Securing Insurance coverage for lactation Care
TIPS FOR GETTING REIMBURSED BY ANTHEM FOR LACTATION CARE
From Serena Meyer of Bay Area Breastfeeding Support
If you are having problems breastfeeding did you know that your insurance HAS to pay for lactation care? Its mandated coverage as preventive health care and you are entitled to it.
Certain insurance covers certain codes but they all have to cover part of it.
1.) Call Anthem’s member phone number and ask for a list of in-network lactation consultants in your area. They may give you the run-around or turn it around on you and ask YOU to provide THEM the names of the consultants you want to see -- only to tell you that those consultants are not in-network. If they do this, insist again that they provide a list of in-network lactation consultants. If they try to give you the run-around again, insist yet again that they provide a list of in-network lactation consultants and, if they can't, make sure they clearly tell you that they can't.
2.) If they can't provide you a list of in-network lactation consultants within a 75-mile radius of where you live, you are entitled to open an in-for-out case. This allows you to get your out-of-network claims processed at the in-network level, so you would only be responsible for the total beyond the in-network total allowed. These cases are handled by a nurse case manager on your insurance company's medical management team. You call the same member phone number but you choose the option for pre-approval or pre-certification and ask to make an in-for-out request.
3.) WARNING: The wait for this particular team is LONG. It can be over an hour before someone picks up. So when you call, be ready with all of the information you need because you don't want to waste your time. You'll need: the CPT/procedure and diagnosis codes that would be used during your visits; your phone number; your full name and date of birth; your baby's name and date of birth; your home address; how many visits you are seeking and which codes your consultant will use for each visit; your consultant's name; your consultant's business's name; your consultant's NPI number; and your consultant's EIN number. You may also need to tell them whether the visits will be at your home or at your consultant's office. IMPORTANT: Make sure the person opens your case in YOUR name and not your baby's. Also make sure the case includes a date range that will cover ALL of your visits. The representative will give you a reference case number and a fax number that your consultant will use to send what they call a clinical.
Here is the info they will ask you for: CPT codes:
99204 for an initial consult and 99404 for preventive health teaching at the same time 99214 for a follow up and 99404 for preventive health teaching at the same time
ICD10 code: Z39.1, care of the lactating mother Modifier codes: 33 and 25
Serena Meyer RN IBCLC
Business Name Bay Area Breastfeeding Support
CA RN license 95048954
IBCLC number 1113721
Phone number 925-257-4023
Fax number 510- 275-0331
4.) As soon as you have the reference case number, ask your consultant to send a “clinical” to your insurance company with your reference case number on the cover letter. Nothing else should be on the cover letter, especially no personal health information. The clinical should outline what your plan for treatment is. The nurse reviewing your case will use the clinical to make a determination.
5.) The nurse has 15 calendar days from the time a clinical is received to respond to you. They'll likely call with a determination, but they'll follow up with a letter. In my experience, calling every day to check in on the case doesn't help or speed up the time of a response.
6.) Once you've been approved, schedule your visits. You'll need to pay for the visits up front. Before your visits, ask your insurance company which claim form you must submit for reimbursement. Print out the claim form and bring it to your visit so you and your consultant can fill it out together. Submit your claim form to request reimbursement as soon as your visit is over. Your insurance company may allow you to submit it electronically via a member portal. That will save you the time of sending it via snail mail.
Other tips: Write down the name of EVERY person you speak to about your case. That way, there is always a trail and someone held accountable. This will come in handy countless times, I PROMISE. Keep track of every conversation you have related to your case and document exactly what was said and what information you provided during each one. Lastly, be aggressive and don't give up -- because that's what they're hoping you'll do. It's not nearly as difficult as it sounds to track down all the information you need. It just sounds difficult because of the alphabet soup they drown you in. Keep your head up and persevere!!
California Network Adequacy standards:
Anthem CA Member Claim Form: https://www.anthem.com/docs/24066CAMENABC.pdf
National Women’s Law Center Toolkit New Benefits for Breastfeeding Moms: Facts and Tools to
Understand Your Coverage under the Health Care LawF
Sample appeal letter for lactation coverage on page 11.
