OFFICE + TELE-HEALTH CONSULTS

YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY

FREQUENTLY ASKED QUESTIONS

• Why don’t you take my insurance? It is NOT up to us. We would take every insurance if we could. Insurance companies have all the power and only they determine if they will contract with any provider. In NJ, only Aetna and AmeriHealth contract with IBCLCs that are not also medical doctors, nurse practitioners or midwives. This is why it is important for all of us to be politically engaged and that we 1) VOTE and 2) DEMAND what we want from our elected officials.

• Why can’t you bill the insurance company to get paid by them? It requires extensive effort and time, sometimes MONTHS, to process claims with insurance companies and even then there is not guarantee that we will get paid at all or that we will get paid adequately. It also requires me to pay a biller to engage in all the work with no guarantee that I will be paid. Because you have the financial relationship with your insurer you have more leverage and RIGHTS to get reimbursed according to your benefits in a more reasonable amount of time, typically about 3 to 4 weeks.

• What do I need to submit to my insurance company so I can get reimbursed? It is called a super bill and has all the required information for your claim to be processed and you will receive it after your consult.

• Why can’t I get the super bill when I pay at the time I book my consult? Because providing you a super bill BEFORE I actually deliver services is insurance fraud. You have a receipt at the time you book to prove that you paid me.

• Why can’t you see me immediately? Because, unlike other healthcare professionals, our consults are not 5 minutes. A typical initial consult takes about 75 minutes and follow up in person consults take 50 minutes, therefore, we can’t just squeeze anyone in.

• Why can’t you give me simple advice over email to tie me over until I see you? While our bodies are designed to lactate and our babies are designed to feed, lactation and the skills required for infant feeding are complex. We have been doing this for many years and there is NEVER a simple answer. In order to give you an accurate and competent answer we need to know QUITE A LOT because what it may seem like to you is the issue or cause is often times not.

• Why can’t you talk to me on the phone so I can explain to you and see if you can help me? Because 1) We are seeing patients back to back with a break just long enough to get charting and care plans done 2) We can not give you advice without a FULL medical, lactation and infant feeding history, which would take about 30 to 40 minutes to get, AND we NEED a signed consent form from you in order to give you any advice and 3) We all have families of our own. We work long hours and when we are done we need to give our children and families our attention and support.

• Will one visit fix everything? NO!! Unless all you really want is reassurance because everything is working effectively. Lactation and infant feeding issues are typically complex and require changes/adjustments to the initial plan. Most moderate cases require 2 to 3 consults and complex cases may require as many as 4 to 6 consults. If you have a medically fragile baby, you may require ongoing support through the first 2 to 3 months after the birth.

• Why can’t you see me on the weekend? We have our own families and need work, life balance just as you need and deserve.

• Can you help me if I am only bottle-feeding? ABSOLUTELY!!!! We can help you optimize your baby’s feeding experience and oral function whether you bottle, cup, spoon, syringe or body feed.

• Can you help me if I am mostly or only feeding formula to my baby? We absolutely CAN!!! We work with families that exclusively formula feed to help them optimize baby’s feeding, oral function and help them learn more about their baby’s behaviors and development.

• Can you help me learn how to prepare my baby’s formula safely? 100% YES!!! We should be teaching this even before birth!

• Can you help me if I am exclusively pumping? You bet we CAN!!! We can work together to optimize your pumping sessions to get the most out of them, ensure you have the best pump AND best fitting flanges and to learn how to maintain the level of production you desire for as long as you have in mind.

• Can you help me when it is time for my baby to start eating solids? YES!!! This is one of our favorite sessions!! We can teach you about optimal nutrition and how to introduce foods in a way that optimizes oral function.

• Will anyone else from your practice be present during my consult? Our administrative assistant may be live scribing to ensure optimal health record keeping and the expediency of delivery of care plans and physician reports.

