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The smart way to create a compassionate and professional lactation private practice, hosted by private practice IBCLCs Annie Frisbie and Leah Jolly.
Leah Jolly is a private practice IBCLC with Bay Area Breastfeeding in Houston, Texas.
Annie Frisbie is a private practice IBCLC serving Queens and Brooklyn in New York City and the creator of the Lactation Consultant Private Practice Toolkit.
Tune in each week to learn all the ins and outs of running a successful private practice lactation business!
Connect with Leah and Annie:
On Instagram: @lactationbusinesscoaching
On Facebook: https://www.facebook.com/lactationbusinesscoaching
On YouTube: https://youtube.com/playlist?list=PLv3-4pMgjlzbXD9KWFCIV3-1LipsTbgsj
Annie: Hey Leah.
Leah: Hey Annie. How are you doing?
Annie: I'm great. How are you doing?
Leah: Really well. Doing really well. Looking forward to Halloween coming up here and my kids are super excited.
Annie: Oh yeah, totally. Mine love it. It's a big, big deal here in our neighbourhood, and it's a lot more fun than our topic for today, which is making sense of insurance coverage for lactation services. And if you're like, Oh my gosh, I would much rather, so would we, to be honest. I'm telling you, when we picked this topic we're like, do we really? But you know what? The thing is that we do, because it's important and we feel like we're going to get through it and hopefully make it enjoyable for you and not really horrendous, and this is why. It's because lactation consultants are awesome and fun and the insurance companies are the problem. So if we keep our focus in the right place, we can have some fun talking about this topic.
Leah: Yes. 100%. So before we get started, Annie, tell us about our sponsor.
Annie: So this episode is sponsored by Acuity, where you can book it like a boss and work it like a champion and you can go to acuityscheduling.com/ref/lbc, which stands for lactation business coaching for a free 45-day trial. Having your online scheduling worked out is going to free up all this mental space for your fight against the insurance companies. So, do it for that reason.
Leah: Yes. 100%
Annie: Stick it to the man with the Acuity Scheduling.
Leah: Yeah, for sure. For sure. I love Acuity and it's definitely freed up a lot of time for my business as well. So before we get started, my marketing tip for today actually has to do with insurance. A lot of families are looking for people who take insurance or can help them get their out-of-network insurance claims filed, and so marketing to that point, sharing with people that, Oh, I'm in-network with these companies or I can assist you with getting your claim reimbursed or I have resources for that. You can market for that specifically, which can really help those people that are looking for that additional factor in your services.
Annie: I think that's great. And a lot of people are doing that actually putting on their website what the Affordable Care Act says, because contrary to what you might think, nobody's actually telling new parents that they have these benefits. Can you believe it? The insurance companies aren't being like, by the way, don't forget. We cover lactation. No, they're hiding it. They don't want their clients to find out that this, these services are covered. So we can advocate for our clients by explaining to them what the Affordable Care Act says. So which is what we're going to be talking about in this episode. Mainly we want to help you make sense of what lactation benefits are and give you some clear talking points that you can put on your website, or use in conversations with your clients to help them understand what their rights are under the Affordable Care Act. So if you're outside of the U S listening to this episode, thank you so much for your support. Go spend the next 30 minutes doing something really lovely for yourself and just enjoy the fact that you live in a country where you don't have to deal with this nightmare that is insurance. So thank you. Have fun. Okay, so I'm going to start by just putting out there with the Affordable Care Act says, which is pretty vague unfortunately. It says that lactation....
Leah: That's our problem.
Annie: That is our problem. It's our problem. It's also goes both ways. It says that lactation services are covered. It doesn't specify who should provide them and it doesn't stipulate limits on when they can get it, and the problem is that either that can be interpreted really broadly to say, yeah, well then go see a lactation coach, an IBCLC. Hire me or Leah. But then some insurance companies are interpreting it the other way and saying, well, don't you get that in the hospital?
Leah: Yes, you've already gotten that.
Annie: You get that from your pediatrician. Have you had clients deal with that?
Leah: Yes. They call their insurance company to see what benefits they have available and the insurance company will only pay for the lactation consultant in the hospital that you got in your global care with your delivery, so it's like considered, well you got that. That was in the global care with your delivery. You already received your lactation help. Done.
