That is a good question and a common misconception. Lactation coverage is determined by each individual insurance plan. Some plans specifically exclude lactation consultations in their coverage. Some roll lactation into the birth services. Most provide  some type of coverage but the degree that they cover is individual plan specific. 

I work through a variety ways to try to make sure that you get as much coverage as possible. I am in network with some insurers ( AETNA and UNITED HEALTHCARE) and I bill through a 3rd party who pays me directly and then bills your insurance such as TLN and WILDFLOWER) and occasionally I may bill out of network. I am not able to bill any government plans at this time. 

The trickier part about billing and the  biggest misconception is that your visits are FREE and you won't be responsible for any cost sharing. That is not exactly true. 

There is only one dedicated billing code for lactation and that is a lactation class code. So, lactation billing becomes very tricky because each individual insurance company decides what, if any, additional "codes" they will cover. Those class codes are considered preventative and don't have any cost sharing associated with them. However some insurers limit the number of class codes you can use - generally 3-6. After that, they wont pay any of them. 

These are also very low paying codes - think of it as they are paying for teaching only - not interventions. So, we typically bill for education but also for the other direct care that we are providing for both you and baby. 

Lactation consultations are very different from other services because we generally are seeing two separate patients - the breastfeeding parent and the baby ( or multiple babies). In order to provide excellent and thorough care for BOTH patients, our visits are very long. Generally 60 - 90 minutes. 

Each patient  - mom and baby is billed for separately. Just as if you went to see your OB and baby went to see the pediatrician.

If your baby is on a different policy than you, that policy will be billed. If that policy does not cover the lactation visit, you could be responsible for the baby's costs. 

The class codes that are lactation specific do not reflect the level of care and time involved in your visit. Because of that, other codes are also billed with the lactation code to reflect the  care that is provided to you. We are not only providing education but also reviewing history, performing physical examination, assessing for problems, formulating a plan and providing that plan in written form for each patient - both mom and baby.

The class codes are preventative care codes and do not usually have cost shares or copays included. The other billed codes may incur cost sharing by your insurance company. We try very hard to bill in such a way that there is no cost sharing or very little out of pocket costs. 

Additionally, some insurance companies ( AETNA)  limit the number of lactation class codes that they will pay. You may have heard that your insurance allows 6 visits. That is also a misconception. Some will allow 6 CLASS CODES total which might be 3 for mom and 3 for baby - and so used in 3 visits. Some will allow 6 for mom and 6 for baby. Some have no limits. This again is determined by your insurer.  If your plan has limits, once those limits are reached, they will no longer reimburse for those codes and you may be responsible for cost sharing on the other codes at that point so that your lactation consultant is paid for the visit. 

IMPORTANT POINT! 

THOSE class codes are attached to YOU not the provider. So, if you have seen another lactation consultant prior to seeing me, then some of all of your class codes may have already been used. 

* Some companies who provide breast pumps through lactation will offer FREE classes when you get your pump through them. These companies often bill your insurance company using your class code. Some patients come to their first visit and ALL their class codes have been used and their lactation coverage is now their financial responsibility.  If this happens, you should call your insurance company and have these classes through the pump company removed so that you can receive the indvidual care you need. 

(Any time someone offers to bill your insurance company for your visit, know that you may be limiting the care that you can receive without cost to you. 

The amount of co pay and cost sharing is determined by your insurer. If I am in network provider with your insurer, I am obligated by my contract to bill you for the cost shares - the copay, the co insurance, the amount applied to deductible. That is not a decision I am allowed to make. 

if your insurer denies coverage of your claim, applies some or all of your visit to deductible, or any other cost sharing, I encourage you to call and ask for an explanation. It is possible that they will reverse copays or cost shares on review.  

If you continue have any questions about this you can call your insurer and ask if lactation care is covered and what codes they pay and if there are any limitations. 

The best way to know if you will have cost sharing responsibility for your lactation visit is to talk to your insurer BEFORE your visit.

Some questions you might ask would be:

What lactation benefits do I have?

What coverage does my baby have? 

What cost sharing might I be responsible for (copays, coinsurance, deductibles that need to be met etc)? If you have a very high deductible plan, you may need to reach your deductible before they pay anything. Or they may only pay the preventative care portion.) 

