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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. Sunshyn practice resources For help with claim submission and payer follow-up, see Sunshyn's medical billing services. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

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. Sunshyn practice resources For help with claim submission and payer follow-up, see Sunshyn's medical billing services. For a structured look at claims and billing workflows, explore the Insurance Billing Mastery learning pathway in the Sunshyn Learning Center.

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. Sunshyn practice resources For help with claim submission and payer follow-up, see Sunshyn's medical billing services. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

One of the most common questions we hear from IBCLCs is: "My local Blue Cross Blue Shield plan won't credential me. A company says they can get me paid anyway. Should I sign?" Before you do, it's important to understand how Blue Cross Blue Shield claims generally work. Blue Cross Blue Shield Is Not One Insurance Company Many providers think BCBS is a single nationwide insurer. It isn't. The Blue Cross Blue Shield system consists of independent, locally operated companies. Each plan establishes its own provider credentialing policies, participation requirements, reimbursement rules, and covered services within its service area. That means an IBCLC who is eligible to participate with one BCBS plan may not be eligible under another. Claims Follow the Provider's Local BCBS Plan When services are furnished, reimbursement is generally determined according to the rules of the provider's local Blue Cross Blue Shield plan, even when the member is insured through a different Blue plan. The BlueCard program is designed to route claims between Blue plans while allowing the local plan's provider participation and reimbursement rules to be applied where appropriate. For IBCLCs, this means the first question is usually: Does my local BCBS plan recognize and reimburse my provider type? If the answer is no, that raises an important question. How Is Another Company Getting Paid? If your local BCBS plan does not credential or reimburse your provider type directly, and another company tells you they can "get you paid," ask them to explain exactly how that works. Questions worth asking include: Under whose NPI is the claim submitted? Under whose tax identification number (TIN) is the claim billed? Who is the rendering provider on the claim? Who holds the BCBS contract? Is there a delegated network or other contractual arrangement? How does the billing model comply with the applicable payer's billing policies? Will I have access to my claims, remittance advice, and explanations of benefits? A reputable company should be able to answer these questions clearly and transparently. If You Don't Understand the Billing Model, Ask More Questions Healthcare billing is heavily regulated. Practices should understand exactly how their claims are being submitted and why the payer recognizes that billing arrangement. If someone tells you: "Don't worry—we have a special way of getting these claims paid." Ask for an explanation. You should understand: Why the payer accepts the claims. Which provider is actually billing. Whether you remain responsible for the documentation. Whether the arrangement complies with the payer's provider agreement and billing requirements. If the explanation isn't clear, don't be afraid to seek advice from a healthcare attorney or qualified compliance professional before signing a contract. Transparency Protects Everyone There are legitimate business models that help providers navigate insurance reimbursement. There are also arrangements that are poorly explained, leaving providers uncertain about who is actually billing for their services or why claims are being paid. As the rendering provider, your professional reputation and your documentation are tied to those claims. You should never feel uncomfortable asking questions about how your services are billed. The Bottom Line If your local BCBS plan does not currently credential or reimburse your provider type, be wary of anyone offering a simple solution. If they can't clearly explain how their billing process works, it should raise concerns. That doesn't automatically mean the arrangement is improper—but it does mean you should understand exactly how the claims are being submitted, who is billing them, what contractual authority supports the arrangement, and whether the billing model complies with the applicable payer's requirements. The best billing partner is one that is completely transparent—not only about what they do, but about how they do it. Sunshyn practice resources For help with payer applications and enrollment, see Sunshyn's insurance credentialing services. For a structured look at enrollment workflows, explore the Credentialing & Payer Enrollment learning pathway in the Sunshyn Learning Center.