Annie: Right. Because everybody knows that you're all set by day three. You're fine. Nothing happens after day 3.
Leah: Yeah. These crazy people that think they need help after day three,
Annie: they're just doing it wrong. That's what your insurance company wants you to think. You're just doing it wrong. You're not doing it wrong. You're having those struggles that people for millennia around the world have had. Everybody needs help.
Leah: Absolutely. Yes. I've had a lot of that. I've had a lot of the insurance companies taking this to mean like, well we'll pay for it only if the, the lactation consultant is also an MD, a doctor, which is like, okay, well there's two in Houston. So, right. Those two people also don't do lactation consultations, so that's not going to work or they have to be some other profession as well
Annie: I've also had people who were told ... this came up when I was a La Leche League leader and doing phone support, people would call ... and this happened more than once where the insurance company said, Oh, you need a lactation consultant, and they gave my number as a leader.
Leah: Oh my gosh.
Annie: They just went on our La Leche League of Queens website and just said, oh yeah, you can go see these people.
Leah: Yeah, cause it's free, and they don't have to pay for it. Ah, that's so frustrating. Yeah. And it's not the level of care that some people need. Some people need more than what can be provided in a La Leche League setting.
Annie: And the La Leche League leaders, they're volunteers and it's unreasonable to expect that a volunteer is going to come to your home and do a two hour visit. If you're a volunteer, please don't do that unless it really brings you great joy and satisfaction on an immense level. That's not really what's required of you and it's not right. It's also not right for insurance companies to expect --
Leah: That that'd be their resource for care. If somebody is calling you for lactation consult in the nuts, the resource, you give them free resources
Annie: Because this has been a problem that has kind of taxed our profession since the beginning, which is that kind of mindset or attitude that we get is like, oh, but don't you just love to do this? Why are you charging for it? Just do it for free, and the insurance companies are kind of kind of banking on that.
Leah: I know. They are totally banking on that.
Annie: Literally.
Leah: Yeah, for sure.
Annie: So what happens is that clients will be told, okay, we have these services. The insurance companies are going to put up some roadblocks. The National Women's Law Center has a great toolkit that includes phone scripts for talking to your insurance company about what your services are. So this is a great free resource to provide to your clients. I send it to my clients as an attachment when they book. You can have it as a download on your web page to the actual PDF to just say, here's what you call and tell them to get covered. Because in most cases ... well, in every case it's either you're looking for in-network services or out-of-network services. So your insurance company is always going to want you to go in-network. That's how the whole network thing works and we've all dealt with that with other healthcare issues, and finding out after the fact that you saw somebody who was out-of-network and what a nightmare that is or your doctor referring you to somebody. This happened to me recently. I jammed my finger and I need to get occupational therapy and the orthopedist referred me to an OT and they're like, Oh yeah, they're just up the street. I walked up the street. I was like, I'm not even going to have to move my car. I walked up the street and they weren't in-network. And so then I spent my morning calling around the places that my insurance provided, but I don't know if they're any good, but they're in-network and I want to stay in-network because I don't want to spend a fortune on this. So that's the mindset that we're dealing with. People are already assuming that it's going to be a hassle and then their insurance companies are saying you have to see somebody in-network. If they have someone in-network that's great. They can there are insurance companies that have in-network people. And when that happens, that means, you know, I'm in-network and I send in the claims to the insurance company. The insurance company pays me. Sometimes I have to charge my clients for cost sharing because even when I'm in-network, the insurance companies do it wrong and but I'm handling that. The client is not really having to deal with that. When they're out-of-network, that means I don't have any relationship with the insurance companies. So I am not obligated to take what the insurance company says I should take for these services. So for in-network, being in-network with an insurance company, I'm in-network with Aetna. That means that I'm agreeing that what Aetna tells me is fair, a fair price for my services. I agree to accept that and I'm not allowed to say, Oh, well, you only paid me $50 for this consult, but I think it's worth $75. I can't then go to the client and say Aetna only paid me $50. Will you give me the extra $25? I'm not allowed to do that. What Aetna will sometimes do though is say, Oh well the patient hasn't met their deductible yet so we're going to cover it at $50, but you need to collect that from the client, which is totally wrong and totally against the Affordable Care Act and not supposed to happen, and this happens all the time, which is the main reason I hired a biller as we talked about in the last episode, because I got tired of just dealing with it. So there's a whole lot that goes along with that, and out-of-network you're just saying, my fee is my fee. Here is a super bill. So Leah, you're providing super bills to your clients to send in for the insurance company. So what kinds of things go on the super bill that your out-of-network clients are sending in to their insurance companies?
