When One Visit Becomes Half a Payment: The Growing Threat of Bundled Healthcare Reimbursement
Updated: Oct 12
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 question deserves attention far beyond any single specialty.
The concern is not whether healthcare providers should be paid twice for performing the same service. They shouldn’t.
The concern is whether insurance companies are adequately distinguishing genuine duplication from separate, medically necessary work.
And in some cases, providers are encountering multiple restrictions at once: limitations on which services can be reported, which patients can be billed, and how much a separately identifiable service will be reimbursed.
Modifier 25: When Separate Work Is Worth Less
Modifier 25 identifies a significant, separately identifiable evaluation and management (E/M) service performed by the same physician or other qualified healthcare professional on the same day as another procedure or service.
Its purpose is to distinguish additional E/M work from the work normally included in a procedure.
For example, a patient may visit a physician for evaluation of a new medical problem and require a minor procedure during that appointment. If the evaluation goes beyond the work ordinarily associated with the procedure, reporting both services may be appropriate.
That distinction has long been recognized in medical coding.
Yet some payment policies reduce reimbursement for separately identifiable E/M services even when the services have been properly documented and reported.
In July 2026, the Centers for Medicare & Medicaid Services (CMS) proposed a particularly significant change for the 2027 Medicare Physician Fee Schedule.
Under the proposal, when the same physician or practice provides a separately identifiable office or outpatient E/M service on the same day as a procedure with a 0-, 10-, or 90-day global period, Medicare would pay the highest-valued service at 100% and other affected services at 50%.
This is a proposed policy, not an established Medicare payment reduction as of October 2026.
The American Medical Association and multiple specialty organizations have objected, arguing that properly valued procedure codes already account for the routine work included in a procedure.
Their concern is straightforward: reducing payment again may subtract reimbursement for work that was never duplicated in the first place.
When Insurance Companies Call Two Patients One Service
Lactation care provides a particularly important example of how reimbursement restrictions can intersect.
A comprehensive lactation consultation may involve two separate insured patients: a mother and her infant.
The mother may require evaluation of milk production, breast health, pain, medications, or other medical concerns.
The infant may require evaluation of feeding effectiveness, milk transfer, weight gain, and other feeding-related problems.
These assessments are connected, but they are not necessarily identical.
The infant’s ability to transfer milk directly affects maternal milk production and comfort. Maternal conditions can, in turn, affect infant nutrition.
Effective treatment often requires evaluating both patients together.
Nevertheless, UnitedHealthcare changed its reimbursement rules for HCPCS S9443 effective September 1, 2026.
Under its published commercial policy update:
S9443 is considered for reimbursement when the mother is identified as the patient.
S9443 submitted under the infant is not considered for reimbursement.
Reimbursement is limited to one session per date of service.
This policy specifically addresses S9443. It does not establish that all other separately billable infant medical services are prohibited.
But it presents an important reimbursement question.
If a mother and infant have separate medical needs, what determines whether their care represents one counseling service or two separately reimbursable services?
The answer should depend on the actual services furnished, applicable coding rules, clinical documentation, and coverage terms—not simply the fact that both patients participated in the same appointment.
Two Patients Do Not Automatically Mean Two Payable Codes
It is equally important to acknowledge that the existence of two patients does not automatically justify two claims for the same counseling activity.
Some elements of dyadic lactation care are genuinely shared.
Others may involve separately identifiable clinical assessment and management.
The appropriate reimbursement approach must distinguish those circumstances rather than assuming either that every activity deserves separate payment or that all work involving the dyad is duplicative.
Obstetrics Is Moving in the Opposite Direction
Perhaps the most revealing contrast comes from obstetric care itself.
For years, traditional maternity billing has relied heavily on global payment codes covering multiple phases of pregnancy and delivery.
But modern obstetric care has become increasingly complex, involving individualized prenatal management, multiple healthcare professionals, telehealth, and more extensive postpartum care.
The American College of Obstetricians and Gynecologists (ACOG) advocated for restructuring those bundled payments.
Beginning January 1, 2027, the CPT code set is scheduled to replace traditional global maternity codes with more detailed reporting for prenatal care, labor management, delivery, and postpartum care.
The purpose is to more accurately represent the services provided.
This is a substantial shift in how medical work is reported. It does not guarantee that every insurer will separately reimburse every reported service, and payer implementation remains important.
Still, the underlying principle is difficult to overlook.
When bundled reimbursement fails to capture actual clinical work, the solution may be more precise service-level reporting—not additional bundling.
ACOG has also specifically advocated reimbursement approaches that recognize the complexity of evaluating and managing two unique patients in obstetric care.
That does not establish an automatic right to separate maternal and infant lactation payments. It does, however, support a broader principle: clinically connected care may involve distinct responsibilities and medical needs that deserve accurate recognition.
During childbirth, maternal delivery services and separately necessary newborn medical services may be billed under their respective patients.
Why should reimbursement for postpartum care be evaluated without the same attention to each patient’s distinct medical needs?
This Problem Extends Well Beyond Lactation
Although maternal–infant care offers a striking example, modifier 25 payment reductions and restrictive bundling policies have implications throughout healthcare.
Primary care and pediatrics: A patient may present for preventive care while also requiring a significant evaluation of a new or worsening condition. In appropriate circumstances, separate E/M reporting is permitted. Payment restrictions may make addressing both needs during one appointment financially less sustainable.
OB-GYN and maternal health: A clinician may manage a separately identifiable medical condition during an encounter involving another service. Policies that undervalue additional work can create barriers to comprehensive care.
