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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. 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.

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.

For OB/GYN practices, the upcoming maternity coding changes reach far beyond updating numbers in a billing system. They affect how care is documented, when claims are submitted, how reimbursement is negotiated, and what patients are told about their financial responsibility. Beginning January 1, 2027, the CPT maternity care structure replaces traditional global obstetric codes with separate reporting for prenatal care, labor management, delivery, and postpartum care. The update includes 17 deleted codes, 12 new codes, and six revised codes. The opportunity is clearer recognition of the care clinicians actually provide. The challenge is making sure payer policies, contracts, and billing systems keep up. What changes? Under the new structure, prenatal encounters use appropriate evaluation and management—or E/M—codes. Labor management receives its own codes, distinguishing initial and subsequent days and straightforward versus complex care. Delivery is reported separately, followed by appropriate E/M reporting for postpartum encounters after the delivery date. Familiar codes—including 59400, 59425, 59426, and 59430—are being deleted for 2027 dates of service. Practices cannot simply keep their existing maternity billing templates and replace the delivery code. Labor management becomes visible Managing labor and performing the delivery are distinct parts of maternity care. The new structure allows both to be reported when the clinician performs both services, including on the same date. That does not mean every clinician covering a shift can submit an additional labor management charge. The rules distinguish coverage from a medically necessary escalation or transfer of care. Practices need documentation and workflows that reflect those distinctions. Delivery and postpartum care have their own rules New delivery codes distinguish vaginal delivery, vaginal birth after cesarean, primary cesarean, and repeat cesarean. Vaginal delivery reporting still includes specified work, such as placenta delivery and first- or second-degree laceration repair by the delivering clinician or group. Third- and fourth-degree repairs have separate new codes. Routine postpartum care on the delivery date remains included in the delivery code. Later inpatient and outpatient postpartum encounters use appropriate E/M codes under the applicable guidelines. Separating phases of care does not make every component separately reportable. Teams still need to understand what each code includes. Pregnancies crossing January 1 need attention now A patient due in February 2027 may already be receiving care in 2026. Waiting until January to decide how to report those encounters creates an avoidable problem. The AMA’s September transition guidance says 2026 antepartum services remain subject to 2026 reporting rules. For care spanning the transition: Three or fewer prenatal encounters in 2026 use individual E/M reporting. Four to six use 59425. Seven or more use 59426. Prenatal encounters in 2027 use appropriate E/M codes. Practices should also confirm payer transition policies. For example, five prenatal encounters in 2026 followed by additional visits in 2027 would be reported with 59425 for the 2026 care and appropriate individual E/M codes for the 2027 encounters. A 2027 due date alone is not a reason to switch every 2026 visit to the new reporting structure. New codes do not answer the payment questions The CPT update establishes how services are reported. Practices still need written answers about reimbursement, claims processing, and benefits. For each payer, ask: What rates will apply to prenatal E/M, labor management, delivery, and postpartum services? How will care spanning 2026 and 2027 be processed? Which modifiers, claim edits, or submission requirements will apply? How will patient responsibility be determined for each service? Will contracts or fee schedules referencing deleted codes be updated? The AMA specifically calls for payer preparation involving contracts, fee schedules, systems, and claims edits. As of October 4, 2026, the Medicare payment values discussed in its guidance remain proposed, with a final rule expected in November. Practices should not present proposed values as guaranteed reimbursement. Patients need an explanation, too Patients accustomed to a maternity package may see more individual claim entries. Practices should explain which services those entries represent and review existing estimates and deposits against the payer’s transition policy. More claim lines do not, by themselves, establish what a patient owes. Staff need verified benefit information before promising either no patient responsibility or a copayment at every visit. Patients should receive a clear explanation before an unexpected statement arrives. Preparation needs to happen across the practice Review documentation templates, code selections, payer agreements, estimates, and collection workflows together. Train clinicians and billing staff on E/M requirements and the new maternity guidelines. Identify patients whose care will cross the implementation date. At Sunshyn Credentialing and Medical Billing, our position is straightforward: practices need usable payer instructions before they submit claims, and patients deserve explanations grounded in their actual coverage. January 1 is the coding deadline. The work to protect reimbursement and patient trust starts now. Sunshyn practice resources For help with billing workflows in your maternal health practice, see Sunshyn's maternal health billing support. For a structured look at claims and billing workflows, explore the Insurance Billing Mastery learning pathway in the Sunshyn Learning Center.

