UHC Won’t Pay for the Baby. Can an In-Network IBCLC Just Charge Cash?
Updated: Oct 12
UnitedHealthcare’s changes to lactation reimbursement have left IBCLCs asking an understandable question:
If UHC won’t reimburse me for the baby’s portion of a lactation visit, can I just charge the family cash for the baby?
For an in-network provider, the answer is not simply yes.
The key distinction is between a charge UHC assigns to the patient and an amount UHC does not allow the provider to collect at all.
Those are very different things.
The Baby Is a Patient
When you provide healthcare services directly to an infant, the baby is a patient.
You may assess feeding effectiveness, observe and address feeding difficulties, provide patient-specific education and training, develop a feeding plan, and document the baby’s response to the care provided.
UHC deciding not to reimburse a particular lactation code for an infant does not make that care cease to be healthcare.
And it does not automatically transform the infant into a private-pay patient.
The appropriate question is:
What service did I actually provide to this baby, how can it appropriately be reported, and what does the baby’s insurance determine the patient owes?
There Are Codes for Services Provided to the Baby
One public example is 98960.
CPT 98960 describes individual education and training for patient self-management by a qualified nonphysician healthcare professional using a standardized curriculum, face-to-face with the patient, each 30 minutes.
That does not mean 98960 belongs on every infant lactation claim.
The actual service must satisfy the requirements of the code. Documentation and time must support it, the provider must meet applicable requirements, and the service must be within the provider’s scope of practice.
But 98960 illustrates an important point:
“UHC won’t pay S9443 on the baby anymore” is not the same statement as “there can never be a separately reportable service for the baby.”
There may be an appropriate code for the actual service performed.
Providers should code the service they actually provided—not simply search for whichever code produces the highest reimbursement.
If You Have an Appropriate Infant Service, Bill the Infant
When a separately reportable service has legitimately been provided to the infant, the cleaner approach for an in-network provider is to submit the appropriate claim and allow UHC to adjudicate it.
Then read the EOB or remittance.
For example, imagine you submit an appropriately documented infant service with a $100 charge.
UHC could determine:
Plan pays: $0
Patient responsibility: $40
Provider adjustment/write-off: $60
If the plan and your provider agreement permit collection of that $40, the family may owe $40.
You don’t collect $100 simply because UHC paid you nothing.
Now imagine the claim comes back:
Plan pays: $0
Patient responsibility: $0
Provider responsibility/adjustment: $100
That is a completely different outcome.
The family does not suddenly owe $100 just because the provider wasn’t paid.
$0 Paid Does Not Mean $100 Owed
This is probably the most important concept for providers to understand.
Insurance payment and patient responsibility are separate fields.
A claim can pay the provider nothing while also assigning nothing to the patient.
That happens all the time.
For an in-network provider, amounts contractually assigned to provider responsibility generally cannot simply be transferred to the patient.
Doing so can become balance billing.
So this equation doesn’t work:
My fee – UHC payment = what I charge the patient
Your contract and the patient’s benefits determine what may be collected.
If UHC pays $0 but assigns $0 to the patient, you cannot automatically manufacture a patient balance because you believe your service was worth $100.
Don’t Skip Insurance Just Because You Expect a Denial
There is another problem with simply announcing that “baby services are now cash-pay.”
If an appropriate billable infant service exists, bypassing UHC means the insurer never gets the opportunity to adjudicate the service and determine the member’s responsibility.
An in-network provider should be very cautious about doing that.
The appropriate sequence is generally:
Determine what service was actually provided.
Select an appropriate code supported by the service and documentation.
Submit the claim under the correct patient.
Allow UHC to adjudicate it.
Review the EOB/remittance.
Collect the amount legitimately assigned to the patient, when permitted by the plan and provider agreement.
If the claim is incorrectly denied, correct or appeal it.
If UHC’s reimbursement policy is the problem, challenge the policy.
Don’t automatically transfer UHC’s reimbursement problem to the family.
“UHC Doesn’t Pay Me for That Code” Does Not Mean “The Service Is Noncovered”
This distinction is especially important.
A service can fail to pay for many reasons.
Perhaps the service isn’t covered.
But perhaps the service is covered and UHC doesn’t reimburse that particular code to your provider type.
Perhaps it is bundled.
Perhaps there is a referral requirement.
Perhaps the claim requires different information.
