We have worked long and hard with the insurance providers in the state of Massachusetts and have found that your chances of being reimbursed are increased if you deal with the insurance company directly. The insurance companies will not reimburse you unless you have already paid for the visits.
- We require payment at the time of service.
- We will provide you with an invoice for you to submit to your insurance company.
- However, coverage for lactation services are determined by your individual insurance plan.
- If your insurance policy covers the cost of our services, they will reimburse you, not us.
- We urge you to file claims for all of your visits and to fight for your rights if your insurance provider denies your claims.
- If your insurance provider persists in not paying please write (see our downloadable sample letter) to your State Insurance Commissioner.
- If you have any further questions, please feel free to call us @ 978-422-9070.
Does my insurance cover visits with a lactation consultant?
- Coverage of lactation services varies from health plan to health plan.
- Services that our lactation consultants provide are frequently covered under your insurance plan..
- We require fee for service for the initial visit. We provide the necessary paperwork for you to file with your insurance company.
- Your insurance company will reimburse you if your plan covers lactation services or if you appeal a denial and win.
Examples of insurance coverage in the state of Massachusetts:
- Some policies cover 5 visits at $75.00 each.
- Some policies cover 3 or more visits at $150.00 each.
- Some policies cover unlimited lactation services during the first 6 weeks after delivery.
- Some policies will pay for the services in full.
- Harvard Pilgrim will cover visits in the first 6 weeks with a referral from the baby's doctor.
- Network Health will cover services with a prior authorization.
- There are some policies that do not pay for any services rendered for lactation reasons, unless you file a complaint.
- Some policies cover for lactation services as long as you have a referral from your OB doctor and your baby's doctor.
- Many insurance plans require that you see an "in-network" or "participating" healthcare provider/lactation consultant.
It is important for you to know that in the state of Massachusetts there are no in-network lactation consultants outside of the hospitals. Unless you delivered at a hospital with an outpatient lactation clinic, you will not be able to go back to your hospital for lactation services. UMass Memorial Hospital and St Vincent Hospital lactation consultants can not see you once you are discharged from the hospital.
It is also important to know that breastfeeding difficulties can not be resolved over the phone, via email or through chat rooms and forums. You and your baby must breastfeed in front of a consultant for your issues to be properly evaluated. We see many mothers that have spent days and weeks and sometimes months trying to resolve their problems in these ways. You wouldn't rely on any of these methods if you were experiencing abdominal pain or had a broken leg. You would go to the emergency room or the doctor's office.
The lactation consultants in Massachusetts have been working for years with the major insurance providers to become part of their networks, but as to date no arrangements exist. Our office works diligently to help you get reimbursement from your insurance provider.
In some cases, going to an out-of-network healthcare provider or lactation consultant may mean that your services may not be covered at all, or that you may have to pay a much higher co-pay than if you saw someone in your insurance plan's "network."
Please call your insurance provider.
Ideally you should call during your pregnancy, to find out what if any coverage you have for lactation services.
It is also a good idea to contact the human resources department of the employer that provides your insurance plan. They can help you determine what coverage you have.
Prior Authorization:
Your health insurance plan may require "prior authorization" before the insurance company agrees to cover (or pay for) certain medical services or equipment. Prior authorization means approval by an insurance company before the service is rendered for the member to receive services, medical products (i.e breast pump), tests or surgical procedures.
Many insurance companies want to know that the prescribed services are medically necessary. In other words, the insurance company does not want to pay for medical equipment or services that are not really needed.
The insurance company will make a decision based on information that your healthcare provider (i.e. Pediatrician, PCP, Obstetrician, Midwife, Lactation Consultant) gives to them.
How to find out if your insurance company requires prior authorization:
- Call the Member Services Department for your insurance.
- The customer service representative will be able to give you the necessary information and tell you whether they require a referral from one of yours or your baby's physicians.
- If you talk with a customer service representative who seems unsure, ask to speak to a supervisor.
- If your insurance plan requires your doctor or lactation consultant to call or send a letter called a "Statement of Medical Necessity" or "Letter of Medical Necessity," you can call your doctor and/or our office to request a call or letter.
- This call or letter may also be needed in addition to a written prescription for a breast pump.
- Even if your insurance company does not require this, it often helps to include a Letter of Medical Necessity from your baby's physician, your physician or one of our lactation consultants indicating why he/she has prescribed the equipment and services for you or your baby.
What to ask your insurance company about prior authorization:
"Does my plan require prior authorization for coverage of RNs* or Lactation Consultants or breast pumps? (* Many insurance companies will cover services with an RN but not a lactation consultant, all of our lactation consultants and counselors function under Debbie Page, RN, IBCLC.)