Will cost sharing be applied for my visits? for baby visits? 

Is there a limit to the number of lactation visits I have? 

Make sure you get the name of the customer service rep when you call because they are not always correct in what they tell you. 

After the claim for your visit has been processed by your insurer, you will receive an explanation of benefits (EOB) from your insurer. That will show  what they paid toward your visit and your patient responsibility - the amount they applied to cost sharing. The patient responsibility is the amount that you would owe. 

( unless your visit was billed through TLN  or WILDFLOWER- these visits have no cost sharing to the patient) 

 Your insurer will send to us an explanation of payment (EOP) after the claim is settled. This can take several weeks or longer. That EOP will tell us what they paid and what your patient responsibility is. We will then send you an invoice for the balance owed. If your invoice is not paid within 10 days we will charge your card on file for the balance unless you have contacted us regarding a payment plan. If you have questions about the EOB you receive and what it says that you owe, contact us. Those are not always accurate.

I contract with two companies who provide billing services for lactation. I am basically a contractor providing care and they are the biller. They pay me a flat one time fee for mom only.

The Lactation Network (TLN)  accepts some BCBS plans, and plans that have a MULTIPLAN or PNOA logo on the card. I use them for plans that I am not already in network with - so I do not use them for AETNA or UHC plans. 

Wildflower bills for my CIGNA patients. 

I will send you my personalized link to have them verify your benefits if you have an insurance that that they bill for.

If your insurer participates with TLN or WILDFLOWER , your visits will be covered at 100%. You will not receive any bills from them, even if your EOB (explanation of benefits) lists a patient responsibility.

I am not responsible for the billing for TLN and cannot answer any questions related to the billing. However, remember that your EOB shows what your insurer paid and your patient responsibility. BUT IT IS NOT A BILL!

Your insurance company cannot bill you for medical care. They can ONLY bill you for your premiums. If you have a patient responsibiIity for your care, the medical provider is the one  you would receive a bill from.

If you receive an EOB that lists patient responsibility for a TLN or WILDFLOWER claim, you will not be billed by them ever. If you have questions about charges, call and talk to them directly. 

If you have no insurance, have a government plan, or a health share or a plan that does not provide lactation care or that does not work directly with me, you will be considered SELF PAY.

You will pay for your visit at the time of booking according to my self pay rates. IIF REQUESTED, I can provide you with a Super Bill to submit to your insurer for POTENTIAL reimbursement. (You must ask for this. I will not provide this automatically) You often will  receive some reimbursement from your insurer directly if lactation is not excluded. You can find the information for how to submit a superbill through your insurer directly. 

Call the customer service number on your card. 

Self Pay appointments require full payment prior to the appointment. Your appointment is not confirmed until payement is received. If payment is not received 24 hours before the appointment your appointment may need to be rescheduled. 

Lactation consultations are very long appointments compared to traditional medical appointments. You are familiar with how much time you get in the OB or Pediatrician office with your provider. Our visits are typically 60 - 90 minutes long and because of this there are very few appointments available per day.

If you are unable to keep your appointment, I ask that you cancel or reschedule your appointment within 24 hours of your appointment time.  I understand that emergencies happen. If you need to cancel with less than 24 hours, you will be automatically charged a cancellation fee unless you reschedule your appointment at the time of your cancellation. If you have more than two cancellations, you may be dismissed from the practice. Late cancellations are difficult to fill and families waiting for appointments rarely have time to prepare for a same day appointment. 

If you have an appointment and do not show up for your appointment, the full self pay rate will be charged to you. 

If circumstances come up at the last minute (i.e.you have a sick child or transportation issues or you woke up late -  all of these happen) we can change your office visit to a virtual visit to be able to keep your visit without cancellation. Send me a message asap and I can switch that for you. 

Please be responsible about your appointments for the sake of the providers and other families.  '

If you are realize that you are going to be late for your visit, please text and let me know. Our visits are long enough that there is a buffer to still see you but your visit will be cut short and we will have to focus on the most important thing. Your visit will still have to end at your regular time to not inconvenience the next family. 

We require an active credit card to be kept on file in order to book your appointment. This is mainly for the purpose of billing last minute cancellations or no shows. These long visits require a lot of preparation and there are a limited number of appointments per day and the loss of one appointment can impact my ability to provide for myself and my family and to provide for families who are waiting for an appointment. 

