Insurance companies are really good at tightening their purse strings. They can very easily find a way with mumbo-jumbo language to make you feel like what you're asking for is too much cough cough FREE and ACCESSIBLE lactation and postpartum care.

As a provider in-network as well as a provider who has tried to infiltrate the brick walls of some insurance companies to become in network, I see behind the scenes and there's very shall I say... interesting things that they do to avoid paying for this care. For example, they insist that the provider must be an IBCLC + another healthcare license, they insist the provider must be an MD, DO, NP, or they have 1 pediatrician practice in an inconvenient location that has lactation care in their network but that practice isn't even your pediatrician.

The last, and I mean very last thing you should be doing as a postpartum mother is calling insurance and waiting on hold to argue with someone for reimbursement.

So, please send this blog post to your partner, mom, friend, neighbor. Anyone else but you. Because you should be chest to chest with your new baby and relaxing.

Here's a script with some talking points for when NOT YOU (remember, you're resting!!!) calls:

pro tip: stay nearby in case insurance needs your verbal authorization to proceed with your designated insurance warrior

Opening:

“Hi, my name is ___ . I’m calling about reimbursement for lactation support services I received and submitted via a superbill. I want to confirm how my plan processes lactation care under the Affordable Care Act’s preventive services requirements.”

let them answer.

“Under the Affordable Care Act, breastfeeding support and counseling are required preventive services. The ACA requirement applies to the service itself—breastfeeding support and counseling—not to a single provider credential, as long as the services are provided by a qualified healthcare provider acting within scope.”

“In my case, the lactation services were medically necessary postpartum care. The care addressed feeding-related concerns that require timely intervention to prevent complications such as ineffective feeding, poor infant weight gain, maternal breast complications, or early discontinuation of breastfeeding.”

“This was not elective or convenience-based care. Lactation support is time-sensitive postpartum care, and delays can worsen outcomes for both parent and infant.”

let them answer that one, boom!

Superbill clarification

“I have a detailed superbill that documents:

• The date and duration of services

• The nature of the lactation counseling and feeding support provided

• Diagnosis information supporting medical necessity

• Provider credentials and licensing”

“I’m requesting that this superbill be reviewed for reimbursement under preventive services coverage. I want to clarify that I’m requesting coverage for medically necessary breastfeeding support and counseling services, which are required preventive services under the ACA and were delivered within the provider’s licensed scope of practice.”

if they say well we have in-network LCs...

“I was told that in-network lactation providers may exist, but access is a key issue.”

“For medically necessary postpartum lactation care, reasonable access must consider:

• Time sensitivity of feeding concerns

• Postpartum physical recovery

• Infant feeding frequency and safety

• Risk of clinical worsening if care is delayed”

“A provider who is far away, has long wait times, or cannot see postpartum patients promptly does not meet reasonable access standards for this type of care.”

“So, can you tell me:

• The closest in-network provider who offers breastfeeding support

• Their distance from my home

• Typical wait time for a new postpartum patient

• Whether timely care was realistically available at the time I needed services”

let them answer.

If access is inadequate whether it was a far away provider or someone not specialized in what you're dealing with

“Given the medical necessity and time-sensitive nature of lactation care, that level of access was not reasonable. When a plan cannot provide timely, accessible in-network care for a required preventive service, the plan must cover out-of-network care at the in-network benefit level.”

Direct reimbursement request

“I’m requesting reimbursement for the lactation services submitted via superbill, processed as medically necessary preventive care under the ACA, at the in-network benefit level.”

If they resist

“If reimbursement is being denied, I’m requesting one of the following:

• Written confirmation that no timely and accessible in-network breastfeeding support provider was available

• Authorization of out-of-network coverage based on medical necessity and access limitations

• Escalation to a supervisor or preventive services or medical management department”

“Please document this call as an ACA preventive services request with medical necessity considerations. If needed, I will request a formal coverage determination and appeal in writing.”

IMPORTANT!!:

“Can you give me a reference number for this call and confirm the next steps and timeline for reimbursement?”

Wishing you all the luck. Fingers crossed you don't have to say every talking point on this script and they just say yes we'll reimburse you.

Feel free to comment below with any questions.

Xo,

Jenna