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Wildflower Health has issued a new Cigna Lactation Statement of Work effective October 1, 2026. Providers are understandably noticing the reimbursement increase. The prior agreement paid $175 for an in-person lactation consultation. The new agreement increases that to $182 in most states and $193 in California, Hawaii, Massachusetts, New Jersey, New York, Oregon, Washington, and Washington, D.C. Virtual visits remain $100 and visits involving multiples remain $230. But the rate increase is not what providers should be paying the most attention to. The new agreement changes the amount of control Wildflower can exercise over independent lactation practices while leaving some very important questions unanswered: What authority has the provider actually given Wildflower? What rules actually come from Cigna? Why can't providers see the Cigna agreement Wildflower repeatedly relies upon? Why can Wildflower change its Provider Manual after the contract is signed without obtaining the provider's agreement to those changes? What happens to money generated by services the independent provider actually performed? And perhaps most importantly: Where is Wildflower given authority to submit claims as though Wildflower provided clinical care that was actually rendered by an independent practice? Those are not minor administrative questions. They go directly to who controls an independent provider's practice, who owns the receivable generated by that practice's services, and how those clinical services are represented to the payer. First, understand what this contract actually is The new document is not a completely new standalone master agreement. Wildflower and the provider already have a Management Services Agreement, or MSA. The Cigna Lactation Statement of Work operates underneath that agreement. The original MSA says Wildflower provides management services described in individual Statements of Work, while the contractor provides the services described in those SOWs. The new October 2026 document expressly says that it supersedes and replaces the previous Cigna Lactation SOW in its entirety. So providers should not look at this as simply accepting a small fee-schedule update. They are signing a replacement agreement containing new contractual obligations. One of those additions is particularly concerning. The old contract did not bind providers to Wildflower's Provider Manual The prior Cigna SOW required the contractor to oversee quality, credentialing, service monitoring, patient safety, and risk management. It then moved directly to the disclaimer section. There was no provision requiring the contractor to follow a Wildflower Provider Manual. The new SOW adds one. The new agreement says the provider acknowledges receipt of Wildflower's Provider Manual. It then says Wildflower may update that Manual “from time to time.” It goes even further. The contract says providers may receive additional Wildflower policies in other forms, including FAQs, protocols, guidelines, and other requirements or procedures. And the contractor agrees to comply with those materials as part of its obligations under the SOW. That is a significant transfer of control. You are agreeing today to rules Wildflower can change tomorrow Read what is missing from that provision. It does not say Wildflower must obtain the provider's signature before changing the Provider Manual. It does not require a formal contract amendment. It does not require mutual agreement. It does not say the provider must affirmatively accept the new rule. It does not even limit future requirements to the four corners of the Provider Manual. Wildflower can also issue policies through FAQs, protocols, guidelines, and other communications. In practical terms, the provider signs the agreement once. Wildflower can then change the Manual later. The provider has already agreed that it will comply. That deserves far more attention than a $7 or $18 reimbursement increase. Independent providers should know what rules they are agreeing to before they agree to them. Then there is an even bigger transparency problem: the Cigna agreement providers cannot see Wildflower's SOW repeatedly relies on another contract: the Cigna Provider Network Agreement. The SOW expressly says that the services are being provided in connection with Cigna and the “Cigna Provider Network Agreement.” The billing section goes even further. Wildflower is given oversight over methods of collecting accounts receivable, settling disputes regarding charges, and writing off charges. But those activities are supposed to remain subject to applicable governmental regulations and the terms and conditions of applicable payer agreements. That same structure remains in the new agreement. There is one obvious problem: The independent provider does not have the Cigna Provider Network Agreement. The SOW does not attach it. The documents we reviewed do not provide an express contractual right for the contractor to inspect its relevant provisions. Yet that undisclosed agreement is being invoked as part of the authority governing how the provider's claims are handled. That creates an enormous verification problem. What happens when Wildflower says, “Cigna requires this”? Suppose Wildflower introduces a new billing requirement next year. A provider objects. Wildflower responds: “Cigna requires us to do it this way.” How does the provider verify that statement? They cannot simply open the Cigna agreement and read the provision. They do not have it. That leaves providers unable to independently determine whether a rule: actually came from Cigna; represents Wildflower's interpretation of its Cigna agreement; is an operational decision made by Wildflower; came from the Wildflower Provider Manual; or was introduced through a Wildflower FAQ, protocol, or guideline. That distinction matters. It is not enough for an intermediary to say that an undisclosed contract gives it authority. Providers whose NPIs, clinical services, records, and reimbursement are affected should be able to determine what authority actually exists. And now Wildflower controls another source of rules The 2026 agreement compounds the problem. Wildflower can potentially point to two separate sources of authority that the provider did not negotiate directly. First: “Cigna requires it.” But the provider cannot review Wildflower's Cigna agreement. Second: “It's in our Provider Manual.” And Wildflower has reserved the ability to change that Manual after the provider signs. That is an extraordinary amount of control to hand to an intermediary. There is also a completely separate claims issue that still has not been answered There is another problem that has existed throughout this relationship and should not be confused with the Provider Manual issue. Where is Wildflower actually authorized to submit claims as though Wildflower provided the clinical service? Because that is not what the provider contract says. The agreement is very clear about who performs lactation care. It says the Contractor provides the Lactation Consultation Services. Those services include in-person home visits, office visits, and virtual telehealth consultations performed by the contractor's IBCLC. What does Wildflower do? Wildflower is the Manager. And when the contract discusses billing, it says: “Contractor hereby appoints Manager as its billing and collection agent for all fees related to the performance of medical services by Contractor.” Read that carefully. Wildflower is appointed the provider's billing and collection agent. The medical services are performed by the Contractor. Those are two very different roles. A billing agent collecting money does not make the clinical receivable its own There is nothing unusual about a healthcare practice hiring someone else to handle its claims. Medical billing companies do it every day. A biller can prepare a claim. A biller can transmit a claim. A biller can follow up with the payer. And, when appropriately authorized, a billing or collection agent can receive funds on behalf of the provider. That last phrase matters. The fact that an agent touches the payment does not, by itself, establish that the agent furnished the healthcare service or that the underlying receivable became the agent's clinical revenue. The agreement here says Wildflower is collecting fees related to medical services performed by the Contractor. It does not say that the contractor sells or assigns the underlying clinical services to Wildflower. It does not say Wildflower becomes the owner of the contractor's clinical receivable. It does not say the contractor becomes a Wildflower group-practice member. It does not say Wildflower becomes the clinician that treated the patient. The commercial arrangement here needs to be evaluated under the actual Cigna and Wildflower contracts. And that takes us directly back to the transparency problem: providers are not being shown the Cigna agreement. There is an additional patient-authority question There is another layer that deserves examination. In the arrangements providers have described, the patient may never independently contact Wildflower at all. The patient sees the independent lactation provider. The independent provider performs and documents the care. The provider's own office staff then enters the claim information into the Wildflower process. If that is the workflow, an obvious question follows: What patient authorization, assignment, or other legal mechanism gives Wildflower an independent right to treat the reimbursement generated by that encounter as payment for Wildflower's own clinical service? The provider contract unquestionably gives Wildflower authority to act as a billing and collection agent. That establishes an agency relationship between the provider and Wildflower for billing. But an agency relationship is not the same thing as proving that Wildflower independently owns the underlying clinical receivable or may represent itself as the provider that furnished care. The reimbursement arises from healthcare services performed by the independent provider. If the patient has never separately contracted with Wildflower, assigned benefits to Wildflower, or even interacted with Wildflower, then the basis for any claim that Wildflower independently owns that reimbursement deserves a clear explanation. If Wildflower's position is that another document supplies that authority, providers should be able to identify that document. Was there a patient assignment? Was there a patient financial agreement with Wildflower? Was the independent provider's receivable assigned to Wildflower? Does the Cigna agreement create a special network payment structure? Does some other contract authorize Wildflower to bill as the clinical entity? Those questions can have answers. But the answer should not simply be: “Trust us. It's in the Cigna agreement you aren't allowed to see.” A biller submitting a claim does not become the clinician who saw the patient Wildflower's provider contract expressly grants it billing and collection authority. What we have not found in either the MSA or the