12. Pediatrics A Newborn Visit Needs Its Own Insurance Intake Birth creates an enrollment task A parent brings a newborn to the practice and provides the mother’s insurance card. The baby needs care now, but the practice still needs to establish the child’s own coverage and the payer’s instructions for reporting that care. The U.S. Department of Labor explains that birth can trigger special enrollment in an employer health plan. Its guidance tells families to request enrollment within thirty days; qualifying birth-related special enrollment takes effect from the birth. These employer-plan protections should not be confused with every Marketplace, Medicaid, or state insurance rule. [1] A practice should give families an early reminder to contact the plan and confirm the enrollment deadline that applies to them. Verify the child rather than assuming Collect the newborn’s identifying information, the intended plan, and the status of enrollment. If the plan uses a temporary reporting process, obtain its instructions and record the source. A shared subscriber number may be valid under a family plan, but the claim still needs to identify the child as the patient. Do not relabel an infant’s evaluation as the mother’s service because the child’s member information is not ready. Where payer instructions are unclear, separate the clinical decision about timely care from the administrative work needed to submit an accurate claim. Build a pending enrollment queue Use a visible process for claims awaiting newborn eligibility information. Assign an owner, a follow-up date, and the applicable submission deadline. Keep the family informed about what information is needed. For example, a first visit may occur before the plan produces the baby’s permanent member record. Track that encounter until the enrollment and reporting details are resolved instead of repeatedly submitting the same incomplete claim. If a rejection occurs, identify whether the problem is enrollment, the patient identifier, another claim field, or a coverage decision. Those problems require different responses. Keep maternal and infant services clear A parent may receive information during a pediatric visit, and a mother may also need her own clinical care. Document any separately provided service under the appropriate patient and verify that patient’s benefit and provider arrangement. Neither patient disappears because both are present. Shared scheduling can make family care convenient while preserving accurate records. A newborn intake should do more than copy the parent’s card. It should establish who the patient is, which coverage applies, how the claim must be submitted, and who will finish the work if enrollment is still pending. Source: [1] U.S. Department of Labor: Life Changes Require Health Choices Sunshyn practice resources For help with your pediatric practice's payer enrollment and claims, see Sunshyn's pediatric billing and credentialing support. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

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

Use the actual credential from the first application A payer application asks the practice to identify its provider type. The clinician is a midwife, but that broad description may conceal the information the payer needs to evaluate the application. Certified nurse-midwife, certified midwife, and certified professional midwife are distinct credentials. The American College of Nurse-Midwives provides a comparison of their education, certification, licensure, and practice characteristics. Its current resources include a comparison chart dated May 2026. [1] A practice should carry the clinician’s actual credential through applications, public descriptions, and payer communications. Choosing a nearby category because it is easier to locate in a portal can create an enrollment record that does not match the clinician. Distinguish qualification from recognition A clinician’s education and certification deserve an accurate description even when a payer’s categories are limited. State authority to practice and payer eligibility also need separate review. ACNM explains that the certified midwife pathway is distinct from nurse-midwifery because CMs are not also licensed as nurses. State recognition must be checked for the credential and location involved. [1] When a payer does not present an appropriate application option, request instructions in writing. Do not infer that the absence of a portal category authorizes enrollment under another credential. Describe the services and settings precisely List what the practice actually offers, where the clinician provides it, and which patient receives each service. Ask how the payer recognizes those services under the clinician’s credential and participating arrangement. A conversation about maternity coverage should also address the relevant practice setting and any separate facility arrangement. A clinician’s participation does not, by itself, explain how every related entity or service will be paid. If a practice treats both the mother and the newborn, each patient’s service and coverage need their own review. Their relationship does not remove the need to identify the actual patient on the record and claim. Help patients understand the arrangement Public information should identify the clinician’s credential and the services available without suggesting that all midwives have the same payer relationships. Before the patient commits to care, explain what participation has been confirmed and which payment questions remain outstanding. Keep estimates grounded in the actual agreement and benefit. At Sunshyn, we want applications to describe the provider who is really practicing. Accurate credential information gives the practice a better basis for contracting, appeals, and patient communication when a payer’s categories fail to reflect the available workforce. Source: [1] American College of Nurse-Midwives: Certified Midwife Credential and Comparison Resources Sunshyn practice resources For help with payer applications and enrollment, see Sunshyn's insurance credentialing services. For a structured look at enrollment workflows, explore the Credentialing & Payer Enrollment learning pathway in the Sunshyn Learning Center.