  We are a teaching practice and during most consults we will have a new IBCLC or an intern present observing and participating. If you are not comfortable with a student participating, you must indicate it during the booking process. We reserve the right to reschedule your appointment based on availability with no students.

• Why do you charge for late cancellation? When an appointment is cancelled with less than 48 hours, we lose income since we turned away other clients to commit to your scheduled appointment.

AETNA FREQUENTLY ASKED QUESTIONS

ONCE YOUR BABY IS BORN, WE HAVE TWO CLIENTS THAT WE PROVIDE SERVICES FOR AND WE BILL FOR BOTH FOR EACH CONSULT. ANY CONSULT THAT INVOLVES ASSESSMENT, RECOMMENDATIONS AND A CARE PLAN FOR YOUR BABY AND YOU WILL BE BILLED TO YOUR INSURANCE FOR EACH OF YOU.

YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY

• Can you guarantee me that Aetna will cover your services 100%? NO, we can not! I We are a contracted party. We hold no power. Aetna, your carrier, holds ALL the power. What I can tell you is that in most cases Aetna does cover most in person services with no patient responsibility. But Aetna, has MANY different plans and sometimes they may assign a patient responsibility to you based on your plan’s coverage. There is NO way to predetermine this. In our experience in 8 years of being in network with Aetna, the overwhelming majority of in person lactation services that are within the initial 6 covered visits, including 1 prenatal, are covered with no out of pocket expense to the client BUT I can not make any guarantee because ultimately Aetna is the only one that decides. Even when they tell you when you call that you are 100% covered when they process your claim, they may still assign a patient responsibility. Even if 999 out of 1000 claims I have filed on behalf of my clients have been covered with no patient responsibility that is still not 100% and I can NOT make ANY guarantees. Ultimately, it is your employer who decides what your coverage is.

• Why do you bill for my baby? Once your baby is born, we provide services for BOTH of you. We deserve to be paid for our expertise and time.

• Will Aetna cover telehealth? Aetna WAS covering telehealth without a patient responsibility from the onset of the covid19 pandemic until February of 2021. At this time, they are often assigning patient responsibility to claims. Here is what they are doing: they will cover some lactation codes with no patient responsibility BUT they have never allowed those codes to be used for telehealth. The codes required for telehealth give them the opportunity to assign a patient responsibility to you. NOT fair, I know! I have no control and I can only code what I am legally allowed to do under my contract.

• What else do I need to know about my Aetna coverage? When your visit is very long or complex we will need to use different codes that allow me to be paid for the level of service and the longer time I have spent. These codes have not yet been assigned under the agreement that covers them as lactation preventive medicine. This means that sometimes Aetna will assign you a patient responsibility. If this happens, my biller FIGHTS extra hard to get Aetna to pay. We resubmit, call, call, call and appeal until we exhaust EVERY option available to fight on your behalf. Once we have exhausted every possible process, if Aetna still determines that you have a patient responsibility we have no control over it and you will be responsible for the payment.

• What if I have another health insurance policy? You MUST notify us when completing and submitting your intake form. Aetna will NOT pay any of your claims until after they have been submitted to the other insurance plan, even if that is your secondary insurance, and we can submit to them a denial letter from your other insurance carrier. This can take MONTHS, especially if you do not initially inform us and we submit to Aetna without this information. If Aetna is your secondary instance you must pay self-pay, submit your super bill to your primary insurance and once they deny you must provide us with the EOB (explanation of benefits) so we can submit to Aetna. Without a physical EOB, we can not file your claim to Aetna. If they pay us, we will reimburse you up to the amount you paid MINUS the credit card processing fee, which Square doe not refund us.

• My baby will not be on the same Aetna plan that I am on until after the birth can you still charge Aetna? You will not need to pay as long as you can CONFIMR that your baby will be added to the same Aetna plan that you are on. We will need you to notify us as soon as you add baby.