Cigna SOW is language authorizing Wildflower to represent itself as the clinician or clinical entity that actually rendered an independent provider's service. There is no provision saying: The contractor assigns its clinical services to Wildflower. There is no provision saying: The contractor becomes part of a Wildflower medical group. There is no provision saying: Wildflower shall be identified as the rendering provider for care furnished by the contractor. And there is no provision turning independently owned lactation practices into Wildflower practice locations. In fact, the master contract says almost the opposite The MSA expressly describes Wildflower as an independent contractor. It says the agreement does not create a partnership, joint venture, association, or other relationship beyond that independent-contractor relationship. It also says the provider is contracting with Wildflower to obtain management services. The contract separately says each party remains responsible for the actions of its own personnel and the services those personnel perform. That does not read like a traditional group-practice agreement. It reads exactly like what the document calls it: A management company contracting with an independent healthcare practice. If another agreement changes that, providers should be allowed to see it Perhaps Wildflower's separate agreement with Cigna contains provisions explaining precisely how Cigna wants claims submitted. Perhaps it establishes a unique network-payment arrangement. Perhaps it gives Wildflower rights that do not appear in the provider-facing MSA or SOW. That is possible. But if Wildflower relies on that agreement to justify how a provider's clinical services, NPI, claims, or payments are handled, refusing providers visibility into the relevant terms creates the exact accountability problem this article is about. The provider is being asked to accept Wildflower's interpretation of an agreement the provider cannot independently inspect. That should not be normal. Providers also have very limited leverage once they sign — individually If a provider disputes Wildflower's actions, this is not a traditional contract where the obvious next step is simply to file a lawsuit. The Management Services Agreement contains a binding arbitration provision. Disputes are submitted to binding arbitration under the Commercial Rules of the American Arbitration Association. The arbitration costs are divided equally between the parties, and the prevailing party may recover reasonable attorneys' fees and costs. There is also a material-breach process. And either party can terminate without cause. But termination generally requires 90 days' written notice. For one small lactation practice standing alone, that creates a very uneven practical relationship. But individually is the important word. Providers have more power than they sometimes realize This industry has spent years treating payer and vendor contracting as something that happens to providers. A contract appears. Providers assume they have no choice. The rules change. Providers adapt. The payment changes. Providers absorb it. That does not have to be the dynamic. A provider network only functions if actual providers agree to participate. Wildflower cannot provide nationwide lactation services to Cigna members through a network of independent clinicians without independent clinicians willing to remain in that network. That gives providers leverage — especially when they communicate with one another, compare contracts, ask the same questions, and demand the same transparency. This does not require anyone to tell another provider whether to sign or terminate a contract. Each independent practice has to make that decision for itself. But providers absolutely can insist on information before making that decision. They can band together around transparency. They can ask the same questions. They can insist that vague references to confidential payer agreements are not enough. They can collectively demand: Show us the Provider Manual before we sign. Explain how future changes become binding. Show us the contractual authority for the claim structure. Tell us which requirements actually originate with Cigna. If you say Cigna requires something, provide the language supporting that claim. Explain exactly how billing, rendering, pay-to, and service-facility information is being transmitted. Transparency becomes much harder to avoid when providers stop asking those questions one at a time. The timing of this new agreement deserves attention too The timing of the new SOW is difficult to ignore. Providers and advocates have been raising increasingly direct questions about Wildflower's reimbursement, billing structure, transparency, Cigna contracting relationship, and the authority underlying its claims practices. Now, during that period of increased scrutiny, Wildflower has produced a replacement SOW that increases certain reimbursement rates and adds new language expressly binding providers to a Provider Manual and future Wildflower-issued policies. We cannot prove from timing alone that provider pressure caused these changes. But the timing is certainly notable. And it demonstrates something providers should not overlook: these arrangements are not fixed in stone. Rates can change. Contract terms can change. Policies can change. Businesses respond when enough pressure is applied to a problem. That is exactly why providers should reject the idea that they have no power. One provider asking for transparency can be dismissed. A network of providers asking the same questions is much harder to ignore. Wildflower is not synonymous with Cigna Wildflower currently has a real relationship with Cigna. That should not be confused with saying that Wildflower is Cigna. It is not. There are legitimate ways for qualifying healthcare providers and appropriately structured ancillary entities to pursue direct Cigna contracting outside of Wildflower. That does not mean every standalone IBCLC in every state will qualify for a direct contract. Provider type, licensure, entity structure, market, network need, and Cigna's contracting criteria all matter. But providers should stop treating Wildflower as though it is automatically the only possible doorway to Cigna. It is an intermediary with a payer relationship. Those are not the same thing. Cigna may still back Wildflower, but Wildflower still needs providers Nothing about these concerns means Cigna has ended its relationship with Wildflower. Cigna may continue to support the arrangement. But Wildflower cannot operate a national lactation network without actual lactation providers willing to participate. That is where provider power exists. A network is not a contract between corporations. A network is the clinicians who actually agree to see the patients. If enough independent practices determine that the lack of transparency, contract structure, billing model, reimbursement, or unilateral policy authority is unacceptable, that affects Wildflower's ability to maintain the provider access the arrangement depends on. Providers do not have to accept a contract simply because a large company presents it. They can ask questions. They can compare contracts. They can choose other legitimate contracting pathways where available. They can decline terms they do not accept. And they can communicate with one another instead of negotiating in isolation. Before signing this agreement, ask questions Every provider considering this new SOW should be asking Wildflower, in writing: Please provide the current Provider Manual that I am being asked to acknowledge receiving. What notice will providers receive before the Manual is changed? Do future Manual changes require my affirmative acceptance? If not, why not? Which requirements originate with Cigna and which originate with Wildflower? If Wildflower states that Cigna requires a particular billing or operational rule, will Wildflower provide the applicable contract language supporting that statement? What provision of my agreement authorizes Wildflower to identify itself as the rendering provider, if Wildflower is doing so on claims for services I actually performed? Am I considered part of a Wildflower group practice for claims purposes? If so, where does my contract establish that relationship? If not, how are the billing and rendering NPIs being submitted to Cigna? What entity is identified in each applicable billing-provider, rendering-provider, pay-to, and service-facility field? What document gives Wildflower ownership of the reimbursement generated by my clinical service rather than merely authorizing Wildflower to collect that reimbursement on my behalf? What patient authorization or assignment supports Wildflower's role when the patient never independently engaged Wildflower? Those are basic questions about a provider's own services. They should have straightforward answers. A few more dollars per visit should not distract providers from what they are signing Wildflower increased its in-person reimbursement. Providers can decide for themselves whether the new rates are financially acceptable. But $182 or $193 instead of $175 does not resolve the larger issues. The 2026 agreement now expressly requires providers to comply with a Wildflower Provider Manual that Wildflower can change after signature. Wildflower continues to invoke an underlying Cigna Provider Network Agreement that independent contractors cannot independently review. The contract appoints Wildflower as a billing and collection agent for healthcare services performed by the contractor, but the agreements reviewed do not expressly establish Wildflower as the rendering clinician, convert independent practices into a Wildflower group practice, or expressly assign the contractor's clinical receivables to Wildflower. And if providers disagree with Wildflower's interpretation of any of this, the agreement channels disputes into binding arbitration while allowing termination with 90 days' notice. The timing of this replacement agreement — following increased provider scrutiny and pressure over Wildflower's reimbursement and business practices — is also worth paying attention to. We cannot say the pressure caused the changes. But providers should absolutely recognize what the changes themselves demonstrate: providers have power when they use it. Wildflower may have Cigna's backing. It still needs providers willing to participate. Providers are not required to negotiate alone. They are not required to accept unexplained rules. They are not required to stop asking questions because a company says an answer exists in a contract they are not allowed to see. Providers can compare information. They can demand transparency together. They can explore legitimate direct contracting alternatives. And they can decide whether the terms being offered are acceptable. Before signing away more control, ask to see the rules. Ask where the authority comes from. Ask who owns the claim. Ask who is being represented as having provided the care. And when someone says: “Cigna requires it,” providers should be entitled to respond: Show us where.