A Short Introduction on Infant Growth
Many families are worried about breastfeeding successfully and having a baby that flourishes and grows well. It can feel very overwhelming to have a small person so completely dependant on your care ( and breast), and it's common for parents to be concerned about weight gain as a sign of health. New parents often confuse frequent feeding as a sign that the baby is not being fed enough or well. In some instances the baby is simply having a growth spurt, in other situations the baby is truly not getting enough to eat, and the baby needs to be supplemented while breastmilk production is pulled upwards. In this post I’ll be talking about why it is important to be able to tell the difference between a healthy baby and a baby not getting enough milk. I will also provide 8 suggestions to correct the problem if your milk production is low.
What is normal weight gain for breastfeeding infants in the first place?
The average term infant will take about 10-14 days to get back to birth weight. This can be complicated by excessive weight loss in the first 3 days of life, jaundice ( sleepy nursing) and preterm infant feeding ( more sleepiness). If the baby has lost 10% or more from original birth weight, then it is reasonable that it might take the full 14 days or a few days longer to regain the weight.
After 2 weeks of life my expectation is that the baby should be able to gain 6-7oz (180-210 grams) per week if they have access to a full supply of breastmilk. If your baby is not gaining weight regularly, losing weight in a prolonged fashion ( still losing on day 5, or still under birth weight at 17 days of life) it’s important to figure out why, and correct the issue. Older babies may gain weight a little slower than infants in their first 8 weeks, but they should still be able to stay on their growth curve without falling off of it.
How to Tell if Your Baby is Gaining Enough Weight
A baby that is gaining weight normally, will stay on their growth curve and grow accordingly. It is also important to watch head circumference as an indication that the baby is healthy and getting enough to eat. Their are percentile for head circumference growth, as well as a separate chart weight. If your baby is gradually dropping weight percentiles and has dropped two weight chart growth curves downwards; it’s time for corrective action. Important to early weight gain tracking is that infants in their first 5-8 weeks should be stooling at least twice a day to indicate that they are eating enough volume of breastmilk. You can’t count weight gain if the baby isn’t stooling appropriately, it might just be a backup of waste material vs real weight changes. A well hydrated infant will have 5-6 wets and 2-3 poops in a 24 hour period, after the age of 5 days old.
How Milk Production Works
Milk production is dependant on the signal to make more, which is effective removal from the breast. Breast emptiness triggers a faster speed of milk production, while staying full over a long period of time slows milk production through the mechanism of the “Off Switch”. The off switch in milk production is called the Feedback Inhibitor of lactation, a small protein that we call FIL for short. Its build up signals a slow down in milk production. This is why pumping after breastfeeding to get very empty helps drive up supply. An emptier breast makes milk faster! The first 5 weeks or so of breastfeeding, the milk is produced in a way that is offset by hormones. Between weeks 5-8 or so, the production of milk is slowly changed over to mechanical milk removal. This means that the baby has to be able to do the work if supply is going to stay up. For women that have oversupply it might be closer to around week 8-12 before they notice a drop in infant weight gain due to tongue tie.
Why Isn’t the Baby Gaining Weight?
Babies that are failing to gain correctly will often have a structural reason for the issue; meaning possible tongue tie or lip tie. Sometimes tongue tie is assessed for by unknowledgeable healthcare providers and it is missed or dismissed, or a parent is told that the tongue tie is “little” or “unlikely to cause any problems”, and then the baby simply can’t get the milk out and no one can figure out why. Once this occurs, the mother’s body responds to the decreased mechanical milk removal, by making less milk. Milk production is dependant on milk removal. Supply follows the demand at the breast, so if the demand is not effective, supply goes down.
In general, a baby is not gaining weight well if the baby isn’t getting enough calories. Instead of focusing on the real reason some HCP will tell women that their milk is watery, low calorie or some other nonsense. When reviewed, there is little evidence to support such claims, and what can be seen is that a mother’s milk is perfectly made for her baby each time. The quantity that the baby is receiving is the usual issue.
Slow Weight Gain Without Infant Tongue Tie
If the baby has been assessed by an International Board Certified Lactation Consult already and it has been determined that the baby has normal tongue and lip function, this section is for you. There is evidence that other health conditions in the mother may influence milk production, such as PCOS, breast hypoplasia, breast augmentation, breast surgery, hypothyroid, anemia, low prolactin levels, postpartum hemorrhage, and diabetes. For those with a low supply that refuses to increase despite these tips, please look into visiting a lactation consultant to make a custom plan of action to pull up milk production. You may also need specific lab work to rule out health problems; your LC can help you figure out what is the best choice for you.