Perhaps the service is subject to another reimbursement rule.
Perhaps UHC considers the amount provider responsibility.
Those outcomes are not interchangeable.
A service being nonpayable to you is not necessarily the same as the service being noncovered for the member.
And only the latter may potentially create an opportunity for an advance private-pay arrangement, depending on the patient’s plan, your network agreement, required notices, and applicable law.
What If UHC Says IBCLCs Aren’t Qualified to Provide Infant Services?
This is where the cash-pay argument becomes even more problematic.
If UHC’s position is that a particular infant service falls outside what an IBCLC is qualified or permitted to provide, then charging cash does not solve that problem.
You cannot say:
“UHC says I’m not qualified to provide this service under my credential, so I’ll provide the exact same service but have Mom pay me instead.”
Payment method does not change professional scope.
Consider the same reasoning in another context.
Suppose a professional isn’t a dietitian and an insurer says a particular nutrition service must be performed by a qualified dietitian for reimbursement.
The answer isn’t:
“Fine. I’ll perform the dietitian service anyway and just charge your member cash.”
If the professional isn’t qualified to provide the service, cash doesn’t make the service permissible.
If the professional is qualified to provide the service but UHC simply refuses to reimburse that provider type, then UHC has a reimbursement-policy problem.
Those are two very different positions.
UHC needs to be clear about which one it is taking.
A Cash-Pay Waiver Doesn’t Automatically Fix It
There certainly are legitimate situations in healthcare where an insured patient knowingly chooses a genuinely noncovered service and agrees in advance to pay privately.
That’s not what we’re talking about.
A signed form doesn’t automatically allow an in-network provider to turn a contractual write-off into patient responsibility.
Before charging an insured UHC infant privately for a medical service, providers should be able to answer:
What service am I charging for?
How would that service ordinarily be coded?
Is the service actually excluded from this baby’s benefits?
Or is UHC simply refusing to reimburse me for providing it?
Does my UHC agreement permit me to collect privately in this particular situation?
Does the plan require advance notice or consent?
If I submitted the service, what amount did UHC assign to the patient?
Those questions matter much more than whether a parent is willing to sign a cash-pay form.
98960 Is an Example, Not a Universal Solution
Providers should also resist swinging too far in the opposite direction.
The fact that 98960 may appropriately describe some infant services does not mean everyone should replace S9443 with 98960.
The service must actually meet the code requirements.
Documentation must support it.
Time requirements matter.
Provider qualifications matter.
Scope matters.
And payer-specific requirements matter.
There may also be other legitimate coding possibilities depending upon the patient’s needs, the service performed, the provider’s credentials, and the particular plan.
Those require individualized coding analysis.
The principle remains the same:
Choose the code because it accurately describes what you did—not because you heard it pays.
UHC Needs to Clarify What It Actually Believes
The larger issue isn’t solved by telling IBCLCs to charge families.
If UHC believes IBCLCs are qualified to assess and provide appropriate feeding-related care to infants, it needs to provide a reasonable pathway for those services to be submitted and adjudicated.
If UHC believes IBCLCs should not provide particular services to infants, UHC should say exactly what those services are and identify which qualified professionals it expects families to see instead.
Those are fundamentally different positions.
What UHC cannot reasonably expect providers and families to do is pretend the infant disappears from the healthcare encounter.
The baby is still a patient.
The service still occurred.
And changing the person writing the check doesn’t change what service was provided.
The Bottom Line
UHC refusing to pay you does not automatically mean the patient owes you.
If you legitimately perform a separately reportable service for the infant, determine the appropriate code. 98960 is one public example that may apply when its requirements are actually satisfied.
Submit the appropriate claim.
Let UHC adjudicate it.
Read the EOB.
If UHC legitimately assigns an amount to the patient and your agreement permits you to collect it, collect that amount.
If UHC assigns the unpaid amount to provider responsibility, don’t simply move it over to the family as a cash fee. For an in-network provider, that can become balance billing.
And if UHC’s argument is that an IBCLC isn’t qualified to perform the infant service in the first place, cash payment doesn’t magically change the provider’s scope or qualifications.
Either the IBCLC is qualified to provide the service or they aren’t.
Either the service is actually noncovered or UHC is simply refusing to reimburse that provider for it.
Those distinctions matter.
A payer reimbursement problem should not automatically become a patient debt.
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