UnitedHealthcare’s reimbursement changes have left many lactation practices trying to determine how they can continue providing financially sustainable care. The concern is understandable. Lactation visits are often lengthy, clinically complex and dyadic. The provider is assessing the mother while also evaluating feeding, milk transfer, weight concerns, oral function and other issues affecting the infant. When a payer recognizes only the mother’s portion of that work, the reimbursement may no longer support the traditional 90-minute or two-hour appointment. However, charging the patient an “administrative fee” to make up the difference is generally not an appropriate solution for an in-network provider. You Cannot Rename the Balance and Bill the Patient Most participating-provider agreements prohibit providers from billing members additional amounts for covered services beyond the patient’s assigned copayment, coinsurance or deductible. The exact language varies by payer and contract, but the principle is usually the same: the provider agrees to accept the payer’s allowed amount as payment in full for a covered service. Calling the additional charge an administrative fee, access fee, coordination fee, supply fee or practice fee does not necessarily make it permissible. If the fee is required for the patient to receive the covered lactation visit—or if it is being charged specifically because the contracted reimbursement is inadequate—the payer may treat it as prohibited balance billing. The issue is not simply what the fee is called. The issue is what the patient is actually paying for. If an insured patient must pay an extra $50 before receiving an in-network office visit, and that $50 exists to supplement the payer’s reimbursement for the visit, it is difficult to separate that charge from the covered service. A consent form does not automatically correct the problem. A patient cannot waive protections contained in a provider’s network agreement simply by signing a practice policy. Travel Fees Are Different—but Still Require Caution A travel fee for a home visit is different from an administrative fee added to an office appointment. The payer may reimburse the professional service without reimbursing the provider’s travel time, mileage, tolls or extended service area. In that situation, a separately disclosed travel charge may be permissible if: The provider’s contract does not prohibit it. The fee applies specifically to travel rather than clinical care. The charge is clearly disclosed before the appointment. The patient has a genuine option to receive care without the travel charge, such as an office or telehealth appointment when clinically appropriate. The fee is applied consistently and is not disguised balance billing. Applicable state law allows it. That does not mean every payer automatically permits travel fees. Each contract and applicable state requirement still needs to be reviewed. An office visit, however, has no comparable travel expense. Adding an administrative fee to every UHC office appointment because UHC reduced reimbursement is much more likely to be viewed as charging the member for part of a covered service. The Difficult Answer: The Appointment Model Has to Change If UHC’s allowed amount no longer supports a 90-minute or two-hour office visit, the safer response is to adjust the amount of time included in that appointment—not transfer the payer’s reimbursement shortfall to the patient through a mandatory fee. That may mean scheduling a shorter initial office visit, addressing the most urgent clinical concerns and having the patient return for a follow-up visit when additional covered care is medically necessary. For example, the provider may need to: Complete the immediate maternal lactation assessment. Address the most pressing feeding concern. Develop a focused initial care plan. Schedule a follow-up to reassess progress and address remaining concerns. This is not about unnecessarily dividing one service into multiple claims. Each appointment must be medically necessary, independently documented and supported by the patient’s condition. Providers should never schedule redundant visits solely to generate additional reimbursement. But providers are also not contractually obligated to donate unlimited time because a payer reduced its reimbursement. A payer cannot reasonably expect a provider to continue delivering two hours of professional care for a rate that supports a substantially shorter appointment. If reimbursement changes, the structure and scope of the appointment may also have to change. Do Not Sacrifice Documentation to Preserve Face-to-Face Time Shortening an appointment does not mean reducing required documentation or attempting to complete uncompensated work after hours. The record must still support: The patient assessed The services performed The clinical findings The diagnoses addressed The care plan The medical necessity of any follow-up The time involved when required by the reported code Providers should build documentation, care coordination and necessary follow-up communication into the operational cost of the service. If the reimbursement does not cover that work, the practice must reconsider the length and structure of the service—not simply relabel part of the covered work as an administrative expense. Optional Services Must Be Truly Optional Practices may be able to charge separately for certain noncovered products or services, depending on their contracts and state law. Examples might include optional retail products, classes, memberships or services that are genuinely separate from the patient’s covered clinical care. The distinction matters. A service is not truly optional if the patient must purchase it to access an in-network appointment. A membership is not separate from covered care if patients who decline it cannot receive the covered service. An administrative fee is not unrelated to the visit if its purpose is to close the gap between the billed charge and UHC’s allowed amount. Before implementing any patient charge, the practice should ask: Would this fee exist if UHC had not reduced its reimbursement? If the honest answer is no, the charge deserves additional contract and legal review before it is collected. UHC Created the Sustainability Problem UnitedHealthcare continues to describe lactation as dyadic care while its reimbursement structure may no longer adequately recognize payable services for both members of that dyad. That creates a real clinical and financial problem. An IBCLC cannot meaningfully evaluate breastfeeding without considering both the lactating parent and the feeding infant. Removing or restricting reimbursement for the infant’s portion of that work does not make the infant’s needs disappear. Providers should continue challenging the policy, requesting clarification regarding payable infant services and seeking appropriate fee-schedule increases. But while those objections are pending, practices must operate within their existing network agreements. The fact that the reimbursement is inadequate does not automatically create a right to charge the patient the difference. Practical Options for In-Network Practices Practices affected by the UHC reduction should consider: Reviewing the actual participating-provider agreement and applicable administrative policies Requesting a written fee-schedule increase Requesting written identification of payable infant codes Shortening standard UHC office appointments to a financially sustainable length Scheduling medically necessary follow-up visits Clearly separating maternal and infant assessments and documentation Offering home visits with a properly reviewed and disclosed travel policy Evaluating whether remaining in network is financially sustainable Obtaining payer-specific or legal review before implementing any mandatory patient fee Providers should not assume a strategy is compliant merely because another practice is using it. Enforcement may occur through member complaints, audits, recoupments, corrective-action plans or network termination—sometimes long after the fee was first collected. The Bottom Line UHC’s reimbursement cut should not be minimized. It places lactation providers in the impossible position of being expected to deliver dyadic care while being paid for only part of that care. But a mandatory administrative fee is not a safe way to restore the lost reimbursement. For most in-network practices, it risks violating the contractual prohibition against billing members beyond their assigned cost share for covered services. A legitimate, separately disclosed travel fee may be different when it is permitted by the provider’s contract and state law. A fee added to an office visit simply because the payer’s reimbursement is too low is much harder to defend. If the allowed amount no longer supports an extended appointment, the honest operational response is to shorten the visit, provide the care that can appropriately be completed within that time and schedule a medically necessary follow-up. Providers should continue fighting for reimbursement that reflects the real work of dyadic lactation care. Until UHC corrects the underlying problem, however, the financial burden cannot simply be renamed and transferred to the patient. This article provides general educational information and is not legal advice. Provider contracts, plan requirements and state laws vary. Practices should review their individual agreements and obtain qualified legal or compliance guidance before implementing additional patient fees.

