Pricing a prenatal episode you cannot see the end of

What are you selling when you sell one price for a pregnancy?

A boundary, and only incidentally a set of visits. A global prenatal package is one fee for an episode whose length nobody knows on the day the money changes hands: one patient needs eight visits, the next needs twenty, and a third moves out of state in the second trimester. The fee has to be a written line around what it buys.

Bundling an episode into one payment is not a cash-practice invention. Medicare pays for most surgery with one package covering the procedure and the post-operative visits inside a stated global period, ten or ninety days for most procedures 1Ref 1Centers for Medicare & Medicaid Services (CMS) (2025).Global Surgery.The general Medicare surgical-package structure this article borrows as a template: one payment covering the procedure plus post-operative visits inside a stated global period of 10 or 90 days for most surgeries, and the modifier 54 / modifier 55 split used when the package is furnished by two clinicians rather than divided evenly.. Maternity sits outside that day count. Pregnancy procedures carry their own designation, MMM, on the Medicare Physician Fee Schedule Database, which is CMS treating an episode of care as its own payment category 2Ref 2Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (2026).Chapter VII - Surgery: Urinary, Male Genital, Female Genital, Maternity Care, and Delivery Systems.The inclusion and exclusion boundary of the total obstetrical package (antepartum care, delivery and postpartum care bundled; ultrasound, amniocentesis, genetic-disorder screening, unrelated-condition visits and additional high-risk visits carved out) and the distinct MMM global-period designation maternity procedures carry on the Medicare Physician Fee Schedule Database..

But the structure is the only part that transfers.

A Medicare allowed amount is a rate under a fee schedule for a payer you are not billing, and none of the sources on this page sets a cash markup over it, a standard number of prenatal visits to assume, or the share of patients who leave mid-episode. What they hold is a boundary the government had to draw in writing, and drawing your own is the work in front of you.

Pricing cash-based physical therapy hits the same wall with a shoulder in place of a pregnancy. Two answers below change at the state line as well.

Borrow the carve-out list before you borrow anything else

The most useful part of the payer's package is the list of what it refuses to include. Medicare's total obstetrical package, the code family that includes 59400 and 59510, bundles antepartum care, the delivery and postpartum care into one fee, and explicitly excludes ultrasound, amniocentesis, genetic-disorder screening, visits for conditions unrelated to the pregnancy, and the added visits a high-risk pregnancy needs 2Ref 2Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (2026).Chapter VII - Surgery: Urinary, Male Genital, Female Genital, Maternity Care, and Delivery Systems.The inclusion and exclusion boundary of the total obstetrical package (antepartum care, delivery and postpartum care bundled; ultrasound, amniocentesis, genetic-disorder screening, unrelated-condition visits and additional high-risk visits carved out) and the distinct MMM global-period designation maternity procedures carry on the Medicare Physician Fee Schedule Database..

Every line on it is a decision somebody makes: you now, in a document, or you and the patient in week thirty with a bill between you.

The high-risk line is the expensive one. A pregnancy that turns high-risk adds visits the flat fee has already spent, and a package with no clause for it prices those hours at zero.

What is a half-finished episode worth?

Decide that before you sell one. Medicare answers the same question with arithmetic: where a single global obstetric fee covers care furnished by two providers, the value of the portion already paid comes off the total first, the remainder is what the second provider shares in, and reduced-service modifiers flag that neither one furnished the whole package 3Ref 3Centers for Medicare & Medicaid Services (CMS) (2025).Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners.The split-fee arithmetic Medicare itself uses when one global obstetric fee covers care furnished by two providers: the value of the portion already paid is subtracted from the total first and the remainder is shared, with reduced-service modifiers flagging partial performance..

The surgical version is blunter. Where one clinician performs the procedure and another handles the follow-up, Medicare does not halve the fee: the surgery goes out with modifier 54 for surgical care only, the follow-up with modifier 55 for postoperative management only 1Ref 1Centers for Medicare & Medicaid Services (CMS) (2025).Global Surgery.The general Medicare surgical-package structure this article borrows as a template: one payment covering the procedure plus post-operative visits inside a stated global period of 10 or 90 days for most surgeries, and the modifier 54 / modifier 55 split used when the package is furnished by two clinicians rather than divided evenly..

But none of the sources on this page tells a cash practice what to refund.

So the schedule in your agreement is your own convention, and the defensible shape of it is stage-weighted. Assign a share of the total to intake and records, a share to each trimester of care as it is furnished, a share to delivery attendance if the package includes it, and a share to the postpartum window. A patient who leaves has earned back the stages not yet reached, on a timeline the agreement states in days.

Where a state has adopted the National Association of Insurance Commissioners model act on discount medical plans, and where that act reaches an arrangement, a member who cancels for any reason other than nonpayment is owed a pro rata reimbursement of the periodic charges already collected 7Ref 7National Association of Insurance Commissioners (NAIC) (2007).Discount Medical Plan Organization Model Act.The model act's definition of a regulated discount medical plan as a third-party arrangement brokering member access to a provider network for a fee, its pro rata refund rule where the act applies, and its disclosure checklist for a written prepaid-plan agreement.. Whether it reaches a practice selling its own care comes up below, and the direction is worth knowing before anyone drafts a no-refund clause.