What You can Do to Correct Weight Gain
Reaching out for Help When Your Baby Isn’t Gaining Weight Right
It’s really hard to have your feelings that something isn’t quite right listened to or validated. Well meaning family may dismiss your worry about your baby as first time mother’s nerves. If you know something isn’t right or you think your healthcare team should be paying more attention, you are probably right. In the field of medicine we are quick to dismiss what we don’t totally understand or agree with. If your baby has not been gaining any weight, or is losing weight its time to start looking for a Lactation Consultant. Before you add in a supplement, please take a moment to really make sure one is needed. Please talk your options over with your Lactation Consultant! If you are not sure how to find one, I wrote another blog post on finding a Lactation Consultant near you that might help you find one!
Meeting Serena Meyer RN IBCLC for an Appointment
If you have given some thought about your situation and you live in the San Francisco Bay Area you can reach out to me through my webpage to book an appt: https://www.bayareabreastfeedingsupport.com/contact-me.html
Finding a Lactation Consultant Near ME
The San Francisco Bay Area is teeming with new life and vivre! It is no big surprise that we have a very high birth rate, given our population of childbearing workers and a bustling tech industry! We are a hub to Google, Facebook, Uber, LinkedIn, Apple, GAP and many other successful organizations!
Silicon Valley, SF and the East Bay all have their own care providers that specialize in the field of pregnancy, birth and postpartum. They work together collaboratively and individually to meet your needs. Having a baby for many people is a once in a lifetime event, and you deserve to have the best help that you can find!
Here is a little summary of the issue that I wrote up for you, as you think about hiring a Midwife, Doula, or Lactation Consultant in the near future.
1.) You are pregnant or plan to be soon! Congratulations, you now have need of the services of someone experienced in childbirth and breastfeeding, non-pharmacological pain management during labor, childbirth classes, and breastfeeding classes, and lactation consults.
2.) Probably you are looking through lots of YELP profile pictures trying to pick a photo that resonates with your soul. A certain hairstyle, age or look is unlikely to be a useful focal point here. You most likely have used the Find a Lactation Consultant Near Me feature for google maps trying to see if that helps. Ultimately what assists many families is a proper information gathering search on a webpage versus using powers of divination!
Some questions to ask yourself might be:
What things are important to you? What is their vaccination status? A person’s background education in lactation or birth? What certifying body they trained with? How many years were they in practice for? What other families think of them? Whether they take a hands off approach? Trauma informed care? You have to think about what type of person you would like in your personal space and whether they will attend to your needs.
3.) Evaluate all of your alternatives for providers. Make a short list of what is very important, and just a little important to you. Think about what type of insurance coverage you have, and whether they have Lactation Consultants that are in-network. In the California Bay Area, some of the big players in the insurance world are United, Cigna, Hill Physicians, Aetna, Anthem, and Blue Shield of California.
United and Cigna for the most part do not reimburse anything no matter what they tell you. You will have to use PAMF for Cigna and United or be willing to pay out of pocket.
For Anthem, you can get a GAP extension for out of network coverage. For Aetna, Hill Physicians, Blue Shield of California, and Anthem (google) I am in-network, but you will need to check with other providers individually. My suggestion is that you load up your FSA card so that you can hire an out of network LC if you have Kaiser.
3.) Make a short list of nearby Lactation Consultants. Now that you have made a list of possible candidates, think about the next step!
How does a regular person evaluate a specialist for competency? I would suggest that they search for detailed reviews on YELP. Are they active locally near you? Has anyone wrote a good or bad review about them? Did they answer your email promptly? Did your Doctor know who they were? What have your friends that were successful said about having a lactation specialist, and what were their names?
4.) Search for a Connection. Did you read warmth from their voice or email interaction? What stands out to you on an emotional level or spiritual level? What is it that this person can offer you in particular outside of their clinical knowledge? Do you feel safer with this person in your corner?
Now that you have thought about all of these things as part of your quest to have the best experience possible, let me remind you that your gut instinct is probably right. No matter how good someone seems on paper, they need to give you the right feeling. If they seem warm and you can imagine hanging out with them (and being comfortable), that is a good indicator that you might have the right fit.
If you are interested in working with me you can find me at Bay Area Breastfeeding Support, I look forward to hearing from you!
Serena Meyer RN IBCLC