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 lactation care fit into codes that were created for something else. I understand why this feels like progress. But I am not convinced that these codes, as currently structured and valued, are something the lactation profession should be heavily advocating for. In fact, I think there is a very real possibility that they could set reimbursement and independent lactation practice backward. What CMS is proposing For 2027, CMS is considering two new CPT codes for lactation care: 978XX for the initial 30 minutes of lactation care 978X1 for each additional 15 minutes CMS has proposed a work RVU of only 0.18 for the initial code. Even more concerning, the additional 15-minute code has no work RVU at all. CMS describes it as a practice-expense-only service. CMS is also proposing a new clinical staff category specifically for a Lactation Consultant, identified as L076A, and is currently proposing to value that clinical labor using the RN clinical staff rate as a pricing proxy. CMS is actively requesting comments on that structure before the September 14, 2026 deadline. (Federal Register Public Inspection) Those details matter much more than the simple fact that “lactation finally has CPT codes.” Medicare is assigning a value to a service it generally does not pay for This is one of my biggest concerns. Medicare is not the payer driving outpatient lactation care in this country. The overwhelming majority of comprehensive postpartum lactation services are being provided to people covered by commercial health plans and Medicaid. Yet Medicare is now establishing a national relative value for these services through the Physician Fee Schedule. That means CMS can assign a very low value to lactation care without experiencing much of the real-world consequence of that valuation. Commercial insurers and Medicaid programs, however, can look to Medicare RVUs when establishing or revising their own reimbursement methodologies. They do not have to adopt the new codes. They do not have to use Medicare’s payment rate. And they do not have to stop paying existing codes simply because new lactation CPT codes exist. That distinction is extremely important. But once a purpose-built lactation CPT code exists with an established Medicare value, payers suddenly have a very convenient benchmark. And that could be bad news. A new code does not automatically mean better reimbursement Right now, commercial lactation reimbursement is inconsistent, complicated and sometimes frustrating. But it is also frequently much better than what these proposed values appear likely to produce. Depending on the payer and provider type, lactation services are currently being reimbursed through combinations of: S9443 office consultation codes home-visit codes education codes other E/M services payer-specific lactation reimbursement policies Some of those arrangements reimburse comprehensive visits at rates that recognize the amount of time and complexity involved. Creating a specific lactation CPT code gives commercial payers another option. It also gives them an opportunity to say: “There is now a code specifically for lactation. Use that.” That is where I become very cautious about advocating for widespread adoption. Imagine a payer that currently reimburses a comprehensive lactation visit at $150, $200 or more through its existing coding policy. It now has a dedicated lactation CPT code carrying a very low Medicare relative value. There is nothing inherently preventing that payer from rewriting its policy and deciding that the new lactation codes are now the appropriate way to report the service. The existence of a dedicated code could therefore become the justification for reducing reimbursement rather than increasing it. That is not theoretical enough for me to ignore. We have watched commercial payers make major lactation reimbursement changes based on policy language, code definitions and provider classifications before. There is no reason to assume they will automatically use these new codes in a way that benefits lactation providers. The additional-time code concerns me even more Comprehensive lactation visits are rarely 30-minute encounters. Initial consultations of 60, 75, 90 minutes or longer are extremely common. Yet under the proposed Medicare valuation, the first 30 minutes receive a small professional work value, while every additional 15 minutes carries no work RVU and is treated as practice expense only. (Federal Register Public Inspection) Think about what that says about a 90-minute lactation consultation. The professional assessment, clinical decision-making, counseling, feeding evaluation, care planning and ongoing reassessment do not somehow stop after minute 30. But the valuation structure largely behaves as though the additional time is simply additional staff expense. That is difficult to reconcile with what actually happens during a comprehensive lactation visit. And if commercial insurers adopt that same framework, the financial consequences could be substantial. There is also a provider-status problem The reimbursement issue is only half of my concern. The other issue is who these codes are actually structured for. The proposed CPT language describes lactation care as being directed by a physician or other qualified health care professional. At the same time, CMS is creating a Lactation Consultant clinical staff category. (Federal Register Public Inspection) Those two pieces together deserve much more attention. For physicians, nurse practitioners and other independently licensed practitioners who also provide lactation care, the pathway is relatively easy to understand. For independently practicing IBCLCs — especially IBCLCs who do not hold another healthcare license — the implications are much less clear. An IBCLC credential and a state healthcare license are not the same thing This is an uncomfortable issue, but avoiding it does not make it disappear. IBCLC is a professional certification. It is not automatically a state-issued healthcare license. Some states regulate lactation consultants through licensure. Others do not. Commercial insurers have nevertheless chosen in many markets to recognize IBCLCs as independently credentialed providers and allow them to contract, render services and submit claims under their own NPIs. That commercial payer recognition has allowed an independent lactation practice model to develop even where the legal classification of an IBCLC as a “qualified healthcare professional” is not particularly clean. The more CMS formally enters this space, however, the more those distinctions matter. And CMS is not currently proposing to classify the lactation consultant as another independently billing practitioner category. It is proposing a clinical staff type. That is very different. “Clinical staff” could change the direction of independent lactation practice If the long-term interpretation becomes: Physician or qualified healthcare professional directs the service → lactation consultant performs the lactation care as clinical staff that does not strengthen independent IBCLC practice. It moves in the opposite direction. For an unlicensed IBCLC, this could ultimately support an argument that the appropriate role is inside a physician or qualified practitioner’s office rather than independently reporting the professional service. And there is another complication. People sometimes assume that putting an IBCLC under a physician automatically solves the billing problem through “incident to” billing. It does not. Medicare incident-to rules contain their own requirements regarding the patient’s course of treatment, practitioner involvement, employment or expense relationships, supervision and setting. An independent IBCLC cannot simply arrange for a physician to “supervise” the practice and automatically transform independent lactation services into legitimate incident-to physician services. So we could end up in an especially awkward place: The IBCLC is not clearly recognized as the independently reporting QHP. But the IBCLC’s existing independent practice also does not neatly fit traditional physician incident-to billing. The practical result could be pressure for lactation consultants to become actual clinical staff within physician or NP practices. That would be a major structural change for a profession that has spent years building independent practices and obtaining direct commercial payer contracts. This is why I am not ready to celebrate these codes I absolutely support accurate recognition of lactation care. I support better coding. I support appropriate reimbursement. I support clear pathways for qualified lactation professionals to provide covered services. But the existence of a lactation-specific CPT code is not inherently a win. A poorly valued code can be worse than no dedicated code at all. A code that commercial insurers use to replace higher-paying existing reimbursement can hurt providers. A payment structure that characterizes much of a comprehensive consultation as clinical staff expense can undervalue the service. And language that increasingly positions the lactation consultant as staff working under another practitioner could undermine the independent billing model many IBCLCs use today. Those risks deserve at least as much attention as the excitement surrounding new codes. What I would advocate for instead Before the lactation community pushes commercial insurers to adopt these codes, I think several things need to be addressed. First, the valuation needs to accurately reflect what comprehensive lactation care actually involves. A 60- or 90-minute lactation consultation is not simply 30 minutes of professional work followed by an hour of low-level staff time. Second, CMS should clarify what it means by physician or other qualified healthcare professional in relation to these codes and what role it expects the lactation consultant to occupy. Third, CMS should make clear that its designation of Lactation Consultant as a clinical staff type for Medicare practice-expense valuation should not be interpreted as determining an IBCLC’s independent professional status under state law or commercial payer contracts. And finally, the existence of these new CPT codes should not be treated as making them the exclusive codes for every service involving lactation. If another CPT or HCPCS code accurately describes a separately reportable service performed by a provider who is qualified to report it, the fact that a lactation-specific code now exists should not automatically erase that coding pathway. Progress is only progress if the result is better The lactation profession has spent years fighting for recognition and reimbursement. That makes it tempting to view any dedicated CPT code as an automatic victory. I don’t think we can afford to do that here. The question should not be: “Did lactation finally get its own CPT codes?” The questions should be: Who can actually bill them? How much will they pay? How will commercial insurers use them? Will they supplement existing reimbursement pathways or replace them? And what happens to independently practicing IBCLCs if lactation consultants become increasingly defined as clinical staff working under another qualified practitioner? Until we have better answers to those questions, I would be very cautious about asking commercial payers to adopt these codes. Something can look like recognition on paper and still result in lower reimbursement, narrower provider eligibility and less independence in practice. That would not be progress. It would be a step backward dressed up as one.