The referral is one step in ongoing care A postpartum patient leaves with recommendations to see a therapist, a pelvic health PT, or a primary care clinician. The chart lists the referrals, but no one knows whether the patient can schedule them. ACOG describes postpartum care as an ongoing process. Its guidance recommends contact with an obstetric care provider within the first three weeks and a comprehensive visit no later than twelve weeks after birth, with ongoing care tailored to the patient’s needs. [1] A practice can apply that approach operationally by making referrals easier to complete and deciding who will follow unresolved concerns. The clinician determines the timing appropriate to the patient. Give the patient enough information to act A referral should identify the reason for the next service and provide a usable destination when possible. Check whether the receiving practice offers the relevant care and accepts referrals for that patient population. An office that provides physical therapy generally may not offer pelvic health appointments. A mental health directory listing may not tell the patient whether the clinician is taking new patients. Before giving a patient a name, verify the information the practice can reasonably check. Explain what records will be sent and whom the patient should contact if scheduling fails. Track the handoff Choose an owner for checking whether the referral reached the receiving office and whether an appointment was arranged. Distinguish a referral sent from a referral completed. For example, if a patient reports that the recommended office cannot see them, the workflow should bring that information back to the clinical team. Reprinting the same referral does not resolve the access problem. Record barriers that affect the plan, such as inability to reach the office or a coverage question. The clinical team can then decide the next step instead of assuming follow-up occurred. Keep the payment explanation tied to the service A postpartum referral can lead to a different specialty, benefit, and participating provider. Help the patient understand that those coverage questions require their own verification. Clinical recommendations and payment rules serve different purposes. A recommended service may still face a payer restriction, and a covered benefit may still lack an available appointment. Document the issue rather than describing the entire situation as handled. At Sunshyn, we want practice workflows that make care easier to reach. A referral is useful when the patient knows where to go, the receiving practice knows why they are coming, and the referring team has a plan if the handoff does not happen. Source: [1] ACOG: Optimizing Postpartum Care Sunshyn practice resources For help with billing workflows in your maternal health practice, see Sunshyn's maternal health billing support. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

Clinical collaboration and claim reporting answer different questions An NP practice has a collaborating physician. Someone then suggests submitting every visit under the physician because the physician already participates with the payer. Before that becomes the billing workflow, ask which rule actually permits it. A collaboration agreement can address clinical or state-law requirements without establishing the claim arrangement for every service the NP provides. Medicare’s incident-to rules are specific. CMS requires, among other conditions, an initial professional service by the physician or other qualifying practitioner, continuing involvement in treatment, and the applicable supervision and setting requirements. The existence of a collaborator does not establish all those facts. [1] Review the actual encounter Identify who provided the service, what treatment was established, and which reporting pathway applies. Keep direct NP reporting, qualifying incident-to services, and other applicable arrangements distinct. For example, a new patient independently evaluated by an NP needs review under the appropriate direct-reporting rules. Staff should not treat the collaborator’s signature as a substitute for examining the incident-to requirements. Use current guidance for supervision, including any setting-specific rules. Avoid relying on an old policy summary that may no longer describe the requirements in effect on the service date. Build participation around the practice’s real services Confirm the NP’s enrollment and participation status, group relationship where relevant, effective dates, and approved practice locations. Obtain the payer’s instructions for the service arrangement the practice actually uses. CMS guidance describes Medicare pathways. Commercial plans may impose different credentialing and reporting requirements. A Medicare concept should not be applied to another payer without checking its agreement and policy. If enrollment is pending, establish a clear scheduling and financial plan. Do not solve an enrollment delay by choosing another clinician’s identity solely because it produces payment. Audit defaults before they become routine Review how the electronic record and billing system populate clinician fields. A correct clinical note can still generate a misleading claim if the default provider is never checked. Ask the team to trace a sample encounter from scheduling through the final submitted claim and remittance. Confirm that the selected pathway has a documented basis and that the system reflects it. Independent NP practices benefit from billing workflows that describe their work accurately. A collaborator can be an important part of the clinical arrangement. The claim still needs its own support under the rules that apply. Source: [1] CMS: Incident To Services and Supplies Sunshyn practice resources For help with payer applications and enrollment, see Sunshyn's insurance credentialing services. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