The share of patients who leave mid-episode belongs in the price. That share is churn arithmetic, and a year or two of your own records will produce it.

The floor under the package

Whatever the package sells for, it has to clear what the practice costs to keep open across the months the episode runs. The Small Business Administration's startup-cost method is the input half: separate one-time costs from recurring monthly expenses, and count at least a year of the monthly ones 4Ref 4U.S. Small Business Administration (2026).Plan your business — Calculate your startup costs.The overhead inputs underneath a package price: separating one-time startup costs from recurring monthly expenses, and counting at least a year of the monthly ones.. Take the overhead for the months an episode runs, divide it by the episodes one clinician can carry at once, and the price floor stops being a feeling.

Capacity is the harder input, because an episode occupies a calendar rather than an hour: a slot every few weeks for months, an on-call window if delivery attendance is included, and unscheduled phone time no visit line records. The number to count is concurrent episodes. If the package sits beside a membership, pricing the tiers is a separate exercise.

Money that arrives before the care does

A package collected up front is prepayment, and prepayment runs into rules that have nothing to do with what you charge. The IRS treats amounts paid this year for medical care to be provided substantially beyond the end of the year as generally not includible as a medical expense for the year they were paid 5Ref 5Internal Revenue Service (2025).Publication 502, Medical and Dental Expenses.The rule that current payments for medical care to be provided substantially beyond the end of the year are generally not includible as a medical expense for the year paid, which is what a package collected up front runs into.. Your patient may hear that from a tax preparer months after the check clears.

The account-funded case is sharper. A health flexible spending arrangement may reimburse only expenses already incurred during the coverage period, with no advance reimbursement of future or projected expenses, and an HSA-qualified expense has to be incurred after the HSA was established 6Ref 6Internal Revenue Service (2025).Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans.The account timing mechanics a prepaid package runs into: a health FSA may reimburse only expenses already incurred during the coverage period, with no advance reimbursement of future expenses, and HSA-qualified expenses must be incurred after the HSA is established.. A patient paying one lump in November for care running through June is asking a plan to reimburse care that has not happened yet.

So the total matters less here than the schedule underneath it, and the question is when each portion becomes earned.

Invoice against the stage schedule already in the agreement, and give a receipt stating the amount attributable to care already furnished. Which amounts a plan or a return accepts is the patient's question, run with their own plan documents and preparer.

Where state law changes the answer

Two questions on this page get answered at the state line, and no federal manual settles either one. The first is who may render prenatal care for a fee, which each state settles in its own practice acts. The second is whether selling care before you furnish it pulls the practice into insurance-adjacent regulation. Neither has a national answer, and the same package can be sold under different rules across a border.

The model act some states drew on is narrower than it looks. The NAIC's Discount Medical Plan Organization Model Act defines the regulated thing as an entity that offers its members access to providers of medical or ancillary services and the right to receive discounts, in exchange for a fee 7Ref 7National Association of Insurance Commissioners (NAIC) (2007).Discount Medical Plan Organization Model Act.The model act's definition of a regulated discount medical plan as a third-party arrangement brokering member access to a provider network for a fee, its pro rata refund rule where the act applies, and its disclosure checklist for a written prepaid-plan agreement.. A practice selling its own future care to its own patients has no broker in the middle and no network to grant access to, so the definition does not obviously reach it.

But none of these sources settles that, and the edge case is untested.

State adoption varies, some states regulate prepaid health arrangements under statutes of their own, and no source here rules on a single practice's bundle either way. The lookup is two places: your state's department of insurance for the prepaid question, your board's practice act for the scope question. Counsel earns the hour here, and the trigger is specific: money collected for care not yet furnished, across a term of months, with a refund promise attached.

The written agreement is the product

Every decision above ends up in one document the patient signs before the first visit. The model act's disclosure checklist for a prepaid plan is a serviceable spine even where the act does not reach you: the member's name, the benefits provided, and the fees and charges, specifically including any limitations or restrictions on refunding them 7Ref 7National Association of Insurance Commissioners (NAIC) (2007).Discount Medical Plan Organization Model Act.The model act's definition of a regulated discount medical plan as a third-party arrangement brokering member access to a provider network for a fee, its pro rata refund rule where the act applies, and its disclosure checklist for a written prepaid-plan agreement.. The third item is the one practices leave vague.

Filled in, that spine holds:

• The total fee, and the visit and postpartum windows it buys
• The carve-out list, each line priced or referred out
• The stages the fee is earned across, with each share
• The refund method, and how many days it takes
• What happens if care transfers, if the patient moves, or if the pregnancy ends before term
• What happens if insurance later pays for something the package covered

That last line is the one that gets skipped. A patient whose plan later reimburses part of what the package covered will ask which of you keeps the payment, and the agreement is where the answer has to be written before the question arrives.