The code determines how units work A feeding treatment lasts an hour instead of half an hour. The clinician provided more care, but the billing team cannot assume the claim should contain twice as many units. The first question is whether the reported service uses a timed or untimed code. ASHA identifies 92526, used for swallowing and oral function treatment for feeding, as an untimed service reported once per date of service regardless of the total treatment time. Applying a fifteen-minute unit calculation to that code changes the claim without changing its reporting rules. [1] For an SLP practice, this distinction belongs in the scheduling and billing workflow. A template that multiplies units for every longer appointment can create errors even when the clinical care is appropriate. Time still belongs in the record Untimed does not mean undocumented. Describe the treatment, the patient’s response, and the clinical decisions that shaped the session. Record duration as appropriate to the documentation requirements that apply. Consider an infant feeding appointment that requires repeated observation, a change in the treatment approach, and caregiver instruction. The note should explain those services. The length of the appointment alone does not establish additional 92526 units. A second code needs a distinct service A practice may provide more than one type of service during an encounter. Each reported service needs to match what actually occurred, with review of applicable coding edits and payer requirements. Do not add a general therapy code simply to compensate for the length of feeding treatment. Ask what separate work the additional code represents and whether the record supports it. ASHA provides guidance for combining timed and untimed services; the team should consult that guidance rather than treating all appointment minutes as interchangeable. [1] Fix the economics without changing the clinical story If a payer’s rate does not support the time required for appropriate care, make that a contracting and practice-planning issue. Compare the allowed amount with clinician time, administrative work, and the cost of maintaining the service. Train the billing team to recognize which codes are timed, which are untimed, and which questions need clinician review. Review software defaults before they affect an entire batch of claims. Patients need enough time for the care they receive. Practices need reimbursement that supports that care. Accurate reporting gives a practice a sound basis for both conversations. Source: [1] ASHA: Understanding Timed and Untimed CPT Codes 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.

You receive lactation care from an independent practice. That practice schedules your visit, performs your care, and maintains your clinical documentation. Then the insurance claim identifies Wildflower as the billing and rendering entity. Wildflower’s explanation, as communicated to Sunshyn, is that Cigna authorized the arrangement. That explains what Wildflower says the payer permits. It does not fully explain what the treating provider authorized—or how the signed provider agreement supports the representation on the claim. Cigna’s approval of a billing structure and the independent provider’s authorization are separate questions. Both deserve documented answers. Different claim roles have different meanings Healthcare claims can legitimately identify different people and organizations. The clinician performing a service, the group billing for it, the service location, and the entity receiving payment may have different names. A billing company may also prepare and transmit claims on a practice’s behalf. Different names therefore do not automatically establish an improper claim. The question is whether those names accurately reflect an authorized relationship. Handling a practice’s billing does not, by itself, establish that the billing company furnished the clinical care. What Sunshyn has identified Claims reviewed by Sunshyn identify Wildflower as the billing and rendering entity for care performed by independent lactation practices. The provider agreement reviewed by Sunshyn appoints Wildflower as a billing and collection agent for services performed by the contractor. That establishes an agency role. Sunshyn has not identified language expressly authorizing Wildflower to represent itself as the rendering entity for the independent practice’s services. This is a finding about the agreements reviewed—not a determination that no other authority could exist. If another provision, enrollment structure, or approved relationship supplies that authority, Cigna and Wildflower should identify it and explain how the treating provider became part of it. What does Cigna’s permission actually establish? Cigna can establish the billing arrangements it accepts and recognize appropriately structured provider relationships. But an agreement between Cigna and Wildflower does not, by itself, demonstrate the independent practice’s authorization for every representation made about its services. The connection needs to be explained. What did the treating practice authorize? Which contractual provision supports the provider roles used on the claim? What enrollment or affiliation records establish the relationship? “Cigna gave us permission” leaves those questions unanswered. If payer permission were enough, where would it stop? Consider the consequence of treating Cigna’s permission as the complete source of authority. What limits Wildflower’s claims to services from practices that agreed to participate? What distinguishes those services from lactation care performed by another independent practice treating a Cigna member? This is not an allegation that Wildflower submits claims for every lactation visit nationwide. It is a question about the boundary of the authority it asserts. The provider relationship must matter. If the signed agreement authorizes billing and collection, while the claim structure relies on a broader clinical-group relationship, where was that broader relationship established? A payer’s willingness to accept a claim does not explain every authority needed to submit it in that form. A billing agent is not automatically the treating practice Independent practices routinely hire companies to prepare claims, follow up with insurers, and collect payment where authorized. Those functions do not automatically turn the agent into the clinical entity that provided the service. An organizational NPI also does not, by itself, explain how independently owned practices became part of that organization for billing purposes. The underlying relationship needs to be clear. Did the provider join a clinical group? Did the provider authorize a particular rendering representation? How does the payer recognize that affiliation? What responsibilities accompany it? Providers should be able to understand those answers from accessible documentation. Access to patient information does not settle the question Wildflower receives information needed to process claims for the provider’s services. But access to patient and clinical information does not, by itself, explain the authority to identify a particular organization as the billing or rendering provider. A company may have permission to handle information and submit claims while still needing to explain the provider identity used on those claims. The agreement should make that distinction understandable. Information access, billing agency, and clinical-group participation are separate issues. “Group practice” needs a documented relationship Wildflower has described its billing in terms of a group arrangement. Group billing can be legitimate. But calling an arrangement a group does not explain how each independent practice fits into it. The agreement reviewed by Sunshyn describes management services and a billing and collection relationship. Sunshyn has not identified language expressly establishing the independent practice as a Wildflower clinical-group member. Cigna and Wildflower should reconcile those descriptions. What establishes the affiliation? Which clinicians and locations are included? How are the treating providers evaluated? What responsibilities does Wildflower assume? The contracts, enrollment records, and claims should describe a coherent relationship. Patients have a stake in the answer Patients deserve to understand why their insurance paperwork identifies a company different from the practice they visited. They may need to know whether that company furnished care or acted as an intermediary, which entity participates in their network, and where to direct a billing concern. A different name can appear on legitimate paperwork. The patient still deserves an explanation. Without one, a claim may leave the family uncertain about who provided the service and what the network arrangement means for their care. Providers deserve to understand how their work is represented Clinicians have a direct interest in claims submitted for their services. Their documentation supports the care performed. Their agreement defines the role they authorized Wildflower to undertake. They should be able to review how their services are represented, understand the authority supporting that representation, and obtain corrections when needed. If Wildflower relies on an undisclosed payer agreement, providers should receive enough information to verify the requirements affecting their own work. They should not be expected to accept an unexplained claim structure simply because another company controls submission. Requests for answers have reached a dead end Sunshyn and providers have sought explanations about the claim structure and its authority. Cigna has redirected questions to Wildflower without substantively resolving them. Wildflower has invoked its Cigna arrangement without supplying the relevant supporting terms. It has also declined to provide the requested compliance or legal department contact. The result is that claims continue to be submitted while the people whose care and services they represent cannot verify the basis for the arrangement. Commercial confidentiality does not prevent an explanation of the relevant authority. It does not prevent identifying a responsible contact to review concerns. An agreement may be private. The representation of independent providers’ clinical services is not beyond accountability. “Cigna authorized it” is the beginning of an explanation This concern is directed at the structure Cigna and Wildflower have established—not at clinicians trying to obtain payment for care they performed. The companies should identify both sides of that structure: what Cigna approved and what the treating provider authorized. They should explain how the provider agreement supports the claim roles used and give providers a meaningful route to review claims submitted for their work. Patients deserve to understand who their insurance says treated them. Providers deserve to understand how their services are represented. Both deserve documentation instead of a circular referral between companies. 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.

