UnitedHealthCare Billing Changes

FOR PARENTSFOR PROVIDERS
Written By Gianna DeJoy

What this means for lactation professionals and families. What’s happening.

In June, UnitedHealthcare (UHC) published an update bulletin that, among other things, announced a revision to UHC’s reimbursement policy on the billing code S9443 – typically used to cover no-copay lactation education and counseling.

Specifically, UHC will only reimburse claims submitted for the lactating parent, not the infant. The health insurer is also limiting the number of sessions that it will reimburse to one per day.

The changes will go into effect on September 1.
Speak Up!
There is a list of contacts at the end of this article. Push back against these changes.

What this means for lactation professionals.

This change only applies to patients with a UHC health insurance plan and only to billing code S9443. Depending on a provider’s licenses and practice setting, other evaluation and management billing codes might still be available unchanged. UHC is not eliminating coverage for preventive lactation services (that would be illegal: see below) nor lowering rates for these services.

However, this change will have the effect of reducing payments to lactation professionals who will no longer be able to bill for both members of the breastfeeding dyad nor for multiple consultations provided in the same day. 

Starting in September, lactation professionals could see more rejected claims in the confusion of the policy shift. Providers have also raised the concern that, in some situations where only the infant is enrolled in a UHC health plan, there could be effectively no coverage for lactation counseling.

The impact on Maine families.

One of the most important elements of the UHC policy change to draw attention to is the fact that it applies to a billing code used for preventive services. Under the Affordable Care Act (ACA), nearly all payers are required to cover lactation support and counselling as a preventive benefit with no out-of-pocket expense for families. This no-copay care is what UHC is stripping down. Coverage of the clinical diagnosis and treatment of certain breastfeeding concerns remains unchanged, but this kind of care includes some cost-sharing requirements. In short, breastfeeding support is getting more expensive at the point of care.

UHC is asking lactation professionals to only extend this type of preventive support to one half of the parent-infant dyad. As providers are pointing out, such a policy is nonsensical to the model of care that IBCLCs and counselors/educators offer. Few if any breastfeeding concerns do not involve the infant. Most sessions center around an assessment of baby’s latch and milk transfer. Under the revised policy, UHC will not reimburse providers for that aspect of their work. This means some might stop accepting UHC insurance, reducing access to lactation care in Maine.

Further, we know that the first hours, days, and weeks after birth are a crucial time for establishing breastfeeding. In the immediate postpartum, feeding issues can arise and turn into serious concerns quickly. Arbitrarily limiting the amount of lactation support that a parent can receive within a single calendar date reflects a lack of understanding of this sensitive period. It’s also potentially dangerous for UHC-covered families.

The bigger picture.

The UHC policy revision is a symptom of a larger disease: legal loopholes, imprecise billing codes, and a resulting patchwork landscape of coverage for lactation care. It also follows a more recent trend of undermining ACA patient protections.

Even though under the ACA “lactation counseling must be covered without cost-sharing by the plan or issuer when it is performed by any provider acting within the scope of his or her license or certification,” vague wording in the law has allowed health insurers to interpret the mandate in a variety of ways. According to a 2019 investigation, plans might technically cover lactation counselling but have no IBCLCs in network; only cover in-hospital sessions; argue that a provider who is not a breastfeeding specialist (such as the attending obstetrician or the infant’s pediatrician) is sufficient to offer lactation support; or bundle a lactation consult in with a standard office visit such as the six-week postpartum checkup. Limiting the number of covered sessions and only allowing providers to bill for the parent (not an infant assessment) are other popular workarounds.

Another issue is that there is no code in Current Procedural Terminology (CPT) – the standardized code book published by the American Medical Association for billing and reporting purposes – that specifically describes lactation consultation services. As a result, there is great variation in how lactation services are billed and which codes different insurers will accept. Code S9443 is officially for lactation classes offered by a non-physician provider but has become a catch-all for preventive lactation services from a non-physician. It falls under a miscellaneous, temporary category of the Healthcare Common Procedure Coding System (HCPCS) Level II. This itself reveals the administrative marginalization and precarity of lactation care. 

UHC is also using that code location as rationale for its policy change. HCPCS Level II is maintained by the Centers for Medicare and Medicaid Services (CMS). In the June update bulletin, UHC stated that the change was “in alignment” with CMS. Even though the “S” category of HCPCS Level II exists to hold supplies and services not covered by Medicare, CMS lists a minimum age of 9 years old for the S9443 billing code. This may be UHC’s defense for eliminating infant reimbursement – however, it doesn’t explain the newly imposed session limit.

UnitedHealthcare has tried to avoid paying for lactation care before.

Trying to circumvent ACA and ERISA requirements is nothing new for UHC. The company faced back-to-back class action lawsuits in 2016 and 2017 for failing to provide coverage of lactation support, failing to include IBCLCs in their networks, and intentionally stalling claims and appeals processing for lactation services.

Speak up!

UHC can choose to rescind the announced changes before they go into effect on September 1 – if there’s enough pushback. IBCLC and business consultant Annie Frisbee created this incredibly thorough guide to fighting back against the UHC revisions. Parents and providers can customize Annie’s templates to contact UHC, the Maine Bureau of Insurance, your state and federal representatives, and your employer’s HR office.

Gianna DeJoy
Next

Stories Are The Salve We Need