Insurance Question Regarding Lactation...

[NurseLaurie]

I have insurance through my husband's employer (Blue Cross Blue Shield PPO). My daughter is 4 weeks old and needed to see a lactation consultant due to a bad latch and possible thrush. We called, got the code for service, called BCBS to precertify that they would pay. I told them the code and they said "Oh, that's just an office visit, we pay for that". Then she asked me what the visit was concerning and I said it was a lactation visit. At that point she said she was flagging my account because they don't pay for that. Even though it was billed as on office visit because I said "lactation" we now had to pay $175 out of pocket for the consult. SO, here's the question. What steps can be taken to encourage BCBS that lactation is an important service to support. I tried telling the person I spoke with that it made more sense to encourage this now than to pay for ear infections and minor illnesses later if we switched to the bottle because of our issues, but she was just the customer service person and didn't really care what I was saying. DD is nursing great now, so we are resolved, but for the sake of mothers everywhere, I would like to try to change this policy. Any advise is appreciated.

[Dimples_2005]

I had the same problem, but I justified the $150 I paid to an LC for a private home visit as being a lot cheaper than formula! My insurance company wouldn't pay for an LC unless the child demonstrated that formula feeding was out of the question, sad. They wouldn't pay for a pump either, unless the child was in the NICU. It's pathetic that the insurance companies view lactation support as optional, I'd be interested in what other posters have to say about insurance.

[grumpyshoegirl]

Hmmm. I have Mass. BCBS and they paid for everything-- six months' rental of a hospital-grade pump, LC consults in the hospital, replacement pump when the rental is up.

[mamanurse]

I was luckily too lazy to call my insurance company and pre-certify for all 8 of my lactation appointments. When I got the bill, it just said Womens Services on it. The insurance company paid all but $20 for each visit. It was just a co-pay. It might be worthwhile to get the word out to other moms to not disclose what their visit is going to be for.

[gentlebirthmothr]

Originally Posted by mamanurse

I was luckily too lazy to call my insurance company and pre-certify for all 8 of my lactation appointments. When I got the bill, it just said Womens Services on it. The insurance company paid all but $20 for each visit. It was just a co-pay. It might be worthwhile to get the word out to other moms to not disclose what their visit is going to be for.

nurselaurie,

to what you meant though with the insurance company, but I'm , how mamanurse handle it. Definetly we need to active for better system then the one now.

[mama-a-llama]

Originally Posted by grumpyshoegirl

Hmmm. I have Mass. BCBS and they paid for everything-- six months' rental of a hospital-grade pump, LC consults in the hospital, replacement pump when the rental is up.

Um, wow, how did you get them to do that? I guess I should call and ask--I just assumed no way! I truly think ins companies should at least partially subsidize pump rentals when baby can't nurse for medical reasons, or latch issues. And LCs should be covered like any other specialist. I wonder how much money it would save over the lifetime of the child?

[gentlebirthmothr]

Originally Posted by mama-a-llama

Um, wow, how did you get them to do that? I guess I should call and ask--I just assumed no way! I truly think ins companies should at least partially subsidize pump rentals when baby can't nurse for medical reasons, or latch issues. And LCs should be covered like any other specialist. I wonder how much money it would save over the lifetime of the child?

Carly,

[Kathryn]

I. HATE. BCBS. I really do. I just had to put my thought in, that's all.

[boobyfeeder]

Originally Posted by grumpyshoegirl

Hmmm. I have Mass. BCBS and they paid for everything-- six months' rental of a hospital-grade pump, LC consults in the hospital, replacement pump when the rental is up.

Me too, 'cept I got a Medela PIS right away, and they considered it a rental (basically if we cancelled the ins before the 6 months, you had to pay the remainder). When I was in the hosp, the LC filled out a form saying sore nipples or something, just so I could get the pump. Don't call the ins company, they probably won't tell you about it, talk to a LC at the hosp.