Leah: Yes. We make sure we have all their client information and the codes that we used and we have them pretty standard across the board for initial visit versus follow-up,that kind of thing, and then that they paid. We have that marked on there and then we sign the super bills and send them out and those go out right after just automatically we send them to everybody who's out-of-network. We get them out to them and we actually have the link for the National Women's Law Center, and I always make sure I talk to my patients or clients about that. Make sure you look at this link. It's going to give you lots of resources to know what to say and how to engage with the insurance company to get this more likely to get it covered.
Annie: And one common thing that we hear about super bills is that people aren't giving them to their clients because they're like, well, my clients aren't going to send them in. They're not going to get covered and my clients don't care, which is fine. Your clients are not obligated to try to pursue reimbursement from their insurance company. That's fine. They're not required to do that, but ethically speaking, I do think we are required to provide them with it. And if anything, just as an advocacy issue to say you do have these rights and I'm not going to gate keep information about your rights under the Affordable Care Act. What you choose to do with this super bill is totally up to you. I don't care. I don't care what you do with the super bill, but I feel it is my responsibility to make sure they have it because I'm not going to make assumptions about whether they are or aren't going to turn it in. But even if they tell me, Oh, I'm not going to bother, just say I'm just going to give it to you anyway.
Leah: Yeah, and it's so simple. If you're using an EHR, you can input one and they all auto fill and it's literally two clicks. It's one click to choose the code and one click to shoot it off to the person. I mean, it's just so simple, and if you have a templated email, that's what we do. Templated email with the resources to get it covered and then just shoots off. It's seconds of our time, but actually can really be beneficial. I talk about it always in my visits. I make sure that I talk about you were out-of-network, but I highly recommend you pursue, even if you get a portion of the visit reimbursed. It definitely tells the insurance company this is a service that's being used and needed, and it will more likely allow us to have the ability to be in-network with more companies if they know that this is a services being used and needed.
Annie: And that's really going to help with helping people who are on Medicaid and who don't have private insurance. If we're seeing that this is a service that's being used and the insurance companies, they are tracking health outcomes. They do have metrics that they're looking for and these are things that we want to show that if you pay up front for lactation services, you're not paying down the road for these other related health outcomes that could have been prevented if breastfeeding was successful or went longer than it did. So that gets into the public health realm and definitely there's crossover there between insurance and public health and trying to really focus on providing the super bill as almost a public health issue. I know there are people out there who are billing out-of-network insurance directly. So the way that Leah and I do it is our clients pay us up front. I know you do it the same way I do. I take cash up front, I take my payment at the time of the visit. They get the super bill and then it's up to them to deal with the insurance company about reimbursement. And sometimes what will happen, I don't know if you've ever gotten this call or a letter from one of the out-of-network insurance companies where they're like, yeah, we got the super bill or whatever, but you know, reasonable and customary, we think it's like $18 now.
Leah: Yes. I have gotten that EOB back. Yeah, for sure. We've definitely gotten quite a few calls as well.
Annie: Do you talk to them when they call?
Leah: Well, my admin...
Annie: Do you ever call them back?
Leah: Yeah, we do if it's something like, Oh they needed to, because a lot of times it's. Even though it's on our superbill, all the information they could ever possibly need is literally at the top of the superbill. You cannot miss it. It's in clear print. There's no way you could miss this, and they will call us and be like, we need your NPI. And I'm like, because you can't read? It's right there or we need your business address or whatever, which is all on the superbill. But that's the call we get most often. We don't get a lot of haggling type calls. But most of the time it's like there's some missing piece of information. They need clarification on it, and I just think it's a waste of everybody's time.
Annie: A total waste! I get those calls all the time too and I definitely cooperate. I want to help my clients, but then I tend to not ... I won't talk to them on the phone because they are going to try to haggle or they are going to try to ... I just don't want to talk to them ...