The address on file may not be today’s location A counseling patient logs in from a familiar account, but today they are visiting relatives in another state. Their insurance card and home address have not changed. Their physical location has. Before the session proceeds, the practice needs to determine whether the clinician has authority to provide care where the patient is located. HHS describes several possible interstate pathways, including a full license, qualifying temporary practice provisions, compact participation, or telehealth registration where available. Each pathway has its own conditions. [1] Knowing the patient for years does not resolve the current licensing question. Make location part of the opening workflow HHS recommends verifying patient location and obtaining consent before an appointment. [1] Build that check into the session opening so it does not depend on a clinician remembering to ask after treatment has started. Ask where the patient is physically located and record the information needed for the encounter. A statement that the patient is somewhere in their usual state may be insufficient for the practice’s emergency plan or documentation. Explain the reason during intake. Patients are more likely to tell the practice about upcoming travel when they understand that the location can affect whether a scheduled session can take place. Separate licensing from coverage Authority to practice and insurance payment are different questions. Confirm the relevant state requirements, then review the payer’s telehealth conditions, provider participation, and reporting instructions. If the patient has moved permanently, review the whole arrangement. A recurring appointment should not continue indefinitely on the strength of the original intake information. When a session cannot proceed under the applicable requirements, use the practice’s clinical continuity process. Do not make a rushed billing workaround the answer to a care-access problem. Plan for a lost connection A location check also supports preparation for an emergency. HHS’s telebehavioral health resources recommend an emergency plan. [2] The clinician should know how the practice will respond if an urgent situation occurs or the connection ends unexpectedly. Give patients clear instructions for contacting the practice and understanding its response hours. Keep the emergency process distinct from routine portal messaging. A virtual appointment still takes place somewhere. A small, consistent check at the beginning helps the practice address licensing, continuity, and patient safety before those questions become a problem during the session. Sources: [1] HHS: Licensing Across State Lines [2] HHS: Preparing Patients for Telebehavioral Health ChatGPT can make mistakes. Check important info. Sunshyn practice resources For help with your therapy practice's enrollment and claims, see Sunshyn's therapy billing and credentialing support. For a structured review of documentation and practice requirements, explore the Documentation & Compliance learning pathway in the Sunshyn Learning Center.

“Free if you have Aetna.” “No out-of-pocket costs.” “We never bill patients.” These promises sound reassuring to a family seeking lactation care. But when the accepted payers assign deductibles, copayments, or coinsurance on correctly processed claims, a universal promise requires an explanation. Is the service covered without patient responsibility? Is another party paying the assigned balance? Or has the organization decided never to collect it? Those are different arrangements. Advertising should not make them sound like the same insurance benefit. The confusion affects patients, independent practices, and even the payer representatives responsible for explaining coverage. Covered does not necessarily mean the patient owes nothing A service can qualify for insurance benefits and still generate patient responsibility. The outcome can depend on the specific plan, service, provider, billing requirements, and benefits already used. Mother and baby are separate patients whose benefits also need to be evaluated separately. Knowing that a practice accepts Aetna—or another payer—does not establish that every consultation will cost every patient zero dollars. A particular visit may process without patient responsibility. That possibility does not support a universal guarantee before the practice knows the patient’s circumstances. “We accept your insurance” and “you will never receive a bill” are different promises. Assistance requires knowing the patient Financial assistance can help families access care. Sliding scales and cash discounts can also serve a legitimate purpose where permitted. But those arrangements must comply with applicable payer agreements and legal requirements. An individualized assistance process considers the patient’s circumstances and the criteria governing the available help. A blanket promise made before knowing the patient does something different: “If you have one of the insurers we accept, you will never owe anything—even if your plan assigns a balance.” If that promise is fulfilled by automatically writing off every assigned amount, it is a routine waiver policy. It is not transformed into an individualized hardship determination by calling it financial assistance. A permitted discount for a cash service is also different from waiving responsibility on an insurance-billed claim. The sequence matters: review the benefits, explain potential costs, and assess eligibility for assistance when needed. Do not promise the outcome of an assessment that has never occurred. Collection requirements are real This is not simply a disagreement about business preferences. Cigna’s published notice expressly states that participating providers are “required to bill and collect applicable in-network copayments, deductibles and coinsurance.” It also describes potential benefit reductions or denials when amounts are waived, subject to individual plan terms and applicable law. (cigna.com) State law can impose additional restrictions. For example, Texas Insurance Code §1204.055 says accepting assigned benefits does not relieve the patient’s deductible or copayment obligation and prohibits waiving those amounts by acceptance of an assignment. Its applicability depends on the particular coverage arrangement. (tcss.legis.texas.gov) Federal healthcare programs have their own rules. HHS OIG distinguishes individualized financial-need assistance from routine waivers and warns that certain routine waivers can implicate federal fraud-and-abuse laws. Those provisions generally do not apply to patients insured solely through commercial plans. (oig.hhs.gov) There is no single rule governing every payer and every patient. But there are concrete collection obligations that a practice cannot disregard simply because it prefers to advertise free care. A blanket no-patient-billing