(With permission, Pat Lindsey, 2003).
(Medicare, Medicaid) and managed care organizations (MCOs).
Medicare applies to individuals over age 65 and is not applicable for breastfeeding except that insurance companies usually follow Medicare rules for payment. Medicaid is a federal program administered by the states, and state regulations apply to mothers and children who qualify on the basis of poverty. The regulations in various states may differ in billing rules and regulations. About one third of US births are paid for under Medicaid. Medicaid reimbursement for health care is further complicated by the fact that some Medicaid recipients are also enrolled in managed care plans. The plans' policies on reimbursement differ from the state and federal rules governing reimbursement when the patient is not enrolled in managed care.
Insurance policies usually spell out by title who may be reimbursed with third-party payment. Physicians and "mid-level" providers such as nurse practitioners and certified nurse mid-wives are recognized by third-party payers as providers who can receive direct payment for their services.
To receive reimbursement from Medicaid, the lactation consultant must be accepted as a Medicaid provider by her state Medicaid agency in order to be admitted to the provider panel of an MCO. Generally, providers are accepted on the basis of having a medical or medically-related degree and national certification. Lactation consultants can receive direct reimbursement if they are a physician or an advanced registered nurse practitioner (NP) (including a certified nurse-midwife) who has graduated from an accredited educational program and is certified nationally in a specialty.
Physicians or nurse practitioners can apply for a provider number through the state Medicaid agency by filing a provider application. If accepted as a provider, they can bill the state Medicaid agency on a HFCA 1500 form using the patient's name and identifying information, the ICD-9 code, the Current Procedural Terminology (CPT) code, the charge, the provider's name, number, and location for services. Fees for CPT codes vary according to locations and providers. For example, in many states in order to receive third-party pay ment, LC services must be provided in collaboration with a physician.
As an example of a successful private medical practice, Pediatrician Tina Smillie set up her breastfeeding practice right after passing the IBLCE exam. She began by writing a series of two- or three-page letters to the HMOs in her area stating benefits of breastfeeding and emphasizing the benefits for the HMO. These letters got her into most of the HMOs as a provider and cover fees for about 95 percent of her patients. She recommends writing these letters as a first step for any physician (or nurse practitioner) going into practice (Smillie, 2000).
If the company rejects a bill, the HCFA 1500 is returned with a short explanation about why it is being rejected. Sometimes several letters back and forth are necessary before the bill will be paid. Persistence is the key, as many claims may not be paid on the first submission. Anyone in a medically-related practice quickly learns from trial and error how to best file third-party insurance claims in order to maximize the number of paid claims.
Payers may require documentation to validate that the care was given, the site of the care, and the medical necessity and appropriateness of services provided. Fees for care of breastfeeding women on Medicaid are based on number and type of services provided using the CPT, published in the ninth edition of International Classification of Diseases (ICD-9) (see Box 2-8) and Health Care Financing Administration's Common Procedure Coding System (HCPCS) codes (see Box 2-9).
Major barriers to third-party reimbursement for nonphysician health-care workers such as lactation consultants have been third-party payers who fear expansion of provider eligibility, state licensure laws, and opposition by the medical profession. The 1997 passage of a provision contained in the budget bill Public Law 105-33 to expand Medicare reimbursement for nurse practitioners allows for reimbursement of NP services including lactation services; however each state has the option of covering NP services. Even though the law has passed, these nonphysician providers have difficulties in getting third-party payment.
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