The activity is only part of the encounter A child practiced dressing. An adult prepared a simple meal. A patient worked through a sequence of daily tasks. Each description tells a reviewer what the patient did, but very little about the occupational therapist’s contribution. AOTA describes documentation as a record of the services provided and the practitioner’s clinical reasoning. Its documentation resources emphasize making the value of occupational therapy understandable. [1] For an independent OT practice, that means the note should connect the activity with the patient’s functional need and the clinician’s decisions. A list of tasks can leave skilled work almost invisible. Start with the patient’s difficulty Describe the relevant starting point. What prevented the patient from completing the activity safely, effectively, or with the intended level of independence? Which findings shaped the intervention? Consider a child working on dressing. A note saying the child put on a shirt does not explain whether the therapist changed the task, adjusted cues, assessed a barrier, or modified the environment. Those details help another clinician understand what to continue and what to reconsider. Use the patient’s actual findings. Do not turn a documentation example into language copied into every chart. Show what changed during treatment Record the intervention and the response. If the therapist changed the level of assistance or adapted the task, explain the reason. If the patient struggled, describe what was observed and how that affected the next decision. At the next encounter, compare meaningful findings instead of repeating a general statement that progress continues. A patient may improve in one part of an activity while still needing support in another. The record should preserve that difference. Clear clinical reasoning also helps distinguish OT’s work when the patient sees other disciplines. Explain the occupational performance goal being addressed instead of relying on a generic rehabilitation label. Build templates that prompt thinking A template should ask for current function, the goal addressed, the intervention, response, and the reason for the next step. It should not require the clinician to select a positive response when the encounter showed something else. Keep billing requirements visible without letting them replace clinical judgment. Review service selection and units under the payer rules that apply, and route uncertain questions back to the treating professional. The strongest note lets a reader follow the encounter from the patient’s difficulty through the therapist’s decision to the result. It gives the next clinician something useful and gives a reviewer an accurate account of why occupational therapy was provided. Source: [1] AOTA: Documentation of Occupational Therapy Services 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.

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.

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. 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.

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. 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.

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. 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.