policy must be evaluated against the requirements that actually govern it. If patients never pay, what happens to the balance? When a correctly processed claim assigns legitimate patient responsibility, the balance needs an explanation. Another party may pay it under an authorized arrangement. A patient may qualify for a permitted waiver or discount. Or the practice may be absorbing it. If no one else pays and the organization never collects, it is choosing not to collect the assigned amount. That does not mean the insurance benefit itself has no cost sharing. “Your plan assigned no balance” and “we wrote off your balance” should not be presented as interchangeable facts. The advertisement alone does not establish a violation. But an established policy of never billing patients warrants scrutiny when the organization accepts payers that assign patient responsibility. Even when the patient owes nothing, someone pays for care A consultation with no patient cost sharing is still paid care. An insurer, employer-sponsored plan, or another funding source pays the provider. “Free to the patient” does not mean no one pays the bill. Sunshyn has encountered this misunderstanding in claim discussions involving a self-funded employer plan administered by Aetna. After claims were denied, we were directed to online advertising suggesting the patient could have chosen a “free” provider instead. But the advertised provider’s offer relied on insurance payment. It was not evidence that the care required no compensation. “You could have gone somewhere free” is circular reasoning when the advertised care is free to the patient because the plan is expected to pay for it. An online advertisement does not establish the member’s benefits or explain a denial. The administrator should identify the applicable plan terms and the actual basis for its decision. Small practices face the consequences of the promise When large groups advertise that patients never pay, families carry that expectation into other practices. An independent provider submits an accurate claim, receives an explanation of benefits assigning patient responsibility, and follows the applicable collection requirements. The patient asks: “Why do I owe you? The other practice never billed me.” That comparison can make legitimate collection look like an unnecessary fee imposed by the smaller practice. But another organization’s decision not to collect does not prove that the patient’s insurance benefit carried no cost sharing. Nor does collecting a properly assigned balance mean the independent provider failed to obtain coverage. A practice following payer requirements should not appear less trustworthy because another organization makes a broader promise. Payer assurances make the conversation harder Patients also contact their insurer and hear that lactation is “covered” or that they will owe nothing. In Sunshyn’s experience, those assurances do not always account for the specific services, codes, provider type, benefit limits, or separate benefits for mother and baby. The claim may then process differently from what the patient was told. That leaves the practice explaining an assigned balance that contradicts the patient’s understanding of the insurer’s assurance. Patients understandably see their insurer as the authority on its own benefits. And when one person says “you owe nothing” while another asks for payment, the first answer is easier to believe. The practice can appear financially motivated—even when it is accurately explaining the insurer’s claim decision. The practice becomes the messenger nobody wants to believe An independent provider may be trying to follow its contract, bill accurately, and preserve the patient relationship. Yet it must repair expectations created by both competing advertising and payer communications. The patient has heard “free” from another organization and “covered” from the insurer. The practice is left delivering the unwelcome distinction between coverage and zero cost sharing. That can damage trust, delay payment, and consume time that a small practice does not have to spare. Patients should not be blamed for believing the assurances they received. Payers and organizations making those assurances should help resolve the confusion they create. Accurate coding should not bend to an advertisement An unexpected balance deserves review. A claim error, incorrect benefit application, or appealable decision may need correction. But accurate diagnoses and service codes should not be changed merely to eliminate patient responsibility. The claim must reflect the care performed and documented. A promise of free care should not pressure providers to misrepresent services or disregard collection requirements. Financial messaging needs to follow the billing and coverage facts—not dictate them. A better promise is specific and supportable Where benefits vary, a practice can say: We accept participating insurance plans and can help review your benefits. Your costs depend on your specific plan and services. Mother and baby are reviewed separately. Financial assistance may be available to eligible patients. Where a verified benefit has no cost sharing, the practice can describe that benefit specifically. Where another program pays patient balances, it can explain the eligibility criteria and services included. These explanations give families useful information without promising an outcome before the relevant facts are known. “Free” needs an explanation Making lactation care affordable matters. So does being honest about how that affordability is achieved. Organizations advertising universally free consultations should explain what happens when accepted payers assign patient responsibility—and what authorizes their policy. Payers should distinguish a covered service from a service with no cost sharing. They should also help resolve discrepancies between their representatives’ assurances and their claim decisions. Patients deserve accurate expectations. Independent providers deserve fair comparisons. Neither should be left paying the price for a promise that the actual benefits and billing rules do not support. Sunshyn practice resources For help with claim submission and payer follow-up, see Sunshyn's medical billing services. For a structured look at claims and billing workflows, explore the Insurance Billing Mastery learning pathway in the Sunshyn Learning Center.

