4 Strategies to Maximize Out of Network Reimbursement Potential for Lactation Consults

Insurance, Affordable Care Act, Lactation, IBCLC, Reimbursement Out of network billing, claims

If you’re a lactation consultant in the US, then you know that the Affordable Care Act says that lactation consults should be covered as preventive services. But the reality is that many of our clients are NOT getting reimbursement for our services.

If you’re anything like me, you’re disturbed at hearing that your clients are having to submit their superbills multiple times, or that they’re not even submitting them at all. You’re wondering which codes to use, and what to do to help your clients get reimbursed.

While there are no magic formulas to use with the insurance companies that will guarantee any outcome for your clients, there are some simple strategies that you can use to maximize their chances.

Gap Exceptions or Single Case Agreements

If you want to help your out-of-network clients get reimbursed for your services, you can encourage them to file for an out-of-network exception. This is also known as a Network Gap Exception, or “In for Out.”

Basically, your client will be telling their insurance company that because there is no in-network lactation consultant available, the Affordable Care Act says that they can see an out-of-network provider with no cost-sharing. In other words, they are going to get confirmation from their insurance company that when they submit your superbill, the insurance company will pay them back for everything they paid to you. 

The goal is to get confirmation on record through a preauthorization number or a written document that promises that the insurance companies have approved the use of an out-of-network provider. The preauthorization will typically be through the parent but in some cases can be through the baby; it will depend on what the insurance company will allow. It’s probably safest to go through the parent unless the baby has coverage and the parent is uninsured.

Some insurance companies will want you to enter into what’s known as a Single Case Agreement (SCA). It’s essentially the same thing, only it may have a slightly different process. Some insurers will allow the parent to initiate the SCA; others will require you as the health care provider to initiate it. In both cases, you are asking the insurer to agree to cover one or several visits with you. You will be asked to provide diagnosis codes and procedure codes in advance.  

To obtain a SCA, you can contact provider relations or see if the insurer’s website has a form you can just submit directly. You can also ask the client to call and inquire about the procedure. You may want to do some research on your own and include information on the process on your website because reimbursement strategies can be great marketing tools.

The SCA or Gap Exception is not a magic wand triggering reimbursement. Some IBCLCs have entered into these agreements only to find themselves caught up in bureaucratic red tape and never getting paid. Best practices are always to take payment up front from the client and never to provide your client with any promise or guarantee of reimbursement. 

What you can promise them is that IF the insurance company sends the reimbursement directly you to, you will refund them in a timely manner according to the amount the insurance company sends you. If you get the whole amount they paid, you’ll send them the whole amount. If you get less than what they paid you, you’ll refund only what the insurance company sent you and keep the rest of the payment. You’ll outline all of this in your payment policies.

Out-of-Network Claims Submissions

If you’ve entered into a single case agreement with a payer, you can still provide your client with a superbill. However, submitting a claim directly to the payer may be more efficient and lead to more timely reimbursement for your client.

In order to submit an out-of-network claim, you’ll need a standardized form called a CMS-1500. If you’ve been at this for a long time, you may have heard of its predecessor, the HCFA-1500, which predates HIPAA and should no longer be used.

The key difference between the CMS-1500 and the superbill is that you’re the one filing it, not the client, and that means you’re also filling it out. The CMS-1500 should be typed on the standardized form. You can purchase this form and type it with a typewriter, or you can use a template in your word processor and configure your printer. Most healthcare EHR platforms will automatically generate a CMS-1500 as long as the correct information is entered into the platform. 

Ideally, the insurance company will send the payment as a reimbursement to the client and you will receive a copy of the estimation of benefits (EOB) showing the charge amount and the reimbursement amount. 

Often the insurance company will not reimburse your client for the full amount they paid you; encourage them to file an appeal if that happens. Do not refund them any money. They agreed to pay you a certain amount whether or not their insurance reimburses. 

