All I Want for Christmas is My Reimbursement

Breastfeeding is hard work. And sometimes we need help! Prior to joining Breastfeed Chicago I had no idea what a lactation consultant was, let alone an IBCLC – International Board Certified Lactation Consultant. So when my little week-old Ruby was leaving me cringing at every hour-long feeding (I’ll spare the gory details), and still not gaining any weight, I was so thankful to be a part of ‘the Facebook group‘. I had seen many moms post about using an IBCLC in their breastfeeding journey, and that insurance was required to cover the costs. Yes. This is what I needed!

Following my IBCLC visit, our nursing improved ten-fold. And my insurance headache increased ten-fold. The Affordable Care Act requires all insurance plans* to cover lactation counseling at 100% with no cost sharing (understand your benefits here). This means no out of pocket costs – like co-pay’s or deductibles. And if there’s no in-network provider, they must cover an out of network provider. At 100%. Seemed pretty straightforward to me! So I made copies of my consultant’s receipt, Dr’s recommendation, and filled out the claim form. Popped it in the mail, and waited.

12369193_10105718333365910_3989303208948215996_nA few weeks later, I get an email that my claim was processed. And that I will be responsible for the full amount. I hopped on the phone during precious nap time, and speak with an agent. The first 45 minute call didn’t get very far, so I immediately called back and spoke with a new representative. She tried to reprocess the claim under the correct code – but couldn’t really find it. So she made a note of our call, cited the ACA section for breastfeeding counseling per my request, and posted it for further review. A week later, no dice. On the phone again. This time I thought – ‘I’m going to just ASK the question: Do you cover lactation consultants?’. The representative said yes! Though it has to be pre-approved and has to be an in-network provider. “What if there’s no time to get it pre-approved? Are there any in-network providers in Illinois?’ No. And she went on to explain that the visit would then be applied to my out-of-network deductible. So I give in and reveal my cover – I have already had this service. Here’s what the law says. How do we make things right, because I’ve already spent hours on the phone at this point? Appeal! That was her best advice. 12311139_10105718333360920_3181067512243130786_n

Appeal I did. I filled out the ‘Lactation Consultant Appeal’ template letter from the NWLC tool kit. And included a personal statement on why this service was necessary and beneficial to my and my baby’s health, the Dr’s recommendation for the service, IBCLC receipt, and copies of the ACA section for breastfeeding. Mailed it, and waited. A few weeks later, I got mail! My claim appeal was deemed illegible and I needed to re-submit if I wanted to appeal. I asked what was illegible (because they were freshly printed copies when I mailed them!) – every page. They sent me a copy of the appeal, and during a scan or fax on their end, my information had gotten white streaks through the text. Illegible. I huffed and sent off a message to my insurance through their web portal. “What can I do to prevent this from happening?’ They said mail in my appeal. So I upped the font size to 24 and mailed in my appeal again.

This is when I read another mom’s insurance headache post on Facebook, and a BFChicago admin advising to submit a complaint to the Illinois Department of Insurance, even if your claim appeal is not yet finalized. I created an account with the IDOI, typed up my experience and troubles, and attached the explanation of benefits. A few days later – Success. My insurance company had formally replied to the IDOI and me, stating that they did not process the claim correctly, would be covering it at 100%, and (finally) apologized for the misinformation and inconvenience. Six months after my IBCLC visit, and 23 days before Christmas, my reimbursement check is on it’s way.

12362708_10105718313286150_8252617483883476182_oEmily Cavanagh lives in Chicago with her husband, Matt and 6 month old Ruby.



UPDATE! Emily received her check, and it is in the bank!

4 thoughts on “All I Want for Christmas is My Reimbursement

  1. I’m very sorry this whole process was so incredibly frustrating for you! Please know that many private practice IBCLCs are doing everything they can to advocate for easier reimbursement and to hold insurance companies accountable to the law. The more parents stay in the fight, the easier and easier it will get. Thank you for taking the time to help pave the way!

    1. Please file a complaint with the IL Department of Insurance, Kristen! We have seen appeals go a lot faster once a complaint has been filed and it shows the IDOI that this actually is a problem (they don’t believe us when we tell them).

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