The Women's Health Reimbursement Landscape
One episode, five economies — and a payer mix pulling in two directions.
In OB/GYN, the money doesn't sit in a single visit. It is spread across a bundled maternity package, surgical GYN, the well-woman panel, imaging, and in-office ancillaries — each priced by a different payer logic.
Obstetrics is paid through the global package — antepartum care, delivery, and postpartum bundled into one code family — so revenue integrity depends on correct global versus itemized billing, appropriate unbundling when care is split across practices, and clean capture of vaginal, cesarean, and VBAC deliveries plus maternal-fetal-medicine high-risk add-ons. A single miscoded transfer of care or an unbilled antepartum record can quietly erase the margin on an entire pregnancy.
The payer mix pulls in two directions at once. A reproductive-age patient base skews commercial, which makes negotiated commercial rates the primary lever on margin — yet Medicaid finances roughly 40%+ of U.S. births, so Medicaid managed-care rates and their carve-outs are decisive for any practice with a meaningful obstetric volume. Meanwhile minimally invasive hysterectomy and other GYN surgery are migrating from the hospital outpatient department to the ASC, in-office LARC/IUD, ultrasound, and lab ancillaries are expanding, and ACA-mandated well-woman preventive services carry no patient cost-share. The same practice can be worth dramatically different amounts depending on how each of these is coded, contracted, and sited — and that is precisely where Fulcrum works.
Illustrative composition. Replace with your confirmed figures before launch; reflects current CMS, MACPAC, and public payer methodology, 2024–2026.