Apparently, this needs to be said: When a mother’s Aetna lactation benefits are exhausted, you cannot simply start billing lactation visits under Dad’s name because he has benefits available. And if Dad wasn’t even at the visit, that should be an immediate red flag. This issue is especially important for lactation providers who work through third-party billing or network organizations and may not have direct visibility into the claims being submitted for the care they provide. If a patient tells you, “They said since my benefits are used up, they’re going to bill the rest under my husband’s name,” don’t assume that’s a normal insurance workaround. Start asking questions. Insurance Benefits Belong to the Patient Receiving the Service Insurance claims are not a pool of household benefits that can be moved from one family member to another when someone’s benefits are exhausted. A claim identifies a patient. It reports a service provided to that patient. The medical record should support that service. And the diagnosis and procedure codes submitted on the claim should correspond to what actually occurred. If Mom was the patient, Mom received the service, and the documentation is for Mom, the fact that Dad has unused benefits does not turn Dad into the patient. Exhausted benefits do not create a new patient. What If Dad Wasn’t Even There? This makes the problem considerably more obvious. Suppose Mom attends a lactation visit. Dad isn’t present. The lactation consultant never sees him. He isn’t assessed. He isn’t counseled. He doesn’t participate in education or training. There is no Dad-specific plan of care. There is no clinical documentation of a service actually provided to Dad. Then someone says: “Mom is out of lactation benefits, so we’ll bill this visit under Dad.” What exactly are you billing to Dad? That’s the question providers should immediately ask. A payer claim isn’t supposed to represent a fictional encounter created because another family member happens to have unused benefits. Dad Can Be a Patient—When Dad Is Actually a Patient This distinction is important. There may absolutely be circumstances in which a father or other parent legitimately receives a healthcare service. If an appropriate covered service is actually furnished to Dad, documented for Dad, medically appropriate for Dad, and accurately coded and billed under Dad’s coverage, that’s a different situation. The problem isn’t that fathers can never be patients. The problem is using Dad as the named patient solely because Mom’s benefits have been exhausted. Those are not remotely the same thing. Outsourcing Billing Is Fine. Lack of Visibility Is the Red Flag. Healthcare providers routinely use third-party billing companies, and there is nothing inherently concerning about that arrangement. The concern is when a provider is unable to see the claims being submitted on their behalf—or the remittance advice showing how those claims were adjudicated. If a claim is being submitted for your professional service, potentially using your NPI and credentials, you should be able to determine what was actually reported to the payer: who was identified as the patient; what procedure codes were submitted; what diagnoses were reported; what units were billed; what charges were submitted; and how the payer processed the claim. That becomes especially important when a patient tells you something as significant as: “They said my lactation benefits ran out, so they’re going to bill the visits under my husband’s name.” At that point, the lack of claim visibility isn’t a theoretical concern anymore. The provider has been given a concrete reason to verify what is being submitted for the care they personally provided. And if Dad wasn’t even present, the question becomes extremely simple: What service could the claim possibly say was provided to him? A third-party billing arrangement should make billing easier for providers. It should not prevent providers from knowing how their own professional services are being represented to an insurance company. Outsourcing the billing function is normal. Outsourcing it without meaningful visibility into the claims and remittances submitted under your professional identity is the red flag. “I Don’t Handle the Billing” Is Not a Reason to Ignore a Red Flag Providers do not need to personally submit every claim. They do not need to become professional coders. They do not need to manage the billing office themselves. But if a patient reports that a visit was or will be billed under a different family member because benefits were exhausted, that should trigger verification. At minimum, the provider should be able to ask: What claim was submitted for the care I provided? Who was identified as the patient? What procedure code was submitted? What diagnosis was attached to it? Was the claim submitted under my NPI or credentials? Does the claim match my clinical documentation? Those are reasonable questions for any healthcare professional whose services are being billed to an insurer. Benefit Exhaustion Is a Coverage Issue, Not Permission to Change Patients If Aetna determines that Mom has exhausted the lactation benefits available under her plan, then the next question is what happens under Mom’s benefits and the provider’s contractual obligations. Maybe additional services aren’t covered. Maybe another appropriate benefit applies. Maybe there are appeal rights. Maybe the patient becomes financially responsible under the terms of the plan. Maybe the network contract requires a write-off. Maybe advance notice is required before a noncovered service can be provided privately. The exact answer can depend on the plan and circumstances. But one answer should immediately raise concern: “We’ll just bill somebody else.” The identity of the patient is not a workaround for a benefit limitation. Your Documentation Should Match the Claim Providers should be able to perform a very simple exercise. Put your clinical documentation beside the claim. Do they tell the same story? If the claim identifies Dad as the patient, where is the documentation showing the service you provided to Dad? What did you assess? What did you teach him? Why was the service medically appropriate for him? How much time did you spend providing that service to him? What diagnosis supports the claim? And perhaps the easiest question of all: Was he even there? If the answer to that last question is no, you have a very good reason to stop and investigate before accepting an explanation that this is simply “how lactation billing works.” Providers Need Visibility Into What Is Being Billed in Their Names This is also a broader lesson for lactation consultants using third-party networks and billing companies. You should know enough about the billing process to recognize when something doesn’t make sense. Ask how claims are submitted. Ask which patient is billed. Ask which codes are used. Ask whether claims are submitted under your NPI. Ask how benefit exhaustion is handled. Ask what happens when a claim is denied. Ask whether you can review claims and remittance information associated with your services. If the answer is essentially, “Don’t worry about it; we handle everything,” that should not necessarily make you feel better. If your name, NPI, credentials, and professional services are attached to the claim, you should have a way to verify what is being represented. Listen When Patients Tell You Something Doesn’t Sound Right Sometimes the provider’s first indication of a billing problem comes from the patient. A patient may receive an EOB. She may notice her husband’s name. She may be told something surprising by the billing company. She may ask you why insurance says Dad received a service when Dad never attended the appointment. Don’t dismiss those conversations because you don’t personally handle claims. They may be giving you information about how your services are being represented to a payer. That deserves attention. The Bottom Line When Mom’s Aetna lactation benefits are exhausted, you don’t solve the problem by finding another insured person in the household with unused benefits. The patient on the claim should be the patient who actually received the reported service. Dad can legitimately be a patient when a medically appropriate service is actually provided to Dad. But if Dad wasn’t evaluated, wasn’t counseled, wasn’t documented, and wasn’t even at the appointment, billing the visit under his name simply because Mom ran out of benefits should be an enormous red flag. And if you’re a provider working through a third-party organization and a patient tells you this is happening, don’t dismiss it because you don’t handle the billing. Ask to see what’s being billed. Ask to see how it was adjudicated. Your documentation tells one side of the story. The insurance claim and remittance tell the other. They should match.

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.

