Re: insurance providers

July 26, 2012

As of this moment, one of our IBCLCs who is also and attorney has been getting

95% coverage even though she is NOT on any provider panels. My husband is a

clinical psychologist and he can pick and choose which panels he is on and he

still has the right to refuse to be on the insurance panels. In private

practice I see NO benefit to being on a provider panel. For the very reason

that others have articulated.

On the other hand, in my husband's profession, professionals have grouped

together to fight to keep fees at particular rates. This is another option.

Is there anything in the Act that FORCES practitioners to be on provider panels?

Best regards,

E. Burger, MHS, PhD, IBCLC

July 27, 2012

No there isn't -- just had a good discussion about licensure and reimbursement here at ILCA with Marsha last night. You don't have to be on a provider panel, but mothers who have this provision in their insurance will look for someone who takes their insurance so they don't have to pay out of pocket. I'm sure there will be many moms, particularly in Manhattan, who will be willing to pay out of pocket, even if their insurance covers it, just to get a specific practitioner. That's what having money does. In my area? Not so much. If you aren't accepting insurance the mom will find someone that does.

Jan

As of this moment, one of our IBCLCs who is also and attorney has been getting 95% coverage even though she is NOT on any provider panels. My husband is a clinical psychologist and he can pick and choose which panels he is on and he still has the right to refuse to be on the insurance panels. In private practice I see NO benefit to being on a provider panel. For the very reason that others have articulated. On the other hand, in my husband's profession, professionals have grouped together to fight to keep fees at particular rates. This is another option.Is there anything in the Act that FORCES practitioners to be on provider panels? Best regards, E. Burger, MHS, PhD, IBCLC

July 27, 2012

I don't think we will be "forced" to do anything. There are a lot of clinicians in my community who have never billed insurance and never will--including osteopaths, massage therapists, acupuncturists, etc. I have a thriving practice--most people say to me when I bring up the money end, "i don't care how much it costs...." so I'm personally not that worried about it. Beebe, M.Ed., RLC, IBCLC Lactation Consultant/Postpartum Doula www.second9months.comwww.facebook.com/thesecond9months To: Sent: Friday, July 27, 2012 11:42 AM Subject: Re: insurance providers

Jan's point is exactly what makes me nervous. Essentially, the market may force us to be insurance providers even if it isn't mandatory.

For this season of my life, I have specifically established my practice in a way that allows my professional life to be simple. I don't sell retail products or rent pumps, I cover small items like nipple shields in my consult fee, and I only take cash/checks. My children are still young and I have a spouse who travels extensively and unpredictably for his job (that pays our bills), so my goal was to do what I love while still keeping it manageable. Getting on provider panels and dealing with the reams of paper would significantly complicate my practice and I'm not sure I have the time to add that extra layer of complexity on top of my other responsibilities. And beyond that, my little business runs on a shoestring. I can't afford to wait long stretches of time for reimbursement or to take a significantly reduced fee.

I work in a hospital as an LC and teach BFing for a big hospital system in addition to my PP work. While I truly like my hospital job, the PP work I do is very gratifying, I feel free to practice as I see fit and I feel like I make a bigger difference in lives of the families I serve because I'm filling a special niche. The overwhelming complexity of the insurance world might be my tipping point though. In my hospital job, I show up, punch the clock, do my work, go home and get paid. End of story. Since I'm prn, I work when I want to and make a good wage with no paperwork headaches other than mastering the latest update to our electronic charting system. While I'm not ready to give up my PP, the lack of headache definitely has appeal.

In my area, there are less than a handful of us in private practice. We are geographically spread out and serve different clientele, so we aren't really competing for the same patients. I also have a pretty loyal following among some midwives and physicians. I hope these things work enough in my favor for me to be able to continue to be fee for service only and have what I see as the best of all worlds.

Thanks for letting me rant a bit...

Carroll

I'm sure there will be many moms, particularly in Manhattan,

> who will be willing to pay out of pocket, even if their insurance covers it,

> just to get a specific practitioner. That's what having money does. In my

> area? Not so much. If you aren't accepting insurance the mom will find

> someone that does.

