now?  Many of my clients receive reimbursement after the visit, simply by submitting the superbill I give to their insurance companies.  However, you won’t know for sure if this is going to work unless you speak to the insurance company ahead of time. I recommend these steps:

1. Call your insurance company and ask about your coverage.

2. If you are told that you must see a participating provider, ask for a list of providers and make sure you are actually getting IBCLCs.

3. If they can’t give you anyone close to you, then tell them you need “in for out” coverage or coverage for a non-participating provider.

4. If you submit and your claim is rejected, resubmit and challenge the decision.  Insurance companies are notorious for rejecting a few times before finally paying.

5. If all this seems like too much trouble, consider just paying for the lactation consultation and worrying about it later.  After all, if you don’t breastfeed, you are going to be throwing away a lot more than $125 on formula in just the next few weeks—and nobody is going to reimburse you for that!

6.  Finally, I never turn anyone away for inability to pay.  If you truly cannot afford the consultation, let me know, and we will work something out.