There is an important distinction providers—and health plans—need to understand: Being a virtual-only provider is legitimate. Listing a mailbox or virtual mailing address as though it were a physical practice location is something entirely different. Providers increasingly deliver care through telehealth, mobile services, home visits, and other nontraditional practice models. Major payers have systems designed to accommodate those models. You do not need to pretend to have a brick-and-mortar office simply because you practice virtually. In fact, listing yourself correctly as virtual-only is far more defensible than supplying an address where patients cannot actually receive care. A Virtual-Only Provider Does Not Need a Fake Office Aetna specifically defines a “Virtual Only Provider” as a qualified healthcare provider who provides healthcare services only through telehealth. In other words, virtual-only participation is not some loophole—it is a recognized practice model within Aetna’s own participation criteria. (Aetna) UnitedHealthcare has gone even further in 2026 by adding specific care-setting designations such as: Office or clinic Mobile health clinic Virtual Home-based care Remote diagnostics UHC explains that these settings are intended to accurately configure provider addresses for claims, credentialing, contracting, and directory purposes. For virtual and other nontraditional providers, UHC says the process may designate an address as a remote billing address specifically to prevent nonphysical addresses from appearing in the provider directory as in-person locations. (UHC Provider) That distinction is crucial. A billing address can be one thing. A correspondence or mailing address can be another. A physical practice location is something else entirely. They should not be treated as interchangeable. A P.O. Box Can Be a Mailing Address. That Doesn’t Make It an Office. There is nothing inherently improper about maintaining a P.O. box or commercial mailing address for business correspondence. The problem begins when that mailing address is submitted, maintained, or published as a practice location—particularly when the directory represents that patients can receive care there. Aetna’s own enrollment materials demonstrate the distinction. Its NPI submission process permits a P.O. box in the billing location information, while its network facility form separately requires the official primary service address and expressly says not to provide P.O. box information for that location. (Aetna) UnitedHealthcare makes essentially the same distinction in its claims guidance. A P.O. box or lockbox belongs in the Pay To Address field when applicable. The billing/practice-location information requires the appropriate street-address information instead. (UHC Provider) CMS follows this same basic principle. Medicare enrollment materials distinguish a correspondence mailing address—which may include a P.O. box—from a business primary practice location, for which a P.O. box is not acceptable. (Centers for Medicare & Medicaid Services) So the issue isn’t whether a provider is allowed to receive mail somewhere. Of course they are. The issue is whether that address truthfully represents where and how care is delivered. Virtual Offices Create the Same Problem When No Care Occurs There Calling something a “virtual office” does not transform it into a healthcare practice location. There are businesses that will rent a provider: a street address, a suite number, mail forwarding, package receiving, receptionist services, occasional conference-room access, or a prestigious business address. Those services may be perfectly legitimate for administrative purposes. But if patients cannot actually make an appointment and receive the services represented in the payer directory at that address, it should not be represented to patients as an ordinary office practice location. The relevant question is not: “Does this address technically exist?” It is: “Does the provider actually furnish the represented patient care at this location?” UnitedHealthcare’s directory requirements are particularly instructive. UHC tells providers to maintain “office locations where the provider accepts appointments only” and separately asks providers to identify telehealth services. (UHC Provider) That makes it very difficult to justify a directory entry simply because a mailing company assigned someone a suite number. Even Medicare Has a Better Solution for Telehealth Providers Working From Home Privacy is a legitimate concern. Many virtual providers work from home and understandably do not want their residential street address displayed publicly. But the solution is not to manufacture a patient-facing office. CMS now expressly allows clinicians providing telehealth-only or other non-patient-facing services from home to identify a home location in PECOS as “Home office for administrative/telehealth use only.” CMS can then suppress the street address from public display while retaining the appropriate city, state, and ZIP information. (Centers for Medicare & Medicaid Services) That is an excellent example of how this issue should be handled: Accurately identify the care model, then protect the provider’s privacy. Don’t solve a privacy problem by creating an inaccurate provider-directory entry. NCQA Also Recognizes “Virtual Only” This isn’t an obscure distinction. NCQA has specifically addressed virtual-only practitioners in directory standards. Its guidance says that when a practitioner has no physical office, the directory should indicate “virtual only.” (NCQA) That is precisely what patients need to know. A patient searching a directory should be able to distinguish among: Office care — “I can go to this address for an appointment.” Home/mobile care — “This provider comes to patients rather than seeing them at an office.” Virtual care — “This provider sees patients remotely.” Those are all legitimate models. What is not a legitimate fourth model is: “The directory says this is an office, but when you arrive, it is actually a mailbox.” “But the Insurance Company Approved It” Is Not the Same as “The Insurance Company Allows It” This may be the most important point. Providers sometimes assume that because an enrollment or credentialing application was processed successfully, every piece of information submitted must have been affirmatively reviewed and approved as compliant. That is not necessarily true. Payer credentialing and directory systems process enormous volumes of provider demographic information. Automated verification, delegated credentialing, third-party data sources, provider attestations, and imperfect address-validation systems can all allow inaccurate information into a network directory. A payer failing to catch an inaccurate address does not convert that address into a legitimate practice location. If a provider enters the street address of a commercial mailbox facility and the payer’s system recognizes it as a deliverable USPS address, that tells us the address exists. It does not establish that the provider practices medicine, nursing, lactation care, behavioral health, or any other healthcare service inside that mailbox facility. Those are two completely different questions. And insurers themselves increasingly recognize the problem. UHC specifically says its newer address configuration is intended to prevent nonphysical addresses from appearing in the provider directory as in-person locations. (UHC Provider) That would not be necessary if every address that made it through enrollment were automatically an appropriate patient-care location. Directory Accuracy Matters to Patients, Too This is more than a credentialing technicality. Provider directories exist for patients. Imagine a patient searching an insurance directory for an in-network provider near her home. The directory produces someone apparently practicing five miles away. She calls—or perhaps simply drives to the listed address—only to discover that it is: a post office, a UPS-style mailbox store, a mail-forwarding company, a registered-agent address, a virtual-office facility where the provider does not actually see patients, or an administrative address belonging to another company. The directory has given the patient false information about access to care. It can also make a network appear geographically broader than it really is. Ten providers assigned ten mailing addresses are not necessarily ten physical access points. That distinction becomes especially important when insurers evaluate whether their networks provide adequate geographic access to covered services. Residential Addresses Are Not Automatically the Problem There is another distinction worth making. A residential address is not inherently a fake practice address. Healthcare professionals legitimately operate businesses from home. Some provide patient care there when permitted by law and payer rules. Others use their home as the administrative base for telehealth or mobile services. The question is always what the address represents. A genuine home-based practice location should not be equated with a commercial mailbox simply because both may look unconventional. Likewise, a telehealth provider’s real administrative location does not suddenly become an in-person clinic because it appears in a database. The goal should be accurate classification—not penalizing nontraditional practice models. The Better Approach Is Simple If you are truly virtual-only, list yourself as virtual-only when the payer provides that option. If you perform home visits, make sure the payer understands that you provide home- or mobile-based care. If you have a legitimate office where patients are actually seen, list the office. If you use a P.O. box, UPS store, mail-forwarding company, or virtual office strictly to receive mail, use it only in the administrative, correspondence, billing, or pay-to capacity permitted by the payer. And if a payer’s enrollment system does not provide a sensible way to represent your actual care model, ask the payer how it wants the location reported rather than inventing a physical office. The principle is remarkably straightforward: Your provider directory listing should tell patients the truth about how and where they can receive care. Telehealth isn’t the problem. Virtual practice isn’t the problem. Home-based practice isn’t the problem. A mailing address masquerading as a patient-care location is the problem. And the fact that an insurer’s screening process failed to catch it should never be confused with permission to do it.

Most healthcare providers spend more time reviewing their reimbursement rates than they do reviewing the authority they’re granting a billing company. That’s understandable. When you’re trying to get a practice up and running, it’s easy to focus on getting credentialed, seeing patients, and getting paid. But one of the most important documents you’ll ever sign may be your billing and collection agreement. A billing company can only exercise the authority you give it. That authority should be clearly defined in your contract, and the company’s day-to-day operations should reflect what you’ve agreed to. What Does a Billing Company Typically Do? Medical billing companies exist to make the administrative side of healthcare easier. Depending on the agreement, they may: Prepare and submit insurance claims. Follow up on unpaid claims. Appeal claim denials. Post insurance payments. Send patient statements. Assist with credentialing and payer enrollment. Communicate with insurance companies regarding billing matters. Manage portions of the revenue cycle. In almost every billing relationship, these tasks are performed on behalf of the provider. The billing company is typically acting as an administrative agent—not replacing the provider or assuming responsibility for the medical services that were performed. The Provider Still Has Responsibilities One misconception is that hiring a billing company transfers responsibility for everything related to insurance billing. In reality, most billing agreements—including ours at Sunshyn Credentialing & Medical Billing—make it clear that the provider remains responsible for the accuracy of their documentation, coding, and the services they perform. Our agreement specifically states that Sunshyn bills on behalf of the provider. We submit claims, follow up with insurance companies, and assist with collections, but the provider remains responsible for the clinical information that supports those claims. This approach is common throughout the industry because billing companies generally rely on the provider’s documentation and coding decisions when submitting claims. Read the Contract—Not Just the Sales Pitch Recently, there has been public discussion surrounding another company’s provider agreement that describes its role as acting as a billing and collections agent. There’s nothing unusual about that description by itself. Many billing companies use similar language. The important question isn’t what the company calls itself. The important question is: Does the company’s day-to-day operation match the authority granted in the written agreement? Every provider should be comfortable answering that question before signing any contract. Questions Every Provider Should Ask Before entering into any billing relationship, ask yourself: Exactly what authority am I granting? Who is submitting claims under my name? Who communicates with insurance companies? Who receives insurance payments? Will I have access to claims, remittance advice, and billing records? Can I review claims submitted on my behalf? What happens if our business relationship ends? Does the company’s actual workflow match what the written agreement says? These aren’t adversarial questions—they’re simply good business questions. Why the Fine Print Matters Contracts exist to define expectations before problems arise. If your agreement says a company is acting on your behalf, the contract should clearly explain what that means. If the agreement grants authority to perform billing and collections, understand exactly what activities fall within that authority. If something isn’t addressed in the contract, ask about it before signing. Clear agreements help protect everyone involved—the provider, the billing company, and ultimately the patient. Don’t Skip the Arbitration Clause One section providers frequently overlook is the arbitration clause. Many billing and service agreements require disputes to be resolved through private arbitration rather than in court. Arbitration isn’t inherently good or bad, but it can significantly change your options if a disagreement arises. If you later discover that you and the company have different interpretations of the agreement, resolving that dispute may require hiring an attorney, paying filing fees, covering arbitrator costs, and investing considerable time before the actual issues are even addressed. For many small healthcare practices, those costs alone can make it difficult to challenge a contract after it’s been signed. That’s why reviewing the agreement carefully before signing is so important. An Hour Today Can Save Months Later The best billing relationships are built on trust, transparency, and clearly defined responsibilities. Whether you’re hiring your first billing company or considering a new one, don’t be afraid to slow down and read the agreement carefully. Understand exactly what authority you’re delegating. Know what responsibilities remain yours. Make sure the company’s business practices align with the authority described in the contract. And if there’s an arbitration clause, recognize that signing the agreement may limit how future disputes are resolved. A contract isn’t just paperwork—it’s the roadmap for your business relationship. Taking the time to understand it today could save you significant time, expense, and frustration in the future.