[NurseLaurie]

It was really strange. I had a friend who has the same policy (BCBS PPO) and they paid for her pump, her supplies, her visits etc... Her baby is now 2 years old. I just assumed they would pay for mine as well. I was irrate when they said they wouldn't because my child didn't have a diagnosed problem. It's all stupid. I think the biggest thing then is to get the word out to keep our mouths closed about why we are seeing the consultant. I ratted myself out and may have messed it up for myself. BCBS Illinois said they consider that an education class and classes aren't covered. RIDICULOUS! I haven't paid them yet because the consultant group that I used said to let them try to sneak it through first. Maybe I'm MOST irritated that I want to be a lactation consultant and I want EVERYONE to have access to this valuable service. Nah, I think I'm most irritated about it because I'm a mom who had some difficulty. If they cause someone to switch to formula because they can't afford the visits (although formula would be as much and probably more)... I just think in the long run it would cost BCBS more money due to more regular illnesses... Oh well, that's my rant. I don't want to bring it up to the company until I know they have paid for it. Then I still don't want them to take it back and make me pay... Plus I don't even know who to approach at the company to complain.

[chelsmm]

I couldn't get the pump- although I could have gotten a rental- but I did get the LC visit paid for. The LC billed it as an office visit and I didn't explain what it was for when I spoke the BCBS. It stinks, it should be covered, but I didn't want to argue.

[aisraeltax]

if you think you hate BCBS, try Harvard Pilgrim!! they are a real PITA! they woudl have paid for 100% of my c/s but refused to pay $250 for the birth center!
i agree that we should all just go for "office visits" w/ an LC but i would really like this train of thought changed! its ridiculous.

it woudl be really nice to see what ins. co's do pay for such services and maybe more mamas can chose those ins. co's next time its up for reenrollment. that will cause a change!

[~Megan~]

Gosh, I don't really know. When dd was a baby to see the LC in her ped's office we also had to see him for a few minutes so they could bill the insurance for an office visit.

[snowbunny]

I have BCBS PPO and have never had to get preapproved for a specialist. While I never had to see and LC--and would have to drive about 5 hrs if I did--I'm thinking they would have covered it just like a trip to my endo or GYN.

Is it possible that you just spoke to an ignorant employee who flagged your file resulting in the denial of the claim. Maybe contacting BCBS via a letter and a call beyond customer service would be in order.

In my policy, it never says that lactation consults aren't covered, but that specialists are covered except for the copay.

[grumpyshoegirl]

Originally Posted by mama-a-llama

Um, wow, how did you get them to do that? I guess I should call and ask--I just assumed no way! I truly think ins companies should at least partially subsidize pump rentals when baby can't nurse for medical reasons, or latch issues. And LCs should be covered like any other specialist. I wonder how much money it would save over the lifetime of the child?

The LC in the hospital took care of everything. Her services got billed as services to my baby, and she called and asked about the pump. It did have to be for medical reasons, which it was-- I have horribly inverted nipples that six months of nursing and aggressive supplemental pumping have had no effect on. I'd say call-- it could never hurt to ask.

[GatorNNP]

billing problem may be solved with licensure

One of the ways that could force the issue is to have LC be a licensed profession by the states and thus the provider could have a standard service, similar to how midwives can bill.

[elanorh]

I ran into the same issue with our insurance company (state employee insurance) - they wouldn't cover pump rental even with a prescription from the doctor. The woman I talked with told me that *she* knew that EIs etc. would cost them more in the end, but "It's company policy."

Later, when we had to be on 100% Neocate formula for awhile (long story) before returning to bf, they also refused to cover that, even though it was medically necessary and by prescription only.

But, they cover Viagra and other drugs. :

We never got anywhere with them, but these are the steps we followed (once Ina was back to breast, life was still just so busy taking care of all her issues that we really didn't pursue things the way we should have - the company probably *should* have paid about $1000 to cover true medical expenses we had) ....

We were told to:
1. Submit the claim.
2. Appeal their denial (within the company), accompanying this with additional documentation from the doctor.
3. Appeal their subsequent denial, accompanying this with additional documentation from the doctor.
4. Contact the state Insurance Board (or whatever the name is in your state), with copies of all your documentation/communication and have them work with the insurance company to try to resolve it.
5. If this fails - contact your local representatives and senators and ask them to work on legislation to mandate insurance coverage for these situations.