Always, always take payment up front from the client when submitting out-of-network claims to make sure you get paid in full. Filing an out-of-network claim, even with a preauthorization, is no guarantee that the claim will be processed or paid correctly. The insurance company might send the money directly to the client, even if you indicate that they haven’t paid you yet. Then you’ll have to invoice the client and hope they send the money to you. Or the insurance company won’t make good on the single case agreement and try to pay you less for the code you used. Accepting payment up front is the only way to guarantee that you’ll be paid for your services. In the event that the insurance company sends you the money, you can refund your client up to the amount they paid you.

A medical biller who specializes in lactation may be able to submit out-of-network claims for your clients for a set fee or a portion of the money recovered.

“I just want to know what codes to use that will DEFINITELY get my clients reimbursed!”

You and me both!

There are a plethora of codes out there that are appropriate for the services we provide, and some insurers may even tell you which codes they prefer to use. But it’s on you to know what the codes mean so that you’re not unintentionally committing insurance fraud.

The most conservative approach is to stick with 4 codes:

  • Diagnosis code Z39.1 (encounter for care of lactating mother)

  • Procedure code S9443 (lactation class, non-physician, 1 unit)

  • Modifier 33 to flag it as preventive

  • Location code 11 for office or 12 for in-home

Because S9443 is the only lactation-specific procedure code in the entire HCPCS, it is the least controversial code we have available to us for use. If you practice anything like most lactation consultants, at any given point in a visit you are going to deliver to your clients a standardized spiel about some relevant topic, and send those clients resources in your care plan that are the same as those you send to every single client. Education provided? Check.

Now, I know you’re thinking “but I did way, way more than just provide a class!” I know you did! But think of it like you went to a restaurant and paid for an appetizer and ended up getting a four-course meal. You have no obligation to charge the client (and therefore the insurer) for any additional services you provided on top of the lactation class.

If/when the insurance company rejects the claim (which will happen much of the time, even with an SCA), then the appeal is straightforward:

  • The ACA says lactation services are supposed to be covered as preventive services and reimbursed 100%.

  • Lactation-specific codes were used.

  • Therefore, this claims should be paid 100%.

Rinse and repeat.

Will this work? I mean, I wish I could say that the insurance companies were easy to understand and played fair and did what they are supposed to do. But at least this strategy gives us a chance.

Using multiple procedure codes

It is possible and ethical to combine preventive, class, evaluation & management, and other codes to try to squeeze more money out of the insurance companies—as long as your charting backs up the codes you’re using. Know what the codes mean before using them!

The idea here is that you’ll use as many codes as can ethically and appropriately apply to the visit. You will set high charge amounts on each code and then push the insurance companies to pay up to the full amount you’ve billed to them. You’ll need to be aggressive with the insurance companies and organized enough to stay on top of them, but it may be worth the risk.

This may be a much higher amount than your advertised rate, which would be your “prompt pay” discount, meaning the amount you will accept if the client pays you at the time of the visit. Be sure to make sure your prompt pay policies are not in violation of any applicable state laws.

One potential downside to this strategy is if the insurance company puts any portion towards the client’s deductible, in which case you’re required to bill them for it. Not billing them for the deductible is insurance fraud and therefore unethical and illegal.

Learning more

Portions of this post are excerpted from Crash Course in Billing and Reimbursement for IBCLCs by Donna Sinnott iBCLC and Annie Frisbie IBCLC. This bundle also includes tech training for creating superbills within many popular EHR platforms, templates you can use to create your superbills, and payment policies that have been reviewed by an attorney.

Additional information can be found here:


Annie Frisbie, MA, IBCLC is the creator of the  IBCLC Private Practice Essential Toolkit , a collection of books, resources, legal forms, training manuals, and workbooks aimed at helping private practice lactation consultants build a private practice that’s ethical, profitable, sustainable, and enjoyable.

ABOUT THE AUTHOR

Annie Frisbie, MA, IBCLC is the creator of the IBCLC Private Practice Essential Toolkit, a collection of books, resources, legal forms, training manuals, and workbooks designed to help private practice lactation consultants build a private practice that’s ethical, profitable, sustainable, and enjoyable.

In 2018 she was honored with the US Lactation Consultant Association's President's Award. Through her popular blog, online store, podcast, and one-on-one coaching, Annie has helped thousands of lactation consultants grow their businesses with simple systems that make their lives feel easier and more joyful!


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