Leah: You don't want to get trapped in that.
Annie: So I'll listen to the voicemail and I'll hear what it says and then I'll send my client, I'm like, here's an updated superbill to send to your insurance. They left me a message, but I have gotten the calls where they're trying to get me to take less money or tell me what the contracted rate is and I just will not call you back. I'm just not going to call you back. Because I know some people are doing differently where they're not charging the ... well, some people are doing kind of an in-between, which is the clients are paying them up front and then they are submitting the super bill on their client's behalf and offering that as a service. You're going to pay extra for this service or their biller will do it or their billing companies that will handle out-of-network superbill submissions, and that seems like it could be a nice service to offer. I think it's something if you were going to try it out and see if it ends up being worth anybody's time.
Leah: Yeah, I'd be curious to see like does putting it in... because what's different about that is like a billing service or if you have access to one of the clearing houses, does putting it in through that method of filing give you a different result than submitting it like a client would, which might be through mail or faxing? It would be interesting to know how big of a difference that is. I don't know if anybody out there has tracked that, but I would definitely be interested to find out.
Annie: I would love to see that presentation at a conference.
Leah: I know. Please! That would be awesome.
Annie: I want to know because if it would make a difference, if I felt like I had tangible evidence that my clients will be more likely to get some money back if I submit the claim through a clearing house, I would totally do it. I really want that to happen for my clients, but I've just had enough kind of shady experiences where it makes me very hesitant that they're even going to make good. So I had I decided to see what would happen if I tried what some others are doing, which is they're not taking payment up front. They are billing out-of-network directly. So going to the insurance companies and saying, we saw your client, saw your member and for these services and here's our bill and they're using the same kinds of codes that we use like for in-network billing to see what they can get and see kind of where that can go. So I said, Oh, I'm going to try that. My friend had a baby and I was like, Oh, let me just see like I want, she's like, I'm willing to call.
Leah: She could be an experiment.
Annie: And so she called, she got pre-authorization for two visits from her insurance company, a preauthorization number, confirmation that they said we will fully cover two visits. So I did that visit in October of 2018. I have received, I don't even know how many different letters from them, back and forth. I have not gotten paid yet.
Leah: Oh my gosh.
Annie: My solicitor has called them. I have called them. She has called them. We've all called them - multiple times. They send a letter. The first letter was like, you didn't send it to the right department. So we sent it to the other address. We got a letter from that department saying, you didn't send this to the right department. We send it to the original department.
Leah: Oh my gosh, it's games. Oh, we don't need the games.
Annie: Well you don't have pre-authorization. Yes we do. It's right there on the claim form. So I don't know and this could be very geographic in nature.
Leah: Oh, I don't think it is. I'm certain it's not, I'm certain it's not. I think the business model is the problem. Their business model is the only way they're going to make money is to make sure they're not paying out too much. So their business model is to try to not have to pay out as much, and then our business model is to try to get them to pay out. So it's like this cat and mouse game is like they're going to run one way and we're going to chase them and then they run the other way.
Annie: The place where I could see something like that working would be if you have a large practice with a lot of providers and there's a term called the Revenue Cycle Management, and when you're dealing with insurance, that means I submit a claim on this date, but I'm not going to get paid for another two weeks or month. So the revenue cycle is the time between when I actually performed the consult and when I got paid. And so if you have a large practice, you're seeing a lot of people, your revenue cycle management can handle not getting paid for a longer period of time. Whereas like for me -- well I now have somebody else doing consults, but I can only do so many consults a week and I kind of need to get paid for them.
Leah: Right? Like right away. Right. So it does make it really challenging. And I think the other thing when you're working with insurance companies that you want to remember is looking at your average pay-outs versus your per-consult pay-outs because sometimes it can get really overwhelming. If you look at this consult, I made this much, this console that me like piecing it out one by one, but if you like total them all up because you're going to get some - and this is just the mind blowing thing about being in-network - some that they pay all the codes and it's like you get this huge - not huge ever huge - but you have this better pay-out and then another one you get this lower pay-out, and it's like finding what your average is. Of course we'd all expect to get paid the same on all of them because that would be what would make sense, but insurance doesn't make sense. And so to really assess kind of how this is working for you and where you're at, I think also looking at the averages as well is helpful. It's just helpful. I mean, I don't know if you do much with it other than like deciding like this average doesn't work for my life and maybe I don't want to be a network anymore.