Dermatology: A clinician may perform a minor procedure while also evaluating a separate or more complex medical concern. An automatic reduction does not necessarily reflect the extent of that additional evaluation.
Otolaryngology: An ENT specialist may need to perform a procedure and a significant E/M service during the same encounter. The American Academy of Otolaryngology–Head and Neck Surgery has explicitly opposed blanket modifier 25 payment reductions.
Ophthalmology: Patients receiving an eye injection may also require significant medical evaluation. Ophthalmology organizations have raised concerns about modifier 25 audits and payment restrictions that may fail to distinguish legitimate evaluation from routine procedural work.
Podiatry: Foot and ankle specialists have challenged policies restricting payment for E/M services alongside minor procedures. In September 2026, Regence BlueShield withdrew a proposed modifier 25 reimbursement restriction after professional advocacy.
Other specialties: Physical therapy, occupational therapy, behavioral health, nutrition, and other disciplines also encounter payer bundling and code-combination restrictions. Their rules differ, and modifier 25 is not applicable to every service they provide. Nevertheless, the underlying issue—whether distinct clinical work is being recognized accurately—remains relevant.
The common thread is not that all these specialties use identical codes.
It is that efficient, coordinated care should not automatically be interpreted as duplicated care.
The Hidden Cost of Reimbursement Restrictions
When payment policies make same-day care less sustainable, providers may face difficult operational choices.
They may need to schedule an additional appointment, spend more time appealing claims, reconsider which services can be offered together, or absorb the cost of work that is medically necessary but not separately reimbursed.
Patients may experience more visits, additional time away from work, transportation challenges, delays in care, or increased financial responsibility where cost sharing is applicable.
None of these outcomes is inevitable for every policy or encounter. But they are foreseeable risks that deserve consideration before broad payment reductions are implemented.
The healthcare system consistently emphasizes coordination, efficiency, prevention, and reduced fragmentation.
Reimbursement policies should support those objectives rather than inadvertently penalizing providers for accomplishing them.
Coverage Does Not Answer Every Reimbursement Question
Breastfeeding support also reveals another important distinction.
Federal preventive-services requirements provide substantial protections for breastfeeding support and counseling under applicable health plans.
However, the federal government has expressly stated that the reimbursement methodology for certified lactation consultants falls outside the scope of the HRSA preventive-services guidelines.
This means that coverage requirements and provider reimbursement rules are related but not identical.
A service may be recognized as a covered preventive benefit while providers still encounter disputes over billing codes, network arrangements, reimbursement frequency, or whether particular clinical activities are separately payable.
For lactation providers, that distinction matters enormously.
A promise of breastfeeding coverage does not, by itself, explain how every maternal or infant service will be reimbursed.
Five Questions Payers Should Be Prepared to Answer
Before implementing reimbursement reductions or broader bundling policies, payers should be able to explain:
Which clinical activities overlap? Identify the actual duplicated work rather than assuming all same-day services share the same resources.
Was that overlap already accounted for? Explain whether existing code valuations or reimbursement rates already exclude routine procedural work.
How are separate patients handled? When care involves two insured individuals, explain which services are covered under each patient’s benefits.
What evidence supports the reduction? A uniform 50% reduction should have a defensible basis in the work and resources actually involved.
What happens to patient access? Evaluate whether the policy encourages unnecessary additional appointments, limits available services, or increases administrative costs.
These questions do not presume that every bundling policy is inappropriate.
They demand transparency about how those policies are developed and applied.
Providers Are Successfully Challenging These Changes
There is reason for providers to pay attention—and to participate.
In April 2026, Blue Cross Blue Shield of Michigan paused a proposed modifier 25 policy that would have reduced payment for certain E/M services by 50%.
In September 2026, Regence BlueShield announced that it would not implement a proposed modifier 25 policy limiting payment for certain same-day E/M services based on a previous encounter with the same diagnosis.
These reversals demonstrate that organized provider advocacy can influence reimbursement decisions.
The objections have not been limited to lost revenue. Professional organizations have highlighted medical necessity, accurate code valuation, administrative burden, and potential consequences for patient access.
Those concerns are relevant to every specialty facing policies that may undervalue necessary medical work.
A Better Standard for Reimbursement
The objective should not be to maximize the number of claims submitted.
It should be to accurately recognize the care delivered.
One encounter may involve one service. It may involve several separately identifiable services. It may involve more than one patient.
These distinctions matter.
A comprehensive approach to reimbursement should account for clinical work already included in another payment, while also recognizing separate services that require additional assessment, decision-making, treatment, or resources.
One appointment does not always mean one service. And one coordinated treatment plan does not necessarily mean only one patient received care.
As the industry prepares for the proposed 2027 modifier 25 payment changes and the restructuring of maternity coding, providers across specialties have an opportunity to ask a common question:
Are reimbursement policies being designed around the medical care patients actually receive—or around increasingly restrictive definitions of what insurers are willing to pay for?
Patients deserve care that is coordinated and clinically appropriate.
Providers deserve payment policies that accurately distinguish necessary clinical work from genuine duplication.
Those goals should not be in conflict.
Sunshyn Credentialing & Medical Billing supports healthcare practices navigating payer enrollment, credentialing, medical billing, reimbursement policies, and the operational challenges of delivering quality patient care.
This article discusses publicly available reimbursement proposals and policies as of October 11, 2026. Individual payment determinations depend on the applicable plan, provider contract, clinical documentation, coding rules, and date of service.
Sunshyn practice resources
For help with claim submission and payer follow-up, see Sunshyn's medical billing services.
For a structured look at claims and billing workflows, explore the Insurance Billing Mastery learning pathway in the Sunshyn Learning Center.
Comments