>

> Jan

>

July 30, 2012

I

will look into a different code for home visits, but I do not think there is

one. The coding for these visits is as a “preventive counseling service”

and I believe it is the same regardless of the setting where it is offered. When

I have answers I will include this in our Q and A and our webinars for USLCA

members. IF anyone wants to email me use my comcast email address from the

list. jlgutowski@....

Judy

Judith

L. Gutowski, BA, IBCLC, RLC

135 McGrath Lane

P Box 1

Hannastown, PA 15635-0001

Cell

Phone

Fax

July 30, 2012

Judy, $93 to $123 per visit would put most Manhattan lactation consultants out

of business. This is a ridiculously low amount of money for what is typically

2-3 hours of work with mothers in their home. No one can do a decent assessment

in an hour unless the baby is completely ready to go the moment the LC arrives.

Would you suggest NYLCA as a group approach Aetna in New York about the rates?

I for one would absolutely refuse to drop my rates by well over 50%. Travel

time alone to clients in Manhattan (not even the outer boroughs is an hour. At

this moment in time many of the private practice IBCLCs I know who are relying

on their income alone really are struggling to make a living in New York City

and this is with the AVERAGE fee for a home visit at $250. One of our members

is already getting 95% or more coverage without being on anyone's provider

panels.

So far, everyone I know who has looked at that letter from Aetna and refused to

consider becoming a provider. It seems to me that this is a lose lose

situation. How can we turn this into a win -- lose not so much situation?

There is really zero incentive for any private practice IBCLCs to sign on.

Best regards,

E. Burger, MHS, PhD, IBCLC

July 30, 2012

Instead of per client contact, can it be per hour? And what about usual and customary rates? Here in Midwest may be less than those in Manhattan, so wouldn't the fee set be higher for NY ? I would hope they would not just make a blanket fee for the entire US. Can you charge the client separate for travel time or mileage ? or only accept what insurance pays for the actual visit? Minnesota To: From: sburgernutr@...Date: Mon, 30 Jul 2012 09:15:59 -0400Subject: Re: insurance providers

Judy, $93 to $123 per visit would put most Manhattan lactation consultants out of business. This is a ridiculously low amount of money for what is typically 2-3 hours of work with mothers in their home. No one can do a decent assessment in an hour unless the baby is completely ready to go the moment the LC arrives.

Would you suggest NYLCA as a group approach Aetna in New York about the rates? I for one would absolutely refuse to drop my rates by well over 50%. Travel time alone to clients in Manhattan (not even the outer boroughs is an hour. At this moment in time many of the private practice IBCLCs I know who are relying on their income alone really are struggling to make a living in New York City and this is with the AVERAGE fee for a home visit at $250. One of our members is already getting 95% or more coverage without being on anyone's provider panels.

So far, everyone I know who has looked at that letter from Aetna and refused to consider becoming a provider. It seems to me that this is a lose lose situation. How can we turn this into a win -- lose not so much situation? There is really zero incentive for any private practice IBCLCs to sign on.

Best regards,

E. Burger, MHS, PhD, IBCLC

July 31, 2012

Maybe I'm misunderstanding how my insurance works from a customer point of view,

but what I have had to do with my what I think is typically lousy insurance is

go to a provider who is within network and then either pay a co-pay, or pay the

balance between what is billed and what is not covered.

For medical care where I use an in network provider my co-pay is fairly low

(10-40 depending on a few factors).

For dental care it is the balance of what is not covered.

As an LC, I have had most of my clients reimbursed to some extent in the last

year or so. The one insurance company that got confused and sent me the checks

apparently reimbursed $45 for a $175.

If AETNA (and soon others I'm sure) will take the dental approach and encourage

or at least not prevent us from charging the balance of what would be covered

then I'm ok with the change in theory.

If AETNA finds a way to limit to co-pays only then I will take the approach many

doctor's do and limit the number of insurance only slots that I will take and

will take the balance as a tax deduction.

None of this is easy and change is always scary and annoying and frustrating.

Hopefully though this change will encourage our profession to be a licensed

profession and allow more women to seek qualified help.

Lea Todaro

Brooklyn, NY

July 31, 2012

I truely believe it is a skill set that the ibclc brings to the consult not the form of payment, however they do not necessarily get a lesser consult because they were self pay.Sent from my iPhone

It is really important that IBCLC's do what dentists have done--most dentists have refrained from becoming in-network providers for insurance companies, because they cannot afford the pay cut.