Annie: Yeah. Which is definitely a legit place to get to. And I think you're totally right with that because, the big difference big when you go in-network and accepting that contractual obligation is that you're then using the codes that apply to what happened during the consult versus saying, this is my fee for the consult. And here's like the most conservative way to code a super bill is to put diagnosis code Z39.1, which is encounter for 'care and exam of a lactating mother' because they're not gender inclusive, the people that write the codes, but that's what that code means. That's the diagnosis, and then the procedure code - what happened during the visit - the most conservative code to use is S-9443 and that is a lactation class (one unit) and that is all that it means. It is vague. It has no time allotted to it. It has no descriptors of what needs to happen during that class. So basically what I'm saying is I came to your house for a two-hour lactation class and this is what it costs and you send that to the client, I mean to the insurance companies. Some of the insurance companies will come back and say we don't cover classes. And then you can say, all right, then it was a one-hour preventative counselling, but I actually stayed for two hours. They don't care if you stay longer. They only care if you try to charge for more than what you did and you put it on 99404. So these are very conservative coding for out-of-network superbills that really it's really hard to argue with that. When you're in-network now you're saying, okay, I was there for two hours and here's S-9443, I'm going to get $60.77. So I'm not going to anybody's house for two hours for $60.77 when my babysitter is $20 an hour, kind of a standard of the cost of living. So I now need to start looking at other codes and say, okay, what other codes apply and how can I combine them ethically so I'm never over coding? I'm never coding for something I didn't do. So that is what Leah was saying about, sometimes I'll go for a visit and it's super complex and I'm there for a really long time and wow, wonder of wonders, AETNA actually pays for everything I did instead of saying, yeah, we think you stayed too long. We're not going to pay for that one code. We don't actually think you should have done that, which is a tale for another day. But then if I go to somebody's house where I ended up going like a fourth visit and I'm there for 45 minutes and we just sit and talk about her going to work, I really can't ethically code for a very complex visit that ends up being a pretty not complex visit and I'm not going to get paid very much money for that visit. So I ended up doing those visits kind of for love, not money. And sometimes I'll say I can't accommodate your request to come back and see you with your baby at eight months or we're going to sit on your floor and play with your baby for 45 minutes. That sounds amazing and the most fun ever, but if...
Leah: I'm not going to get paid for that.
Annie: I'm not going to get paid enough, and if I've got a client with a more urgent request and more complicated situation, you do find yourself starting to make some of those decisions and saying, I don't know that I can actually afford to do those fun visits. Whereas with self-pay, I'm like, yeah, if you want to pay my self-pay rate for me to come to your house for 45 minutes and show you how to do tummy time, I'm so there. I don't know, I might not charge them the whole fee for that either.
Leah: But yeah, I definitely think it's important to talk to the fact that we have to be really smart in how we code because one, we don't want them to over code and that could be getting into the place of being fraudulent is to over code and kind of overbill, so that you can make some extra money. But we also don't want to set this precedent that could flag all lactation services. If we start just billing these super high amounts, then we're going to get flagged as a place that money is draining out of the insurance companies, and then that can make it hard for all of us lactation consultants to get our coverage, to be in-network and to get coverage. so I think it's really smart and I know there's been so many discussions on a lot of the Facebook groups about coding and just like how to code ethically and appropriately, and I think there's some great resources out there like the wonderful book that you put out there that really help us understand coding, because that's not anything you're ever going to learn in your training at IBCLC unless you go out and find it, because it's not going to be in that lactation management class is not also coding. But in every other healthcare profession, there is at least one class on billing and coding. Everything else, so we really have to seek out that information just so you have a general understanding of how it all works because that's something I didn't have. I really had to go seek out that information when we decided to go and network. I really had no idea, just the nuances of it all. You really have to be looking at so many factors when you choose your coding and that kind of thing. So I just wanted to speak to that, really educating yourself so that you feel confident that you're using the appropriate codes and that way, you know, for sure you're ethically coding and certainly not doing anything fraudulent.
