Aetna Updates
AETNA POLICY UPDATES FOR LACTATION COVERAGE:
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There have been some changes with how Aetna deals with lactation care. Please read the following carefully to understand what your actual benefits may be.
Unfortunately, we don’t have staff to confirm your benefits, so please confirm with Aetna that we are in-network with your plan and what “lactation” benefits you have remaining — those are typically coded as “s9443”.
Are my visits free if I have Aetna?
You need to be aware that your visits with us may not be as “free” as you’ve been led to believe.
If you’ve been told you are entitled to “6 free visits” you have been mislead by Aetna. In order for us to be paid fairly for the complex, individualized care we provide you and your baby, we have to use a combination of codes at each visit depending on the circumstances and time taken during the consult. Combining appropriate visit codes is a common practice among health care providers as a way to account for time and complexity of visits.
If you have worked with Nest Collaborative or Aeroflow, some or all of your lactation benefits have been used up without your knowledge or consent. What this means is that you will have fewer “free” visits and should expect to have some cost-sharing with us. This has everything to do with changes in Aetna’s coverage of lactation care, not how we bill.
Insurance billing is very complicated and in order for us to remain in-network with Aetna, we have to bill appropriately so that we are paid fairly for the time we spend with you. Many providers are leaving Aetna because of these changes. We will remain in-network as long as we can, but your visits may not be “free” — no different than when you see other medical providers — very few visits to the doctor are free.
We Bill for Two Patients
Your first visit with us will run 90 -120 minutes and we have to use a combination of procedure & visit codes to account for that consult. For follow-up visits, we don’t need to use as many visit codes but Aetna processes your lactation visits differently than all other healthcare providers which is unfair to you, the consumer, and to us, the provider.
Examples of billing: When you take your baby to the pediatrician, they bill for just the baby — that is their only patient. When you go to Urgent Care with a fever & cough, they will bill for the physical examination, the labs and the chest x-ray — 3 codes for one visit on the same day. Normal. Logical. That does not count as 3 separate visits. One visit, 3 codes.
In lactation land, visits are not treated the same way. Aetna is now billing visit counts based on how many codes are used, not by visit date alone. In other words, if we use 2 visit codes at your initial visit (s9443 + 99404), they will likely process that as 2 out of your 6 visits! There is no other healthcare visit that is handled in this way.
What we do is unique. When we see you and your baby for a visit, we are treating two individual people — you — the mother/lactating person, AND your baby (or babies). While you and your baby are a feeding unit, each of you has separate issues that require individualized care, separate examinations and separate problem solving. If we never weighed, examined, touched or discussed the baby’s role in your feeding experience, then we wouldn’t need to bill for the baby. That rarely happens though.
Aetna’s New Policy:
Unfortunately, Aetna keeps eliminating the types of codes we can use which means they are systematically and deliberately paying us less and less. We have to bill for the time we spend with you and your baby and that means multiple codes, otherwise we cannot afford to remain in-network. You need to be aware that Aetna’s new directives may end up triggering cost-sharing. If you call Aetna to complain, they may tell you we filed incorrect claims but we are meticulous in our coding and now, with so few codes, errors on our part are not possible.
Most of our families do not end up with any cost-sharing, but it does happen occasionally and you just need to be aware that it may happen. If a claim comes back processed improperly, we will resubmit and appeal on your behalf but the outcome is unpredictable.
Final Important Comments:
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We no longer offer Aetna tele-health visits.
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If your baby is not covered under your Aetna policy, there will be an additional charge per visit of $50.
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If you have taken any classes with Aeroflow or done a tele-health with Nest Collaborative, you will fewer s9443 codes available which is the only code allowable for the baby and one we often use for the mother as well. Without you knowing it, Aeroflow and Nest use up those s9443 codes which will deduct from your allotted 6 with us. They are not transparent about this use of your limited s9443 codes, so you may need to ask your Aetna agent how many you have left. Warn your pregnant friends to steer clear of Aeroflow’s “free classes” and avoid using Nest more than 1 time.
Pre-authorization Instruction for Self-Pay Clients
If you have an insurance plan that is not covered for our services, you may be able to petition for reimbursement. If you have a Care Coordinator at your work (many CT state employees do), then reach out to them for assistance. The Affordable Care Act says that you are entitled to lactation coverage, but unfortunately, it’s never that easy. Your insurance company may provide you with a name of a physician who also has the IBCLC credentials, but they do not do private lactation consults, or your pediatric practice may have a lactation counselor or consultant (very different credentials) but those visits are typically short, not as comprehensive as our visits and you will be charged for those visits — often considerably more than what we charge.
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If you are not eligible for insurance coverage, you can try to get a pre-authorization for your consults, but you must do this beforehand by requesting an “in-for-out” (to be considered as if we are in-network).
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Request that this be expedited. Write everything down -- who you spoke with, case number and the case/authorization number. Ask that you be sent confirmation in writing.
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Ask for unlimited visits.
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Make sure they understand we are not medical doctors.
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You will be required to pay up-front for our services and we will provide you with an official receipt called a “super bill” to submit for reimbursement.
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Get directions for how to apply for reimbursement for our services. We cannot/will not bill your insurance directly on your behalf even if you get approval because they rarely cover the full cost of our visits and they may not allow us to charge you for the unpaid portion or difference. This is very important, so please write down exactly how they want you to do this.
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The typical procedure codes we use are s9443 or 99404 so find out which is acceptable. The diagnosis code used is z39.1 (Maternal Lactation Care).
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Our tax ID/EIN 87-0890714 associated with our legal name: Central CT Lactation Services, LLC
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Our Group NPI #1891361127
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Our individual NPI numbers: Susan Forrester #1710201942, Lauren Akers #1740820521 and Brittany White #1477314375.
If you need any other information, please reach out to us:
text or call: 860-255-8583