Your insurance and your responsibility
Our office cannot 100% guarantee any amounts covered: for services provided until it has been submitted and fully processed per your insurance plan. The amount due to our office is set by your plan.
It is your responsibility: to know your coverage and communicate with your insurance to determine what you will be responsible for.
*Any balance due that is set by your insurance plan is your responsibility, not the insurance’s responsibility.
If our staff gives you an insurance “estimate” of cost: please keep in mind that it is only an estimate and that your insurance carrier has a disclaimer on it stating that it is only an estimate and cannot guarantee it until they fully process your claim(s) and they amount may change based on your plan and coverage amounts.
If you or your baby have multiple insurance plans: we will need each of those and need to know which one is the primary one to bill.
*Your insurance plan may require both plans to process claims(s) before covering any services. If one policy denies the claim due to “other coverage” and we do not have your other plan on file, it will be your responsibility for any portion due since claims need to be filed in a timely manner to all insurances or they may decline.
If for some reason your insurance processes your claim and marks it as out-of-network: it is ultimately your reasonability to verify and work with them and are liable for any portion set as due to our clinic they list on your explanation of benefits.
It is your responsibility to track your explanation of benefits (EOBs). Your insurance provides this to you. This shows you how they processed/covered your claim(s).
*If a claim is submitted to your insurance and you get an invoice from our office, then it has been processed and our system automatically sends out the invoice to you. It is not uncommon to have a deductible amount due and is not because your insurance was not billed first.
In the event that your insurance carrier requests a refund from us: after they had covered your claim or retroactively deny coverage, you will be responsible for the amount that they request for a refund and assign due to our clinic.
If you do not wish to use your insurance benefit: you will be required to pay the full self-pay amount at time of service.
*If you provide your insurance information to us, we assume you chose this with the intent of us submitting claims on your behalf, and you will then be required to pay any out-of-pocket amount set by your insurance plan regardless of cash pay price collected.
*If we are in-network with your insurance, you won’t be able to submit a claim to your insurance on your own after paying us a cashpay price.
Member responsibility (out of pocket amount due to our office) is commonly determined when claims are processed and may be different due to a number of factors including differences in services rendered, changes in patient eligibility, other payments made, provisions of the plan including recent amendments, applicable law, and other relevant factors.
If your appointment was scheduled the same day, or we do not have time to provide an insurance coverage estimate, we cannot guarantee anything and will collect what our cash pay amount as a deposit.
*If you do not know what your out-of-pocket will be, you will need to decide if you want to do cash pay or not. If you do “cash pay”, a claim will NOT be able to be submitted after this.
For most insurance plans that we are in-network with, the “average” out-of-pocket range if your deductible was not met is typically between $300-$500, and is of course set by your plan.
We collect your co-pay(s) at time of service based on what is printed on your insurance card. Based on service(s) provided, there may be multiple co-pays due.
*If we do not have a benefits estimate when you check in, by default we will charge you the Specialist copay listed on your card since we are not a PCP clinic.
If we run your insurance benefits beforehand and it shows zero (0) copay due at time of service: then your insurance processes your claim and assigns a copay amount due after it was submitted – you will be responsible for the updated, processed amount since it is set by your insurance plan/coverage and you will be sent an invoice. We have no control over their final say.
If we collect a copay at time of service and your insurance processes your claim and designates zero (0) copay due: then a refund will be provided to you via original form of payment.
*Since these are processed manually, sometimes months later, contact us if you receive your EOB and you notice zero (0) copay due and please let us know so we can expedite your refund.
How we bill
We bill your insurance for both mom and baby for feeding issues accordingly, since we are primarily a breastfeeding clinic.
Because we are an office-based practice and meet with you one-on-one and often discuss multiple issues to help you with your own specific lactation needs; the office visit may have a co-pay due even though you are coming in for a “lactation” visit. It is still an office visit based on the level of care we provide (in addition to lactation).
*We have no control over how your insurance plan will process the claim(s) and every plan is so different we want to let you know that we have no control over how they will process these claims and will do the very best we can to work with you on “estimating” your responsibility if we can.
Please also note that some plans have a deductible and although they label breast-feeding as covered with sometimes up to six (6) visits per calendar year. They may not cover our services how we bill them (as a one-on-one office visit to collect health history, chart issues, etc., in addition to one-on-one lactation counseling to meet your specific needs).
If your infant/child has a tongue-/lip- tie procedure and they have no insurance coverage, then it will be considered a self-pay for the procedure only, unless specified. We do not bill baby for self-pay for follow up appointments, unless a procedure is done during that appointment. If you come in and see one of our lactation consultants for an office appointment, we will bill the mom’s insurance and you will be responsible for the amount set by your insurance for the lactation office appt portion set by insurance.
For an initial (2 hour) in-office visit we will use CPT codes 99205 and S9443 for the mom and 99203 for the baby for a breastfeeding consultation visit.
For a standard (1 hour) follow up in-office visit we will use CPT codes 99214 and S9443 for the mom and 99213 for the baby for a breastfeeding consultation visit. Baby will be billed if a procedure is performed.
Procedure codes (for tongue/lip-tie revisions) are available at your request, based on procedure performed.
Please understand that our billing system will electronically send you any statements to the email that we have on file, in order to reduce use of paper. If your balance goes unpaid after 45 days of being sent out, you may be sent to a 3rd party collection service.