insurance

The breastfeeding billing battle

Adobe

UnitedHealthcare is cutting back on paying for lactation counseling, and the clinicians who provide those services are up in arms, another example of the deepening rifts between providers and insurers.

Starting this September, UnitedHealthcare’s employer plans will no longer pay for lactation counseling for both the mother and baby separately. Instead, the service will only “be reimbursed for one session per date of service” under the mother, according to a new update from the company. Any medical claim submitted for the baby won’t be paid, so clinicians who bill for both mom and baby will see their pay cut in half.

The Affordable Care Act requires health plans to cover lactation counseling with no out-of-pocket costs for patients. Previous reporting from Undark has shown coverage varies widely because the law is vague, although the government has made it clear that “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.”

Lactation counseling coverage really is all over the place. Some, such as Cigna and Horizon Blue Cross Blue Shield in New Jersey, don’t explicitly prohibit billing once for the mother and once for the baby. Others, such as the BCBS plans in Illinois, Texas, and Louisiana, consider the mother and the baby as one patient and “should be billed on one claim per session.” Blue Shield of California views breastfeeding as part of “the maternal care visit, and therefore not separately reimbursable.” Big employers, of course, can do their own thing.

UnitedHealthcare spokesperson Dustin Clark said the company was taking cues from the Centers for Medicare and Medicaid Services, which currently allows the lactation counseling billing code for people ages 9 to 64 and from other insurers. “We are updating our approach so that we reimburse each counseling visit once, as many other insurers already do. We recognize this is a change for some care providers and are committed to working collaboratively with them to support a smooth implementation,” Clark’s statement reads.

Christine Pfundstein, a nurse practitioner and lactation consultant in New York, said this new policy ignores how clinicians like her are independently assessing both moms and babies during the sessions. She also said payments for lactation services not only differ widely among insurers but have decreased a lot since the ACA went into effect. Ten years ago, she used to get paid $350 for a session. Now, she said she’s lucky to get between $60 and $80, if the claim doesn’t get denied.

“This is like a really big stab in an already chaotic environment that’s never had any clear guidance,” Pfundstein said. “Insurance companies, under the ACA, have to pay for lactation, and then they have just determined that to be whatever the hell they feel like paying.”

medicaid

The new ‘medical frailty’ standard

States have a little more than six months to stand up work requirements in their Medicaid programs, and the Trump administration has added even more paperwork for very sick people to get exempted from those requirements.

People deemed to be “medically frail” — those who are blind, disabled, or have serious medical conditions like cancer and kidney failure — typically qualify automatically for an exemption so they don’t have to work and can keep their Medicaid coverage. But the new rule from CMS adds an extra step for those people: They have to show their conditions impair their ability to work. 

States were not expecting this, and it likely could mean that more people get booted off Medicaid. Read more from my colleagues Tara Bannow, Chelsea Cirruzzo, and Daniel Payne.

hospitals

Ascension the outpatient giant

Tara with the skinny about a big takeover that is now in the books: Ascension is the country’s third-largest ambulatory surgery center operator with more than 300 facilities, thanks to the feds greenlighting its $3.9 billion bid to buy Amsurg. The Federal Trade Commission initially found the deal to be anticompetitive, but was satisfied after Ascension agreed to sell seven ASCs in the markets where the nonprofit system and the surgery center chain compete (more on this below).

Like some of its peers, Ascension has been aggressively culling its hospital portfolio, which once numbered 140 and is now down to 90. Traditional hospital operators like surgery centers because they’re inexpensive to run relative to hospitals and tend to be more profitable. Plus as more and more procedures move outpatient, it’s a way for them to stay in the game.

Tenet Healthcare has more surgery centers than anyone, with a stake in over 535 facilities, and they’re way more profitable than its hospitals. SCA Health, which is part of UnitedHealth’s Optum subsidiary, has more than 370 — and it is the entity that is buying six of the seven Ascension ASCs. Competition!