IBCLC's should be charging about 300 dollars per visit in NY, and this is a bargain if the mother is getting a good IBCLC.

I do think that people will start to get what they pay for. I have recently heard from two mothers whose babies had posterior tongue ties and they each hired IBCLC's to come to their home, and in both cases, the IBCLC's did not even check the baby's mouth or do a weighed feed.

Thank goodness they were able to get god help afterwards. One of the mothers even complained that she went back to the hospital for free help (at a hospital where outpatient lactation support is provided) and the lactation consultants still failed to identify the ptt, and her baby was gaining 2 ounces a day on her pumped milk but they scared her by saying "feed the baby!!" and gave her free formula on more than one occasion.

There are a lot of wonderful, brilliant and talented LC's out there, but I sincerely doubt that many of them are willing to work at the proposed ins. co. rates.

Paciullo, New Hyde Park, NY

July 31, 2012

Judith Gutowski posted something on LactNet that is interesting. That the ACA

requires that there is no cost sharing with the patient. I know she reads here

to, so if you see this, would you mind commenting on the possibility that we as

PP LCs might be able to do a combination of self pay and insurance?

Lea Todaro

Brooklyn, NY

August 1, 2012

And why is the IBCLC being singled out as no cost sharing when other healthcare fields do this all of the time? Cheryl n, IBCLC, RLC To: Sent:

Tuesday, July 31, 2012 1:08 PM Subject: Re: insurance providers

Judith Gutowski posted something on LactNet that is interesting. That the ACA requires that there is no cost sharing with the patient. I know she reads here to, so if you see this, would you mind commenting on the possibility that we as PP LCs might be able to do a combination of self pay and insurance?

Lea Todaro

Brooklyn, NY

August 1, 2012

The Affordable Care Act, also known as Obamacare. This part of the act kicks in tomorrow and it covers a range of women's health issues, of which breastfeeding support is just one.Sharon

what is the ACA? Beebe, M.Ed., RLC, IBCLC Lactation Consultant/Postpartum Doula

www.second9months.com

www.facebook.com/thesecond9months

To:

Sent: Tuesday, July 31, 2012 7:04 PM Subject: Re: Re: insurance providers

Because that is what the ACA mandates.

And why is the IBCLC being singled out as no cost sharing when other healthcare fields do this all of the time?

Cheryl n, IBCLC, RLC

To:

Sent:

Tuesday, July 31, 2012 1:08 PM Subject: Re: insurance providers

Judith Gutowski posted something on LactNet that is interesting. That the ACA requires that there is no cost sharing with the patient. I know she reads here to, so if you see this, would you mind commenting on the possibility that we as PP LCs might be able to do a combination of self pay and insurance?

Lea Todaro

Brooklyn, NY

August 1, 2012

The idea is that 'preventive' services should come at no cost for the policy

holder. This is an effort to promote the use of services that aid in disease

'prevention', and breastfeeding falls into this category.

>

> And why is the IBCLC being singled out as no cost sharing when other

healthcare fields do this all of the time?

> Â

> Cheryl n, IBCLC, RLC

>

> ________________________________

>

> To:

> Sent: Tuesday, July 31, 2012 1:08 PM

> Subject: Re: insurance providers

>

> Â

>

> Judith Gutowski posted something on LactNet that is interesting. That the

ACA requires that there is no cost sharing with the patient. I know she reads

here to, so if you see this, would you mind commenting on the possibility that

we as PP LCs might be able to do a combination of self pay and insurance?

>

> Lea Todaro

> Brooklyn, NY

>

August 1, 2012

I need some help! I saw a post today that said as of today, (among other services) breast pumps and lactation consults are FREE! thanks to ObamaCare. This is related to an article in NPR. Do you have an official response? I do NOT want to speak for all LCs but I am concerned about erroneous information being distributed in social media. Thank you, Dana"All new insurance plans will be required to cover additional services and tests for women, with no out-of-pocket costs," she said, "including domestic violence screenings, FDA-approved contraception, breast feeding counseling and supplies, and a well woman visit, where she can sit down and talk with her health care