Effective immediately, Georgia Medicaid now requires the initial lactation consultation to be provided in person before any follow-up services may be delivered via telehealth. While telehealth continues to play an important role in improving access to lactation care, this policy changes how Georgia Medicaid beneficiaries begin treatment and may require providers to adjust scheduling workflows. What Changed? Under Georgia Medicaid’s updated policy: The first lactation visit must be completed in person. Follow-up visits may still be provided via telehealth when they otherwise meet Medicaid requirements. Providers should ensure documentation clearly identifies the initial face-to-face encounter before billing any telehealth follow-up services. Why This Matters Many breastfeeding challenges arise during the first few days after birth—often before families have reliable transportation, childcare, or the ability to travel. While an in-person assessment can provide valuable clinical information, it may also create additional barriers for some families who previously relied on virtual access immediately after hospital discharge. Practices serving rural communities, medically underserved areas, or families with transportation challenges should consider how this policy may affect appointment availability and patient access. Operational Considerations for Providers Georgia Medicaid providers should review their scheduling and billing processes to ensure compliance. Recommended steps include: Update scheduling protocols to identify Medicaid patients requiring an initial in-person visit. Educate front office staff on the new requirement. Verify telehealth eligibility before scheduling follow-up visits. Clearly document that the first lactation consultation occurred face-to-face. Maintain documentation supporting medical necessity and services provided for every encounter. Impact on Patients Patients should be informed that: Their first breastfeeding consultation must now occur in person if they are using Georgia Medicaid. Once the initial visit has been completed, subsequent follow-up care may still be available through telehealth when appropriate. Early scheduling after delivery is encouraged to avoid delays in breastfeeding support. Looking Ahead Telehealth remains an important tool for improving breastfeeding support, particularly for follow-up care. As state Medicaid programs continue refining telehealth policies, providers should monitor updates closely to remain compliant while minimizing disruptions to patient care. SunShyn Credentialing & Medical Billing will continue tracking Medicaid policy changes affecting IBCLCs nationwide and will provide updates as additional states revise their lactation coverage requirements.

Nebraska Medicaid has taken another step toward expanding access to breastfeeding support by adding Certified Lactation Counselors (CLCs) as an approved provider type for one specific Medicaid service. Effective July 1, 2026, CLCs may now provide breastfeeding instruction sessions within Nebraska’s Prenatal Plus Program (PPP), a Medicaid program designed for pregnant individuals who are considered at increased risk for poor maternal or infant outcomes. (dhhs.ne.gov) What Changed? Previously, Nebraska’s Prenatal Plus breastfeeding support services were generally limited to licensed Medical Nutrition Therapists and IBCLCs. Under the new Medicaid guidance, Certified Lactation Counselors have been added as an approved provider type for breastfeeding instruction sessions within the Prenatal Plus Program. (dhhs.ne.gov) This is an important expansion because it allows more qualified breastfeeding professionals to participate in prenatal education for Medicaid beneficiaries. What Is the Prenatal Plus Program? The Nebraska Prenatal Plus Program is intended for Medicaid-eligible pregnant patients who have been identified by their prenatal provider as being at increased risk for adverse maternal or infant outcomes. The program provides enhanced prenatal services that include: Nutrition counseling Psychosocial counseling and support General health education Breastfeeding support Targeted case management The goal is to improve pregnancy outcomes by providing additional education and support before birth. (dhhs.ne.gov) This Is Not General Medicaid Recognition of CLCs One important distinction is that this policy does not make CLCs general Nebraska Medicaid lactation providers. Instead, it authorizes CLC participation only for breastfeeding instruction sessions provided under the Prenatal Plus Program. Outside of Prenatal Plus, Nebraska Medicaid’s broader lactation counseling benefit continues to follow its existing coverage policies. Nebraska also already covers up to 10 lactation counseling visits for eligible mothers and infants under its standard Medicaid benefit, separate from Prenatal Plus. (dhhs.ne.gov) What This Means for Providers For CLCs: New opportunity to participate in Medicaid-funded prenatal education. Limited to the Prenatal Plus Program. Does not automatically allow billing for postpartum lactation services or other Medicaid lactation benefits. For IBCLCs: IBCLCs continue to play a significant role in Nebraska Medicaid’s broader lactation coverage. This change expands prenatal support without replacing the need for IBCLC services in more comprehensive lactation care. Why This Matters Across the country, states are taking different approaches to improving breastfeeding access. Some states are: Expanding Medicaid reimbursement for IBCLCs. Creating state licensure pathways. Adding additional provider types for limited services. Increasing reimbursement rates. Nebraska’s latest change falls into the “expanded provider access” category. Rather than broadly recognizing CLCs as Medicaid providers, the state is allowing them to participate in a specific prenatal program designed to improve outcomes for high-risk pregnancies. While limited in scope, it represents another example of states exploring ways to increase access to breastfeeding education through Medicaid. SunShyn’s Take This is a positive development for prenatal education, but providers should understand its limits. The announcement does not create full Medicaid billing rights for CLCs, nor does it replace Nebraska’s existing lactation counseling benefit. Practices should carefully distinguish between services provided under the Prenatal Plus Program and Nebraska Medicaid’s standard lactation counseling coverage to ensure claims are submitted appropriately. As more states revise their Medicaid lactation policies, these distinctions are becoming increasingly important for providers seeking to expand insurance-covered breastfeeding services.

For months, California Assembly Bill 2160 generated excitement within the lactation community because it proposed something many advocates have been seeking for years: allowing International Board Certified Lactation Consultants (IBCLCs) to enroll directly as Medi-Cal providers and bill independently for lactation services. Unfortunately, after recent amendments, that proposal is no longer part of the bill. While AB 2160 remains active in the California Legislature, the legislation has shifted its focus away from creating a new Medi-Cal provider type for IBCLCs. (legiscan.com) What Changed? Earlier versions of AB 2160 included language requiring the California Department of Health Care Services (DHCS) to: Allow IBCLCs to enroll directly as Medi-Cal providers. Permit IBCLCs to bill Medi-Cal independently for lactation services. That language has now been removed from the current version of the bill. Instead, the legislation focuses primarily on improving clarity and consistency regarding Medi-Cal coverage of lactation services. (legiscan.com) What the Bill Still Does Although the direct enrollment provision has been eliminated, AB 2160 still contains several meaningful reforms. If enacted, DHCS would be required to: Publish updated statewide guidance explaining Medi-Cal coverage of lactation services. Clarify what services fall within the continuum of lactation care, from education to clinical consultation. Clarify managed care plan responsibilities for covering lactation services. Seek stakeholder input before issuing new guidance. Improve consistency across Medi-Cal managed care plans. (legiscan.com) For providers and families, clearer guidance could reduce confusion surrounding covered services and reimbursement expectations. What This Means for IBCLCs The biggest takeaway is that IBCLCs will not gain a direct pathway to enroll with Medi-Cal under the bill’s current language. That means California’s current system largely remains unchanged: IBCLCs generally cannot enroll independently as Medi-Cal providers. Lactation services typically continue to be billed through eligible licensed providers or clinics under existing Medi-Cal rules. Access to reimbursement continues to depend heavily on employment arrangements and supervising provider relationships. (billtexts.s3.amazonaws.com) For many independent IBCLCs, this represents a missed opportunity to expand access to care, particularly in underserved communities where standalone lactation practices could fill significant gaps. Why the Original Proposal Mattered The original version of AB 2160 addressed a longstanding issue in California. While many commercial insurers recognize IBCLCs as independent providers, California’s Medicaid program has historically not offered a direct enrollment pathway. This creates administrative barriers that can limit patient access, reduce provider participation, and make reimbursement more difficult than necessary. Removing the direct enrollment provision means those barriers remain. The Conversation Isn’t Over Although this amendment is disappointing for many advocates, it does not end the discussion. The legislative analysis accompanying earlier versions of the bill acknowledged that recognizing IBCLCs as billable provider types represents a significant opportunity to improve access to breastfeeding care. Even without statutory changes, updated DHCS guidance could still improve consistency and transparency for providers currently delivering lactation services within Medi-Cal. (billtexts.s3.amazonaws.com) Future legislation could revisit direct provider enrollment as California continues working to improve maternal and infant health outcomes. SunShyn’s Take AB 2160 remains an important bill because statewide guidance can reduce confusion and create more consistent coverage expectations across Medi-Cal managed care plans. However, the removal of direct IBCLC enrollment leaves one of the largest access barriers unresolved. We’ll continue monitoring this legislation and any future proposals that could establish a true independent provider pathway for IBCLCs in California’s Medi-Cal program. As always, we’ll provide updates as the bill continues moving through the legislative process.

