Understanding the Global OB Package: Why Referrals Can Cost a Practice

Reviewed by Sina Haeri, MD, MHSA, maternal-fetal medicine physician.

The global OB package is one of the most important, and most misunderstood, features of obstetric billing. Under the global obstetric package, a practice bills a single bundled fee that covers routine antepartum care, delivery, and postpartum care for a normal pregnancy. It is efficient and predictable. But it also creates a quiet financial dynamic that many practices overlook: because the payment is bundled and fixed, the way a practice handles referrals and co-management can directly affect what it actually earns from that package. This article explains how the global OB package works and why OB billing referrals deserve a closer look.

What is the global OB package?

The global obstetric package, described in CPT and followed by most payers, bundles maternity care into one payment. It typically includes the routine prenatal visits, the delivery itself, and routine postpartum care. Rather than billing each prenatal visit separately, the practice submits a global code after delivery that covers the full episode of uncomplicated care.

The logic is that a normal pregnancy involves a predictable series of visits, so a single bundled fee simplifies billing for everyone. Certain services fall outside the package and are billed separately, including the initial visit that confirms pregnancy, lab work, ultrasounds, and care for complications or conditions beyond routine pregnancy. But the core antepartum, delivery, and postpartum services are bundled.

Why can referrals cost the practice money?

Here is the part that catches practices off guard. Because the global package pays a fixed amount for the full course of routine care, that payment can be reduced when another provider delivers part of it.

Consider what happens when a patient develops a condition that prompts a referral, or when the practice sends a patient elsewhere for a stretch of care. If the patient receives a portion of her prenatal care from another practice, the global package may no longer apply cleanly. Payers often expect the care to be unbundled and split, so each practice bills only for the portion it provided. That can mean itemized antepartum visit codes at lower cumulative value, additional administrative work, and in some cases a smaller net payment than the intact global fee would have produced. In short, fragmenting the episode of care can fragment the revenue that goes with it.

The dynamic is not about doing anything improper. It is about recognizing that co-management arrangements have billing consequences, and that reflexively referring a patient out, when the practice could safely keep the care in house with the right support, can leave money on the table while also disrupting continuity for the patient.

What does this mean for co-management decisions?

Co-management, where an OB practice shares care of a higher-risk patient with a maternal-fetal medicine (MFM) specialist, is clinically appropriate and often necessary. The question is how the co-management is structured.

The traditional route is to refer the patient out to an MFM practice, frequently at a distant academic center. That can be the right call for the most complex cases. But it also means the patient leaves the practice for part of her care, travels for appointments, and, from a billing standpoint, may pull that portion of care out of the global package. For a subset of patients, this is unavoidable and correct. For many others, it is a default that carries hidden costs to both the practice and the patient.

There is a middle path. A practice can bring specialist expertise to the patient rather than sending the patient to the specialist. That is where tele-MFM changes the equation.

How does tele-MFM change the referral calculus?

A tele-MFM referral, or better, a tele-MFM consultation and co-management arrangement, lets an OB practice access maternal-fetal medicine expertise without transferring the patient out of the practice. The specialist consults, advises on management, and supports the OB team virtually. The patient stays in her medical home. The practice retains continuity of care and, in many arrangements, retains more of the associated revenue rather than losing it to an external practice.

This is the model Ouma Health is built around. Ouma is a real medical practice, not an app: physician-led and founded by MFM specialists, designed to work alongside OB practices rather than pull patients away from them. Practices can add specialist depth, keep patients local, and protect the integrity of their care and billing at the same time. See how this works for clinics.

Deciding when to consult versus when to fully refer is a clinical judgment. For a practical framework on that decision, see our guide on when an OB practice should refer to MFM.

The takeaway

The global obstetric package rewards continuity. When a practice keeps a routine pregnancy intact within its own care, it earns the full bundled payment. When care fragments through unnecessary referrals, both the revenue and the patient experience can suffer. Understanding this dynamic does not mean avoiding appropriate specialist involvement. It means choosing co-management models, increasingly tele-MFM, that deliver the expertise without giving away the care.

What changes on 1 January 2027

The argument above rests on the global package, and the global package is being restructured. The change is settled on the coding side and unsettled on the payment side, and those two things are worth keeping apart.

The referral calculus survives the change, and gets simpler to see. Today the loss from referring a patient out is partly hidden inside an unbundling exercise. Under per-encounter antepartum reporting it is direct: a practice bills the visits it provides and does not bill the visits it hands to somebody else. Either way, the practice that keeps the patient and brings subspecialty input in remotely keeps the work. What changes is that the arithmetic becomes visible on the claim rather than emerging at the end of the episode.

What a practice should do now is narrow: confirm how each of its major payers intends to handle the transition, and make sure the practice management system will carry both structures through the changeover. What is decided and what is still proposed →

Related: High-risk pregnancy care · Ouma for clinics

CPT is a registered trademark of the American Medical Association. Descriptions here are written by Ouma Health and are not the official CPT descriptors. This is general information, not coding or billing advice. Verify current codes and payer policy before submitting claims.

Frequently asked questions

What is the global OB package?

It is a bundled payment, defined in CPT and used by most payers, that covers routine antepartum care, delivery, and postpartum care for an uncomplicated pregnancy under a single global code, rather than billing each visit separately. The CPT Editorial Panel accepted a restructuring in September 2025 that deletes the global obstetric codes effective 1 January 2027 and reports care in four separate phases; payer adoption of the new structure varies.

What is not included in the global obstetric package?

Services outside routine maternity care are billed separately, including the initial pregnancy-confirmation visit, lab work, ultrasounds, and management of complications or conditions beyond a normal pregnancy.

Why can referring a patient out reduce a practice's payment?

If another provider delivers part of the prenatal care, the global package may need to be unbundled and split, so each practice bills only its portion. That can lower the practice's net payment compared with an intact global fee, plus added administrative work.

How does tele-MFM help with co-management and billing?

A tele-MFM referral or consultation lets an OB practice access maternal-fetal medicine expertise virtually while keeping the patient in house. This preserves continuity of care and can help the practice retain revenue that a full external referral might shift elsewhere.