Re:Billing pp

[Guest guest]

Dear , and others,

I have worked in a physician practice, The Breastfeeding

Center of Pittsburgh, which bills for my services for two years. We have

presented this model of care at ILCA, ABM and AAP Conferences. It is a

successful, financial viable, way to provide lactation sercices. This is my

understanding of the process. I hope it is helpful to you.

Billing for lactation visits can be done in two ways.

As a private practice LC.

As a “physician extender”

under the physician’s name and credential

In either case you are submitting the bill to the insurance

company so it requires a “superbill” format.

The superbill has 2 sets of codes. I have attached an old

one from Medela, there may be some new code changes, I haven’t looked it

over thoroughly for a while, but it gives you the idea.

The HCP Codes which tell the

insurer basically how much you want paid. This code is based on the time

you spend and the complexity of the visit.

The insurance company

determines whether they will reimburse any particular HCP code depending

on your credential and maybe whether they have negotiated a contract with

you. So, if I am insured by Aetna and I

see my PCP who is “in-network” they will pay him at a pre-set

rate from their contract. For the Aetna plan I have if my PCP is not in

their network, they pay that PCP at a different rate, probably a

higher rate, and I have a bigger copay to make up for it. Some Aetna plans that are HMO’s would not pay at

all for a PCP who they didn’t have a contract with and I would have

to pay for the entire visit myself. This works the same way for LC’s.

If you negotiate a contract with an insurance company they may reimburse

you. However, since IBCLC’s are not licensed professionals, this

rarely occurs. It takes a lot of work on your part to become a named “lactation

provider”. Having an NPI may be very helpful in securing

reimbursement because some won’t pay unless you have one.

For example if they already

deemed you were a payable provider and you billed a 99214 code. This

would be a brief, simple visit for an established patient such as a

follow up after you had seen the mom twice already and basically checked

the baby’s weight and reviewed the final feeding strategy

(hopefully this is feed on demand at breast) and they leave. This code

would bill for about $140, but reimburse somewhere around $40 to 70.

Another example, 99244 would

be a long visit, over an hour, involving a detailed history and many

breastfeeding difficulties i.e. (low milk supply secondary to maternal

PCOS and feeding difficulty secondary to tongue tie ) The patient

was referred to you by another provider, it is the first time you have

seen them, so it is also a consultation also. This code would bill in the

$300 range and probably would pay out around $270.

There are also codes for

breastfeeding supplies on the superbill. I don’t know what these are

called. You can bill for equipment and supplies, but each individual

insurance plan has pre-determined which of those codes it might pay for

and how. For example, in PA the Medicaid insurers are required to provide

breastpumps. One of them requires only a phone call from the doc and the

pump is shipped from their DME company. Another requires a completed form,

prescription, call it in one place, fax it in another place and they

deliver. Another yet just has me make a call to one of several DME

companies and order the pump. Some private insurance pay nothing for

pumps. One big Western PA insurer

provides a personal use pump for any mother with a sufficient diagnosis

code, however they will never reimburse for a rental. It is all decided

ahead of time and it can vary within the same insurance company depending

on which plan the patient has. It is very complicated. So you can always

submit the bill, but reimbursement will vary.

The third set of codes is the

ICD-9 or Diagnoses Codes. This tells the insurance company what the

problem was. They have also pre-determined what it should cost to provide

services for say an ear ache. A typical straightforward visit, look in the

ears, prescribe an antibiotic if it is infected and out of the office in

20 minutes. So even if a doc spent an hour listening to mother cry about

her husband who lost his job that day. The code says this took 20 min and

the reimbursement is for 20 min of docs time. They won’t pay him to

comfort the mother. So in their decision to reimburse they look at the

problem and what you have asked to be paid and they give you what they

want to pay. (That is a problem in itself, but not the subject of this

email).

In any case, you can bill who ever you want and see what

happens. However, you have to bill all patients uniformly. You can’t just

tell patient A you will take $50 for their visit and then bill the insurance $300

for the same kind of visit for a patient who does get reimbursed. You can have

a sliding fee scale that is uniformly applied if you want to charge less for

low income but everyone has to be billed the same. I think you have to charge

the self pay clients the same as you charge insurance, but I would have to

double check that.

The AAP document gives instructions for how MD’s in

private practice can bill for providing lactation services. We can code the

same way, but we are not MD’s so the insurance company may decide they

don’t pay someone who is not an MD or they may decide that you are X type

of provider and pay you at the X provider rate or not at all.

As far a physician’s losing money employing an LC that

is really not likely unless they were paying you tons of money. Where I work

the reimbursement ranges from $70 to $270 per office visit. The physician has

office staff in place to do scheduling, billing, he is already paying for his

facilities, utilities, etc so though that costs something it is a little

compared to the rest of his practice. So if he pays me$20 / hr and I see the

patient for 2 hrs including the documentation and writing a consult letter and

a couple of follow up phone calls that costs him $40. He spends 15 minutes at

that visit examining mom and baby and reviewing my documentation, writes a prescription.

His time is worth $75/hr so that cost him < $20. He has spent $60 on the

visit time, plus $10 on owning and running his office for that patient. If his

reimbursement will be a minimum of $70, but could be $270 plus the copay. Usually

the parent paid a co pay in addition to the reimbursement so that $5 to $25 is

also income. He has at least broken even. And he has adequately provided

for breastfeeding support which the AAP Policy Statement on Breastfeeding and

the Use of Human Milk recommends.

These are the basics. I had a booklet that I bought from

ILCA, written by Marsha about reimbursement. I can’t find it now.

That would be helpful to you all as well if you can get it.

Good Luck,

Judy Gutowski, BA, IBCLC

[Guest guest]

Hello All,

I have uploaded the Medela superbill to the files. I couldn’t

find it on their new website.

Judy