Effective July 1, 2026, BlueCross BlueShield of Tennessee (BCBST) implemented updated Commercial Provider Administration Manual guidance that includes important clarification for lactation providers. While much of the guidance formalizes existing billing expectations, it also provides greater clarity regarding who may provide lactation services, supervision requirements, and the procedure codes available for reimbursement. For IBCLCs and practices providing breastfeeding support, this is an excellent opportunity to review documentation, billing workflows, and staffing models. Who Can Provide Lactation Services? BCBST continues to recognize several different provider types that may participate in lactation care. According to the July 1, 2026 Commercial Provider Administration Manual, lactation services may be provided by: Physicians (MD/DO) Nurse Practitioners (NPs) Physician Assistants (PAs) Certified Nurse Midwives (CNMs) International Board Certified Lactation Consultants (IBCLCs) Registered Lactation Counselors (RLCs) In addition, the manual recognizes several non-licensed lactation credentials, including: Certified Lactation Counselors (CLCs) Certified Lactation Educators (CLEs) Certified Lactation Specialists (CLSs) Certified Breastfeeding Specialists (CBSs) However, these providers must work under the supervision of a contracted in-network provider, and billing occurs under that supervising provider rather than under the counselor’s own credential. (bcbst.com) IBCLCs Continue to Have an Important Independent Role One particularly noteworthy clarification is that BCBST specifically recognizes IBCLCs with medical licensure as supervising providers for certain lactation personnel. This reflects the growing recognition of IBCLCs as specialized clinicians capable of leading lactation care teams when their underlying professional license allows supervision within Tennessee law. Practices utilizing IBCLCs alongside CLCs or other breastfeeding educators should carefully review whether their current supervision model aligns with both payer policy and Tennessee scope-of-practice requirements. Billing Codes Listed by BCBST The Commercial manual identifies several procedure codes that may be used when medically appropriate: S9443 – Lactation classes (per session) 99401 – Preventive counseling (15 minutes) 99402 – Preventive counseling (30 minutes) 99403 – Preventive counseling (45 minutes) 99404 – Preventive counseling (60 minutes) (bcbst.com) As always, listing a CPT® or HCPCS code in a provider manual does not guarantee reimbursement in every clinical situation. Coverage depends on the member’s benefits, medical necessity, provider eligibility, contract terms, and claim editing rules. Documentation Still Matters The July guidance does not reduce documentation requirements. Practices should continue documenting: Medical necessity Time spent (when billing time-based services) Assessment findings Education and counseling provided Patient response Plan of care Appropriate rendering and supervising provider information Clear documentation remains the strongest defense during audits and post-payment reviews. What This Means for Tennessee Practices For practices employing both IBCLCs and lactation counselors, the updated guidance reinforces several important operational points: Verify that rendering and supervising providers are correctly identified. Ensure non-licensed lactation personnel are billed under an eligible supervising provider when required. Review workflows to confirm documentation supports the services billed. Confirm that provider contracts and credentialing accurately reflect each clinician’s role. Our Perspective We are encouraged to see BlueCross BlueShield of Tennessee continue recognizing a broad range of lactation professionals while also providing additional clarity regarding supervision and billing expectations. As payer policies continue evolving across the country, clear guidance benefits providers, reduces billing confusion, and helps practices remain compliant while expanding access to breastfeeding support. At SunShyn Credentialing and Medical Billing, we’ll continue monitoring BCBST policy updates and other commercial payer changes affecting IBCLCs, nurse practitioners, physicians, and lactation practices nationwide. Need help navigating Tennessee payer policies? Whether you’re opening a new lactation practice, reviewing compliance, or optimizing reimbursement, our team specializes exclusively in lactation billing, credentialing, and payer policy interpretation. We’re here to help you stay compliant while maximizing appropriate reimbursement.

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 important to understand that many of the implementation details have not yet been determined. Oregon Was Already Ahead of Many States Unlike most states, Oregon has long recognized International Board Certified Lactation Consultants (IBCLCs) through a state licensure program. Qualified IBCLCs may obtain an Oregon Lactation Consultant license regardless of whether they hold another healthcare license such as an RN. In addition, Oregon Medicaid has already covered lactation services in certain circumstances through existing Medicaid enrollment pathways. SB 1568 does not create Oregon’s IBCLC license. Instead, it creates a new framework for lactation counselors, a separate category that will be defined through future rulemaking. What SB 1568 Changes Beginning with Medicaid contracts and applicable health plans issued, renewed, or amended on or after January 1, 2028, the law requires: ● Coverage for services provided by registered lactation counselors. ● No referral from another healthcare provider. ● No physician signature requirement. ● Coordinated Care Organizations (CCOs) to make information about accessing lactation counselors readily available to Medicaid members. ● The Oregon Health Authority to periodically review Medicaid reimbursement rates for lactation counselors to help support a sustainable workforce. ● The Traditional Health Workers Commission to establish a voluntary registration system, continuing education requirements, and standards of practice for lactation counselors. The Most Important Detail Has Yet to Be Decided One of the most significant changes made during the legislative process was removing the statutory definition of “lactation counselor.” Earlier versions of the bill tied that definition to a specific national credential. The final law instead directs the Traditional Health Workers Commission to define who qualifies as a lactation counselor through administrative rulemaking. This means the law does not currently specify which credentials will qualify. Questions that remain unanswered include: ● Will Oregon recognize one or more existing national lactation counseling credentials? ● Will licensed IBCLCs automatically qualify? ● Will additional education or competency standards be required? ● Will providers need to obtain a new Oregon registration regardless of their current credential? ● Could the Commission create a broader or narrower definition than many stakeholders expect? Until the Commission publishes proposed rules, these questions remain open. What This Means for IBCLCs The legislation does not replace Oregon’s existing IBCLC licensure program. Instead, Oregon will now have two separate regulatory frameworks: ● Licensed Lactation Consultants (IBCLCs) under Oregon’s existing licensure law. ● Registered Lactation Counselors under the new Traditional Health Worker framework created by SB 1568. How these two pathways will interact has not yet been fully defined. SunShyn’s Take SB 1568 is an exciting step toward expanding access to lactation care, but it is not the final chapter. The legislation establishes the framework, while the upcoming rulemaking will determine who is eligible to register as a lactation counselor and ultimately provide services under the new law. For that reason, we encourage providers to avoid assuming the law automatically applies to any particular credential until Oregon publishes its proposed rules. SunShyn Credentialing & Medical Billing will continue monitoring the rulemaking process and will provide updates as additional guidance becomes available.