From my understanding, many of the states which have good coverage for LCs, pumps, prescription formulas or etc., are a direct result of parents getting angry and getting enough public support behind them that legislators mandated that coverage in their particular states. Which is why I feel bad that we wimped out after our attempts at #3 failed repeatedly .... I know that other families with less resources than we had, probably are struggling with the same thing now.

[hopefulfaith]

Originally Posted by elanorh

We were told to:
1. Submit the claim.
2. Appeal their denial (within the company), accompanying this with additional documentation from the doctor.
3. Appeal their subsequent denial, accompanying this with additional documentation from the doctor.
4. Contact the state Insurance Board (or whatever the name is in your state), with copies of all your documentation/communication and have them work with the insurance company to try to resolve it.
5. If this fails - contact your local representatives and senators and ask them to work on legislation to mandate insurance coverage for these situations.

I used to work for an HMO as a clinical review nurse : - I need to add that I quit because I couldn't sleep with myself at night. At any rate, to make a long dissertation about the way HMOs function, what elanorh said above is exactly correct.

You won't get anywhere with customer service or with the first-level clinical review staff with coverage sorts of issues. They can only pay or deny what the company says you can. If you're getting stuff paid that normally wouldn't be paid for, they're either:

-paying it in error
-paying it because they think it should be paid ("Oops! You mean I shouldn't have paid for that? Sorry, HMO manager!" We did this occasionally....!! If it was caught on QA, though, you'd get busted, so it happens pretty rarely)
-paying it because the hospital/office billing people know how to code and bill to get their services paid for (this is *always* the best approach, IME)

If it is company policy to deny a certain claim (i.e., lactation consults), they won't pay it; you will automatically be told that you have three appeals (or whatever your company does), and that they will likely deny all of them. Make sure you use up ALL of your appeal options, and do it within the timeframe that the company and state insurance commission have established; if your company/state have a 60-day appeal timeframe for the consumer, make sure you're within the 60-day timeframe every time. If you aren't, you have no ground on which to stand and you will most certainly get turned down.

If you want something to be paid for that isn't typically covered, it's an incredibly long series of WRITTEN appeals (never do by phone, ALWAYS in writing) just as was noted above. Get the names of the unit and division managers and address your concerns to them. Write to the medical directors; they have serious power over what gets covered, though it is a lengthy process to do so.

Write in your letter that you are taking your issue to the state insurance commission -- and DO IT -- these letters, IME, were actually taken quite seriously, as opposed to the basic "please pay my claim" letters.

Enlisting the help of your state representatives and senators is never a bad idea. Make sure you put that in your letter and refer to them by name.

Also, if you want something covered that should be (i.e., lactation services!), it is always quite helpful to enclose copies of the pertinent literature that supports your claim - actual studies from peer-reviewed journals get the most attention; synopses off the internet from layperson sites do not. The medical directors used these to support advocating coverage for particular items.

Finally, did I mention ... write, write, write ... don't waste time on the phone with customer service reps or first-level review staff arguing your case. It was admirable that you tried to reason with the rep about paying now for lactation services rather than paying later for medical claims, but they seriously have no power to change HMO payment rules.

Ph, and make sure you get the "rules" for your state from your state insurance commission. I worked for one of the nation's largest health insurers, and they operate all over the country. How claims are processed, how correspondence is handled and responded to all depends on which state you live in...i.e, Delaware had a 30-day limit or something like that in which you had to respond to appeals coming from subscribers in that state; Maryland had a 90-day limit, or something like that. Know what your state's rules are and make sure you note in your letter that you acknowledge that such-and-such company has x number of days to respond to your query, and that you look forward to hearing from them, etc., etc. Most people don't know that the companies can be fined by the insurance commission for not responding in a timely fashion....

Just my experience; HTH - sorry if this is rambly...tired day!

[NurseLaurie]

Thanks for the info Emily! At least now I know what to do if they do deny the claim.

[MaryJaneLouise]

Here's some hints from medela:

http://www.medela.com/NewFiles/reburstmt_pro.html