provider." http://www.npr.org/blogs/health/2012/08/01/157674061/under-health-law-no-cost-birth-control-starts-today Dana Schmidt, BS, RN, IBCLCCradlehold Breastfeeding Education & Supportwww.cradlehold.netPlease follow us on Facebook at www.facebook.com/CradleholdBreastfeedingEducationSupport No information submitted electronically through the Website or email to us will be treated as privileged, confidential, sensitive or personal health information unless we have

previously entered into a written agreement with you to protect such information. Any person submitting confidential or sensitive information to us without first entering a prior written agreement with us to protect such information waives all rights to confidential protection or doctor-patient privilege. We assume no responsibility for the loss or disclosure of any information that you transmit to us via the Internet. Please call or visit www.cradlehold.net for an evaluation. To: Sent: Wednesday, August 1, 2012 1:57 AM Subject: Re: insurance providers

I think that breastfeeding support of any kind is seen as preventative because if breastfeeding is successful, it will help to prevent future health problems for mothers and their babies.Sharon

Who are the attorneys advocating for us and negotiating with the insurance companies? Of course, every similarly situated professional organization has legal advocates to handle these matters. Please do not tell me that someone thought that somehow she could handle the negotiations without an attorney??!!

Obama Care Act--If insurance companies are required to provide LC services, then we are in the POWER SEAT for negotiating and should be asking for a lot more than is currently proposed!

Re preventive services--gee, a mtg. before the baby is born is preventive, but what about seeing a mom and baby for breastfeeding problems?

re no cost--this should not have anything to do with what we charge. BUT there would have to be an out of network option. Many health plans cover only in network. For example, DMO dental plans pay for in network dentists and there are hardly any of them, so you'd have to drive an hour to get to a dentist who is, by the way, incompetent. Are DMO's still in existence or did they finally all go out of business for this reason?

Health insurance plans that allow for out of network providers to be reimbursed would mean that our client could be reimbursed and pay us the difference for our services. That is not a co-pay. A co-pay is when an insurance company pays for a portion of an appt. but makes the insured pay for the first 10 dollars, or 20 or 30 or in my case the first 50 dollars for in net-work providers. When a health insurance company actually allows for out of network coverage, there is sometimes a deductible (such as 100 dollars per person per year, meaning the insured pays the first 100 of any out of network bills, but only once in a calendar year) and then the insurance would cover 80 or 90 or 100 percent of what they feel is reasonable and customary.

Most important, can we all band together and demand representation by a skilled negotiator? Approaching this without a skilled negotiator, an attorney who is experienced in negotiating these matters, is an error that can never be remedied. Why not use the same attorneys that the AAP uses?

August 1, 2012

Please

see the links below to understand the Affordable Care Act Requirements

regarding cost-sharing and network providers.

Cites

breastfeeding as a preventive service

http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen

For

and - Describes and defines “no cost sharing” and “In-network”

http://www.healthcare.gov/law/features/rights/preventive-care/

Sharon you are correct in that lactation visits

are “preventive” of future illness for mother and baby.

As an

aside, for the record, Medicaid because it is not subject to the ACA and it is

irrelevant here because IBCLCs cannot be “credentialed “ Medicaid

providers since we do not have license.

,

Be

advised that your arguments are jumping the gun, here and on Lactnet. The

single code that I have cited as a mere example in the discussions is only one

code. A PRE-EXISTING code that has been and is being used for provision of

services by many health professionals all over the US. A code which has rates assigned

to it. That is the code and that is what it pays. That one code you are griping

about is for office visits, not home visits. It remains to be seen IF HOME

visits are going to be covered and what the reimbursement rate for those will

be. Also, Aetna is only one provider,

insurance carriers have a range of reimbursement as you should know. Some pay

better than others.

Additionally,

this is only a miniscule first step in the process and a temporary workable

solution for the present time.

The

USLCA has applied to CMS for our own codes specific to our visits, long

definitions below. If those codes are approved then the associated fee

schedules are next to be negotiated.