I have recently implemented the necessity of providing a credit card in order to book an appointment. Unfortunately, other people make this a requirement for all people. 

We require the credit card on file (and it is checked to see if active - you may see a charge of 1 cent to make sure the card is active and then an immediate refund) The only incidences in which your card would be charged automatically would be if you just did not show up for a scheduled appointment (we send several reminders) and you did not cancel in advance, or you cancelled with less than 24 hours notice and did not reschedule at the time of cancelling. 

If you have a cost share or patient responsibility for your visit after the insurance pays, then you will receive an invoice from us. I will not ever chargenyour card without you having the ability to pay first. 

I do not offer HOME visits. I offer visits in the office in my home  in Cumming (North Forsyth  off Ga 400 exit 16) and virtual visits. 

I used to offer home visits but I stopped for a few reasons. 

#1 I see patients who come from ALL OVER NORTH GEORGIA. Scheduling the travel for home appointments to coordinate with the geographic area is virtually impossible. You KNOW how traffic is in Atlanta. If I offer HOME visits I have to drastically limit the number of patients I am able to care for in a day. It is important to me to provide expert care to as many patients as possible. 

#2 I have a LOT  of supplies and equipement that I use to help mothers and babies. I never know what I might need to help you and your baby and in my office I can just reach for it. 

But there is NO way I can carry all of that with me. SO you are limited in a visit in your home by what I can provide to you. 

Pumping and flange fitting is just ONE example of this. I have many different brands, sizes, shapes and functions of flanges in my office in ALL the sizes to try out. I cannot carry all of those. Many people doing flange fittings only carry the silicone inserts for sizing. I find this to not be a good or accurate option for fitting. 

I also have many tools for working with babies on oral function, body tension etc. There is no way to provide all of this in a home visit. 

#3 There are a lot of distractions in the home and I think that being in my office allows you to turn off all the distractions in your home and focus only on you and baby. ( Many moms tell me they look forward to coming to my office and meeting with me) 

#5 If you are traveling from a distance, we can often do a combination of in office and virtual visits if needed. This is a good options for some families 

I love virtual visits because I get to meet people who need my help from all over the world.
And YES. I find virtual visits to be really effective - as long as you have a skilled provider and are willing to deal with technology glitches on rare occasion. 

VIrtual visits are not easy. And they should not be treated as a shorter, lower quality, easy consultation.

I put the same amount of effort and attention into my virtual visits as I do my office visits - maybe more because they require a lot of preparation before and after the visit to make them as efficient.

Virtual Visits require my very best teaching skills and tools and that keeps me on my toes. . They also require a partnership between you and I to be able to gain all the information that we need. 

Virtual visits have some technical challenges at times but we all learned how to trouble shoot and overcome those during COVID zoom calls.

But for the most part I find that I can accomplish everything that I do in an office visit except for weighted feedings in a virtual visit. 

i greatly rely on parents' skills in a virtual visit and this is actually a PLUS. I teach YOU how to evaluate your baby FOR me. I talk you through the exam and together we make assessments.

Sometimes, virtual visits require you to take some videos and send to me before or after the visit.  I send very detailed instructions about what I am asking for and looking for and it helps you to get your hands on your baby and feel what I would be feeling. Then as we progress YOU get to understand where your baby is improving and where you might need more help.

You will have even better knowledge and skills to work toward progress when you are acting as my eyes, ears  and hands.  I have very advanced skills but that doesn't mean that I cannot teach those needed skills to you.

Virtual visits are a great option for people who would like expert care in a particular area and that expertise is not available near them. I would much rather have someone have a virtual visit with an expert than a home visit with a provider with basic skills and knowledge. 

There are some visits that work particularly well in a virtual visit -  prenatal appointments, weaning appointments, back to work appointments, or appointments that don't require baby to be present are really easy to do virtually. But I have not found any appointment type to not work in a virtual visit. 

Virtual visits are a great option to add in between office visits for followup if travel is difficult.

If you have a question about whether a virtual visit is a good fit for you, message me and we can discuss it. I have seen very complex cases in virtual visits from all over the US and even Mexico. We make it work.