Policy & Advocacy

The Challenge of Secondary Insurance A patient finds a lactation practice advertised as “in network with Cigna through Wildflower.” She has Cigna coverage and expects to use that benefit. However, she soon discloses that Cigna is her secondary insurance. Unfortunately, Wildflower will not allow the patient to be entered into its system when Cigna is not the primary payer. The actual practice does not have a direct Cigna contract. If the practice bills Cigna independently, its

October 2026 | Sunshyn Credentialing & Medical Billing Healthcare providers are being asked to deliver more comprehensive, coordinated, patient-centered care. At the same time, reimbursement policies are increasingly raising a troubling question: How much clinical work can an insurance company classify as overlapping before it stops paying for that work separately? Recent developments involving modifier 25, maternity billing, and lactation reimbursement illustrate why this qu

“Free if you have Aetna.” “No out-of-pocket costs.” “We never bill patients.” These promises sound reassuring to a family seeking lactation care. But when the accepted payers assign deductibles, copayments, or coinsurance on correctly processed claims, a universal promise requires an explanation. Is the service covered without patient responsibility? Is another party paying the assigned balance? Or has the organization decided never to collect it? Those are different arrangem

Mother and baby arrive for lactation care together. The mother may need assessment of pain, milk production, breast concerns, or other factors affecting feeding. The baby may need assessment of feeding effectiveness, milk transfer, growth concerns, or other difficulties. Their care is connected. That is why lactation is often described as dyadic care. But they remain two separate patients, with separately documented services and their own healthcare needs. Coordinating their

You receive lactation care from an independent practice. That practice schedules your visit, performs your care, and maintains your clinical documentation. Then the insurance claim identifies Wildflower as the billing and rendering entity. Wildflower’s explanation, as communicated to Sunshyn, is that Cigna authorized the arrangement. That explains what Wildflower says the payer permits. It does not fully explain what the treating provider authorized—or how the signed provider

Two patients receive lactation care from the same practice. Both have Cigna coverage. The mother’s visit can be processed as in-network care through Wildflower. The baby’s separately documented visit does not have a clear, reliable in-network payment pathway through that arrangement. For advanced clinicians, the divide can affect the same patient, too. A nurse practitioner or physician may provide covered lactation care through Wildflower, then evaluate and treat a related me

The lactation community has wanted dedicated CPT codes for years. So when two new lactation-specific CPT codes appeared in the proposed 2027 Medicare Physician Fee Schedule, the immediate reaction was understandably excitement. Finally, codes that actually describe lactation care. Finally, recognition that a comprehensive lactation visit involves assessment, education, counseling, training, and significant professional time. Finally, something better than trying to make lacta

Oregon has once again positioned itself as one of the nation’s leaders in expanding access to lactation care. With the passage of Senate Bill 1568, Oregon is taking another significant step toward improving access to breastfeeding support by requiring Medicaid and many commercial health plans to cover services provided by registered lactation counselors without unnecessary barriers. While much of the discussion surrounding the bill has focused on who may qualify, it is import

On its face, New York's proposed Senate Bill S1670 / Assembly Bill A4677 is exciting news for breastfeeding families. The legislation would require many health insurance plans to provide coverage for outpatient lactation services, helping more families access the breastfeeding support they need. As someone who has spent years working in lactation billing and insurance credentialing, I strongly support expanding access to quality lactation care. However, after reviewing the bi