IBCLC visit

How to get reimbursed for a IBCLC home visit

Posted on Posted in IBCLC, Insurance, Licensure, Massachusetts

As I’ve mentioned in the past, the Affordable Care Act of 2012 requires most health insurance companies to cover “breastfeeding support, supplies and counseling” in conjunction with each birth.  This means that most insurance companies should cover a home visit from an IBCLC- though due to a gnarly licensing loophole, most private practice IBCLCs are out-of-network providers

IBCLC home visit

Oh Kermie… it actually IS my business.

Unfortunately, this means that I can’t just take your insurance card when I arrive at your house and then bill your insurance carrier for my services.  I’m working to become an in-network provider for any insurance company who will have me, and I’m also working to gain licensure for IBCLCs in Massachusetts.  For now, though, all my clients have to pay me directly and then submit my receipt/superbill for reimbursement from their insurance company.

Trust me- I know that this is a giant pain in the butt, particularly considering you probably have a baby at home and have a million other things to spend your time on. I give every client a superbill, but I often hear that families never even bother to submit it for reimbursement because their insurance company makes the process too complicated.

But you really, really SHOULD submit for reimbursement for my services.  Why?  Because you’re paying for it and you have the right to get that money back.  In a very broad sense, you’re paying your insurance company to cover my services.  If your insurance plan claims to cover breastfeeding support and counseling, then they should reimburse you for my services. 

In the U.S. we tend to think of health insurance as something that we’re required to pay into- like taxes.  We don’t really think about how much money we pay for insurance and then how much money we “get” from the company- how much money the company actually pays out for our care each year.  Insurance doesn’t cover anything for free- you’re paying for it!  You should get your money’s worth and take advantage of anything that your insurance will cover, even if it means jumping through hoops.

The other reason I encourage you to submit for reimbursement isn’t fact-based… it’s related to my own cynicism about how the health insurance industry operates in this country.  I can’t help but believe that insurance companies are banking on the fact that many families won’t actually go through with submitting for reimbursement for out-of-network providers.

Any time a health insurance company makes you jump through a hoop to get coverage, they know it’s likely you just won’t bother.  And if nobody submits for reimbursement for private practice IBCLCs, the insurance company doesn’t need to pay attention to how many of their clients are getting breastfeeding support.  They can get away with saying they cover breastfeeding support, but not actually ever paying for it.  They can pretend that families don’t need this kind of help, and that it’s not something their policies should cover- in the end, that hurts every nursing family and every nursing baby.

Let’s talk about exactly how to submit for reimbursement.  Every health insurance company is different so you should ALWAYS to call the member services phone number on the back of your insurance card.  When you get a human on the phone, ask them what your policy covers for breastfeeding support and counseling.  Find out if they require you to see someone in-network, and if so, ask them to tell you exactly who your in-network options are.

If you have no in-network options, or they can’t give you a list of providers, ask them how much money they will reimburse you for obtaining breastfeeding support and counseling from an out-of-network provider.  They may ask you for a procedure code- if so, I generally bill using 99404-33 (Breastfeeding Counseling) and 99203-25 (Lactation Consultation, Initial Visit).  For diagnosis code I use Z39.1, Maternal lactation care.

While you are on the phone with member services, ask them exactly how to submit for out-of-network service reimbursement.  Do you mail the superbill, fax it, or scan and upload it through a web portal?  Don’t be concerned if you don’t own a fax machine or scanner- you can use an app like Cam Scanner (referral link) on your phone to scan the superbill and then send a fax for free online using a service like sRfax or HelloFax.

I’ve heard through the IBCLC grapevine that some health insurance companies (like Harvard Pilgrim and Neighborhood Health Plan in Massachusetts) are great about reimbursing for IBCLC home visits, while other companies (*cough* Blue Cross Blue Shield *cough*) seem to automatically deny the first claim.  I’ve even heard that certain companies make patients resubmit the claim 4 times before they’ll reimburse for the services.

Please, don’t give up!  If your insurance company told you they will cover breastfeeding support and counseling, they need to do so.   

If they deny your initial claim for reimbursement, call Member Services again and ask them where to send an appeal.  Ask them if you need an appeal form that they provide you.  The National Women’s Law Center has a Breastfeeding Toolkit you can download that includes a step-by-step guide for drafting an appeal letter to send to your insurance company with your superbill/receipt.  If you have any problems or questions during this process, you can call the National Women’s Law Service directly at 1-866-PILL4US or email them at pill4us@nwlc.org.

ibclc home visit superbill

Don’t worry, this paperwork doesn’t belong to a real person. She’s a drag queen. Turns out Katya is having nursing problems because her breasts are actually a latex chestpiece from boobsforqueens.com. That’s boobsforqueens.com.

If your health insurance plan is one of the few that isn’t required to cover breastfeeding support and counseling, or you’re not interested in submitting for reimbursement, you should be aware that home visits from an IBCLC are eligible Health Savings Account (HSA) expenses.  If you have a HSA through your work or your insurance company, you can use your superbill to submit for reimbursement from your HSA funds- you may even be able to use your HSA debit card to pay for the visit.

If none of these options work for you, then there should be free breastfeeding support groups in your area like La Leche League, Boston Nursing Mothers’ Council and Baby Cafes.  All of these are staffed by educated breastfeeding helpers and can provide support to nursing families, although they’re not equipped to handle more complicated situations.

Remember, you’re paying for your health insurance coverage and most insurance companies are required to cover breastfeeding support, supplies and counseling.  You have a right to be reimbursed for these services if your insurance company covers them.  Do not let all the rigamarole and tomfoolery keep you from getting your money back– there’s no need for you to pay for my services twice.

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17 thoughts on “How to get reimbursed for a IBCLC home visit

  1. Hello Rachel! I am an IBCLC just starting up my private business. Can I ask where you got your superbill? I am looking to get one for my consults and am in need of some direction. Thank you in advance!

    1. Hi Gale! I’m flattered! Please feel free to share any of my posts as long as they are attributed to me and linked back to the original page 🙂

  2. This is such a hot topic right now. I hope through the push for licensure for IBCLCs that insurance companies start covering home visit IBCLCs. It’s so important that mothers be able to have access to the care they need-especially in their own home where they’re comfortable.

  3. Has anyone heard of Cigna reimbursing for claims? I just called and it seems that across the board, unless the lactation support happens at the hospital or a postpartum visit, they won’t cover it. So i’m not sure whether it’s worth submitting the claims or not?…

  4. Tricare is covering lactation (up to 6 hours per baby). The process is straightforward – all electronic, straight into your business account. And they have just extended maternity leave to 12 weeks! Yeah to benefits for our military families!

  5. The client may be able to get in-network reimbursement even if the IBCLC is out-of-network. My policy includes this verbiage “Any reduction in benefits or additional per hospital admission Deductible applied to charges of a Non-PPO Provider
    will be waived if it can be shown that non-Preferred Provider care was needed either for practical or for medically
    necessary reasons, as determined by the Plan Supervisor. Some, but not all, of such reasons are: • No Preferred Provider was within fifty (50) miles of the residence of the Covered Person;
    • Medically necessary care is not available from a Preferred Provider;

    1. I’m not sure if there was more to this comment that didn’t come through, but it’d be great if an insurer did this.

      1. Not really. The other conditions aren’t applicable such as an emergency while away from home. It’s something you can let your clients know to ask about.

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