• Why can’t you just take the payment they give you and not charge me the patient responsibility? Under contract Aetna REQUIRES us to bill you the patient responsibility they determine and assign to you. We also spend a significant amount of time preparing your chart, providing in person services, preparing and sending your care plan, physician reports, referral reports, when required, and answering your questions on the patient portal. We need to be fairly paid for the level of expertise and time we provide to you and your baby.

• Can I get more than 6 consults? YES! You can. Sometimes you can get Aetna to extend the benefits with full coverage but you will have to call them and get this approved or you can get the services and they will assign a patient responsibility fee that you will be responsible for paying.

• Is it 6 visits per lactation provider I see? NO! It is not. Aetna covers six consults TOTAL for ONE year from the date of your first lactation consult, NOT per lactation specialist you see.

• What if I need help with my older nursing child? As long as it has not been more than one year since your first lactation consultation , you are covered. Aetna covers 6 consults for a full year since the date of your first consult.

• Since I am going to be working with you after the birth can’t you just answer my questions now about what to buy, which pump to get, which bottles are best and give me some quick tips for the hospital? YES, we absolutely can. This is called a prenatal consult and Aetna covers one of these under your benefits so you can book a prenatal appointment and we can cover all your questions about pumps, bottles, getting started, what to do in the hospital. Telehealth consults may have a patient responsibility assigned. In person consults are less likely to have a patient responsibility assigned.

• Why can’t you just charge Aetna when I cancel late instead of charging me a late fee? Because this would be insurance fraud.

AETNA MEMBERS/CLIENTS

YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY

It is your responsibility to check with Aetna to ensure that you are covered for lactation services. Even though Aetna may tell you that you are covered 100 percent, it is possible that some Aetna plans may assign you a ‘Patient Responsibility’ fee which will be charged to the card you have on file. If only your baby is covered under Aetna and you, the lactating parent, are not covered under Aetna, you MUST book a self-pay consult. If your baby is not on the lactating parent’s Aetna plan you must book the baby not on plan appointment and you must pre-pay the appropriate fee for each appointment.

Aetna typically assigns patient financial responsibility to tele-health consults which varies from plan to plan.

Your claim(s) will be submitted to Aetna for payment. If Aetna applies any portion of the fees towards a deductible or otherwise charges a coinsurance payment your card on file will be charged for the patient responsibility amount. By scheduling your consult, you grant us permission to communicate with Aetna regarding the services provided to you and your baby(ies) and you agree to our payment policies.

CIGNA + BCBS MEMBERS/CLIENTS

YOU ARE RESPONSIBLE FOR INFORMING US OF ANY INSURANCE COVERAGE CHANGES FOR YOU AND YOUR BABY

It is your responsibility to check with Lactation Network to ensure that you are covered for lactation services.

TELE-HEALTH DISCLAIMER

There are inherent limitations because a digital suckling assessment and a physical breast/chest can not be completed. Potential risks to the technology used for tele-health, are beyond the control of the provider, including interruption of connectivity, unauthorized access, and other technical difficulties.

LANGUAGE

If we have used any language that has caused you harm or if there is a better option that we could use, please let us know.

CANCELLATION POLICY

Appointments canceled with less than 48 hour notice will be charged the FULL consult fee which is not covered by insurance. ALL fees for services are non refundable and expire 60 days after the original purchase. The payment and no refund policy is SEPARATE from the cancellation policy. Refunds will NOT be issued once you book. Each client is responsible for all fees associated with each consult. Payment is charged at the time the appointment is scheduled. By scheduling your consult, you grant me permission to communicate with your insurance company regarding the services provided to you and to your child(ren).

Rental agreements: no refunds will be issued for any unused part of the rental terms. All equipment must be returned the day prior to the scheduled new charge in order to avoid being charged for a new rental term.

OFFICE CONVENIENTLY LOCATED AT 51 NEWARK STREET, SUITE 404 C, HOBOKEN