Two patients receive lactation care from the same practice. Both have Cigna coverage. The mother’s visit can be processed as in-network care through Wildflower. The baby’s separately documented visit does not have a clear, reliable in-network payment pathway through that arrangement. For advanced clinicians, the divide can affect the same patient, too. A nurse practitioner or physician may provide covered lactation care through Wildflower, then evaluate and treat a related medical condition through their independent practice—where that professional service may be handled as out-of-network or cash care. The patient, clinician, and office have not changed. The financial pathway has. This is the situation Cigna needs to explain. Instead, Cigna and Wildflower have withheld the information needed to understand the arrangement—not only from Sunshyn, but from providers asking about their own services and obligations. What families understand when care is advertised as covered Cigna’s Individual & Family Plans provider resource page describes Wildflower lactation support as an in-network service without a copay or deductible. Wildflower similarly advertises Cigna lactation appointments without copays or deductibles. (static.cigna.com, wfh.wildflowerhealth.com) That promise influences where families seek care. A parent may expect covered feeding support for both mother and baby. They may choose a clinician with an advanced license because that person can also evaluate and treat related medical concerns. But the coverage message does not explain the boundaries between Wildflower’s billing arrangement and the independent practice’s other services. Those boundaries can determine whether a family uses insurance, pays cash, or must find another provider. Two patients, different payment pathways Mother and baby are separate patients receiving separately documented care, even when they are seen together. The issue is not that two patients have separate visits or charges. It is that the same treating practice can access an in-network payment pathway through Wildflower for the mother while the baby’s visit is handled outside it. One advanced provider told Sunshyn that she used Wildflower for the lactation service and charged cash for the baby’s visit. That account illustrates the arrangement’s consequences. It is not an accusation against that clinician or a description of every participating practice. Infant lactation services may be payable when appropriately billed directly to Cigna, including under available out-of-network benefits. Payment depends on the patient’s plan and applicable claim requirements. A restriction in Wildflower’s process is not the same as an exclusion in the baby’s insurance benefits. Families deserve to know which limitation they are facing—and what covered alternative Cigna makes available. The same patient can experience the divide Consider a hypothetical patient seeing a nurse practitioner or physician who also holds an IBCLC credential. The clinician provides lactation support through Wildflower. During that care, the clinician identifies mastitis and provides a related medical evaluation and prescription. If the independent practice does not participate directly in Cigna’s medical network, the professional medical service may be handled as out-of-network or cash care. The prescription’s pharmacy coverage is a separate question. From the patient’s perspective, the clinician appears in network for lactation but out of network when treating a condition connected to it. The clinician’s professional responsibilities do not switch off during lactation care. Yet the payment arrangement can divide access to that clinician’s services. Any separately billed service must meet applicable documentation and billing requirements. The concern here is that patients may choose a clinician expecting covered care without understanding that related treatment follows another financial pathway. One practice operates through two businesses The provider agreement reviewed by Sunshyn appoints Wildflower as a billing and collection agent for services performed by the independent provider. It is nonexclusive. It does not establish the independent practice’s direct participation in Cigna’s medical network. That creates two potential pathways: Wildflower’s process and the practice’s independent billing process. Financially, it can be as though the family is receiving care from two medical offices while remaining with the same clinician in the same office. For IBCLC-only practices, the divide may concern the mother’s and baby’s visits. For advanced clinicians, it may also concern lactation support and related medical care for the same patient. Providers are responding to this structure. Cigna and Wildflower are responsible for explaining it and demonstrating how patients are protected. An undisclosed agreement does not explain the provider’s obligations Wildflower has invoked its arrangement with Cigna as a source of rules providers must follow. Yet the relevant terms have not been supplied to the providers seeking to verify those requirements. Even if Cigna’s agreement with Wildflower says a maternal payment includes infant care, a separate question remains: Where did the treating provider agree to accept that payment as compensation for the baby’s separately documented services? What Cigna pays Wildflower for and what the independent provider agrees to furnish are different contractual questions. If Wildflower relies on incorporation by reference or another provision, it should