In-Patient:

Lactation evaluation and management by a qualified

lactation consultant, in patient hospital

Brief visit (often happens when immediate

problem is identified and patient is not scheduled):

Lactation counseling and/or breastfeeding risk factor

reduction intervention(s) provided to an individual; approximately 15 minutes

Out-patient, Office:

Lactation evaluation and management by a qualified

lactation consultant, initial out-patient office visit, 60- 120 minutes

[to include at

least the following: (1) maternal, infant, birth and feeding comprehensive

history, (2) a physical examination that includes: (a) maternal nipple and

breast ( infant oral anatomy © infant suck assessment (3) feeding

observation and (4) problem assessment, and (5) management plan and patient

education]

Lactation evaluation and management by a qualified

lactation consultant, follow-up out-patient office visit, 40-90 minutes

[to include at

least the following: (1) maternal, infant, birth and feeding pertinent history,

(2) a limited physical examination that includes: (a) maternal nipple and

breast ( infant oral anatomy © infant suck assessment (3) feeding

observation and (4) updated problem assessment, and (5) revised management

plan and patient education]

Out-patient, Home:

Lactation evaluation and management by a qualified

lactation consultant, home health visit, initial, 60- 120 minutes

[to include at

least the following: (1) maternal, infant, birth and feeding comprehensive

history, (2) a physical examination that includes: (a) maternal nipple and

breast ( infant oral anatomy © infant suck assessment (3) feeding

observation and (4) problem assessment, and (5) management plan and patient

education]

Lactation evaluation and management by a qualified lactation

consultant, home health visit, follow-up, 40-90 minutes

[to include at

least the following: (1) maternal, infant, birth and feeding pertinent history,

(2) a limited physical examination that includes: (a) maternal nipple and

breast ( infant oral anatomy © infant suck assessment (3) feeding

observation and (4) updated problem assessment, and (5) revised

management plan and patient education]

Classes, Prenatal or Return to Work:

S9443 Lactation Classes, Non-Physician

Provider, Per Session

Apparently

you are not a dues paying ILCA/ USLCA member, or if you are, you do not care to

read your eNews which comes monthly and has been providing information on this

regularly. Are you aware of all of these efforts made by USLCA for the past 6

years as one of its main missions?

Perhaps

since you considered yourself one of the “good IBCLC ” providers ~ and

you were so successful getting high rates of reimbursement ~ you could

have shared some of your knowledge, time and talents with your peers to prevent

those of us who have good intentions, but who are ignorantly moving our

profession in the wrong direction, from violating your requirements. Perhaps if

you had contributed, by now we would all be getting paid $300 for consults and

all the women in the US

would have access to adequate breastfeeding support and our breastfeeding duration

rates would be exceeding the Healthy People 2020 goals. Perhaps rather than

issuing argumentative challenges even this week, you could have used a tone of

kindness and offered help and cooperation. Maybe you would even pay for some

attorney fees since you are one of the few IBCLCs who is paid well.

I am

one among many, including Marsha,

at USLCA who give countless volunteer hours – daily - and we contribute

financially by dues and other incurred costs of working for the USLCA Licensure

and Reimbursement Committee. I work 3 or 4 part-time jobs as an IBCLC, all in

the out-patient setting. I do not get health benefits. I do not attend the

Conferences often ( 3 since becoming and IBCLC 17 years ago) because I can’t

afford it. I am a good IBCLC regardless of getting paid only $30 an hour.

I also help lots of women volunteering as a LLL Leader for 24 years. I volunteer

for my state and local breastfeeding coalitions and my local USLCA chapter as

well. I really don’t like being attacked. It is unnecessary and

counterproductive. We could be solving these problems together rather than this

mean spirited dialogue.

Judy

Judith

L. Gutowski, BA, IBCLC, RLC

August 1, 2012

This is a stressful time for everyone. Trying to bring lactation consultants into the professional realm of recognized health care providers has been a long and sometimes painful process. We come from many backgrounds and work in many venues. This is a time when we need to pull together and work towards some common goals.

I think that many PPLCs are feeling particularly anxious at this time with insurance issues that they don't fully understand as well as the increasing frustration with the blurring lines between the CLCs and IBCLCs and CLCs with advanced certification. Very few if any PPLCs are truly earning a living as full-time lactation consultants. I myself have always held another fulltime job, but do not consider myself a " dabbler " - I am pretty darn good at what I do despite my light client list and have spent much of my adult life as a breastfeeding advocate and counselor, both as a volunteer and a paid professional.

We all need to pull together, join both local, state and national workgroups to investigate these issues and come up with a viable plan. USLCA has been working on this and will continue to do so - I think that they would welcome our input.

Back to work at my " other " job.Sharon Knorr, IBCLC, ILCA/USLCA member for many years