Annie: And I think it's good to seek information from a variety of sources. So I wrote a book but I didn't write the book and the way I explain might not totally go. You might have trouble understanding the way I'm explaining it, but you might resonate with how somebody else explains that. I really like Rebecca Costello has an online course on billing that I highly recommend. I think this is an area where you really don't want to look to just one person to tell you what to do. And people ask me what codes do I use? And I say, I can't tell you that. I just cannot tell you what codes. You have to understand why you're coding. You have to understand how to document what you're coding, all of this. There's so much that goes into it and it's an area where the more you know, the better off you're going to be. And when you have questions, specific questions, you're going to want to go to your own legal counsel or hire a professional biller because these are going to be things that are going to come back to you directly and so ultimately you are responsible for the codes that you choose and that you provide to your clients and the way that you bill, and if something goes wrong, you are going to be responsible. And so you really need to know what you're doing. And if you're feeling confused, it's not really a place to crowd source. You may really want to seek targeted, specific individual information from somebody who has your best interests in mind.
Leah: Yeah, I think that's such a good reminder because there's so much out there. Oh my gosh. If you start getting online and reading stuff, there's a lot of information out there and a lot of different perspectives on coding and billing, and so you really want to go to the authorities, the people that are trained in this area to make sure that everything you're doing is ethical and sound and is going to best promote our profession in general. We don't want to be known as the money hungry people out there that are like, oh, but if I added 20 more codes, I could... we don't want to be known as that. We want to be known that we're ethically billing and we're getting a fair fee for the work that we're doing, and I think that will promote our profession as a whole.
Annie: Definitely because we also don't want to be known as the people who don't care what we get paid. We're just happy to be doing this work. Of course we're happy to be doing this work and there is no conflict between getting paid for work that you love. It's just not a thing. Make your money. Be proud about it and don't be afraid to be assertive and say, as long as you feel confident that you are coding ethically and you're billing ethically and your payment policies are ethical, there is nothing wrong with you saying, I'm going to go for the most that is ethical. Go for it, whatever that is, and that's a line that you are going to have to draw for yourself. Nobody can tell you where that line is, but the more you know, the better equipped you're going to be able to make those ethical decisions that are in the best interest of your business and your clients.
Leah: Yeah, definitely. Definitely. This has been a tough talk, but a great one because I think it's a hard thing to talk about because there is like so little information about lactation specific billing, but I think if we keep this conversation open and we keep talking about it and we keep trying to bring in more resources for our clients and for ourselves, I think we're going to continue to have success with getting more insurance companies to view us as healthcare providers that they should be covering.
Annie: Absolutely.
Leah: Yeah. So do you have a tech tip for us today, Annie?
Annie: I do. So I recommend if you're using, this is going to be for those of you who are using electronic charting platforms, use the superbill capability in your platform and collect the client's insurance information up front. Have them actually type it all in, even if they're out-of-network because then your EHR platform is then going to generate a typed super bill. So you're not handing them saying they're going to hand write in their name and their address and their plan number and their group number. Have that printed for them. It's going to take them a little extra time upfront, but it'll be worth it. And if you're not using an electronic platform, but you are using Acuity for scheduling and say you're charting on paper, but doing online scheduling, have Acuity collect that information for you up front and just offer that as a service that the superbill is typed but include that. Don't say and for $5 more, I will type your super bill, but just bundle that into the fee for the service and provide it as a courtesy, because I do believe that ... and again, I would love to see the data on this. One of your research heads can go there and get this done. But I do think that they are going to have fewer obstacles to reimbursement the more things are typed on that superbill, versus things that are filled in by hand.
Leah: Yeah.
Annie: So it's just a nice thing you can do for your clients and you can have custom intake fields and Acuity that will collect that information for you up front.
Leah: That's awesome. Yeah, I forget about that they have all those customizations are so awesome. So awesome. Well, it's been great talking to you today and kind of hacking through this maybe not so fun topic, but we always seem to have great conversation and I love it. I love to keep this conversation going. So if you have comments or perspectives that you'd like to share, we'd love to hear that as well. So definitely share that with us and we'll look forward to getting back with you guys the next time. It was good talking to you, Annie.
Annie: You too, Leah.