identify that provision, explain its scope, and supply the relevant requirements. Neither company has supplied Sunshyn with documentation substantiating how Wildflower’s payments to providers compensate them for infant services or identifying the binding terms supporting that position. Providers should be able to verify the obligations attached to their own work. They should not be expected to accept an undisclosed agreement as a complete answer. Infant guidance and submission restrictions need to agree Based on Sunshyn’s experience assisting practices, Wildflower’s infant claim process has become increasingly restrictive and no longer offers a clear, reliable submission pathway. Meanwhile, the Wildflower manual reviewed by Sunshyn describes infant coverage, while the restrictions communicated and enforced have treated the arrangement as mother-only. That contradiction needs a documented explanation. If infant care is included, providers need an accessible billing process and clear compensation terms. If restrictions apply, the companies should identify their source and explain how the baby can access applicable benefits. The contractual terms should also reflect the services providers are actually expected to perform. Families should not bear the cost of unresolved differences between written guidance, submission rules, and provider agreements. Who is represented on the claim? Claims reviewed by Sunshyn identify Wildflower as the billing and rendering entity for care performed by independent practices. The provider agreement appoints Wildflower as a billing and collection agent. Authority to prepare, transmit, and collect a provider’s claims does not, by itself, establish authority to identify another entity as the provider that rendered the care. Sunshyn has not identified language in the provider agreements reviewed expressly granting that additional authority. Cigna and Wildflower should identify the contractual and payer enrollment basis supporting the claim structure. Providers should be able to understand how their clinical services are represented and what authorizes that representation. An assurance that the Cigna arrangement permits it is not a substitute for supplying the relevant basis. Credentialing and financial protections require clear answers Cigna publishes a medical credentialing process for network participation. Wildflower publicly states that it manages credentialing and contracts with IBCLCs. Those statements do not explain how an advanced clinician’s broader professional role is evaluated within this arrangement. (cigna.com, meet.wildflowerhealth.com) Cigna also publicly states that covered services from in-network providers should not generate additional charges beyond applicable cost sharing. (cigna.com) How do those protections reach the treating practice? Which services does the covered payment include? What may be billed independently? What prevents additional charges for work already included in covered care? Who reviews a patient’s concern? These questions concern the arrangement’s safeguards. They are not allegations that individual clinicians are improperly billing. Providers need clear obligations, and patients need understandable coverage information. Providers are being denied answers too This is not simply a dispute over information requested by a billing company. Providers have also sought information about the requirements governing their own services, claims, and compensation. The relevant information has not been supplied to them either. Cigna has redirected questions to Wildflower without substantively resolving them. Wildflower has declined to provide the requested compliance or legal department contact. That creates a circular process: Cigna points to Wildflower, while Wildflower invokes its Cigna arrangement without providing its relevant terms or a meaningful route for review. The companies continue enforcing rules while the clinicians expected to follow them cannot verify their source or scope. The practical message is that the arrangement must be accepted without scrutiny. That is not a satisfactory answer for providers—or for the patients whose care and costs it affects. A company can protect confidential commercial information while explaining patient protections, identifying a contractual obligation, and providing a responsible compliance contact. The consequences are not private Cigna promotes this benefit and directs members toward the pathway. Wildflower administers it. Their arrangement affects whether a baby’s care can be submitted, whether related medical treatment has an in-network pathway, how providers are compensated, and what families may be asked to pay. Those consequences make the questions legitimate. The agreement may be private. Its effects on patients and providers are not beyond accountability. Cigna and Wildflower need to reconcile contradictory guidance, document the obligations they enforce, explain their claim structure, and provide a meaningful route for compliance review. Providers should not be left interpreting rules they cannot inspect. Families should not have to untangle two businesses to understand care from one practice. A promise of covered care needs clear rules, documented protections, and someone willing to answer for how it works. Sunshyn practice resources For help with claim submission and payer follow-up, see Sunshyn's medical billing services. The Sunshyn Learning Center offers practice education and tools to help you work through billing, payer, and practice questions.