Dr. LanderOver the past year, private payer advocacy activities by AAP chapter pediatric councils have resulted in improved coverage and payment for services such as fluoride varnish and vision screening and resolved carrier-specific issues reported by pediatricians. In addition, pediatric councils have engaged payers in long-term discussions on the development of models for alternative payments and telehealth financing.
Most chapters have pediatric councils that meet with payers to discuss issues impacting access, quality, cost, coverage and payment as well as payer policies and administrative practices affecting pediatrics. Topics addressed have included enhanced immunization rates, improved asthma control and lead screening.
Following are highlights of recent successes reported by pediatric councils:
- The Maine, Massachusetts, Pennsylvania, South Carolina, Tennessee and Virginia Chapter pediatric councils are working with carriers as they look to develop new payment models. The Ohio Chapter leadership also is addressing value-based payment models with payers.
- AAP chapters in Kansas, Minnesota, Ohio and Pennsylvania are discussing telehealth issues with payers. For example, the PA Chapter is part of a state medical society multispecialty work group that is drafting principles for a telehealth bill.
- Pediatric councils have had some successes with payers in Alabama, Hawaii, Minnesota and New Mexico in securing coverage and payment for the pediatric medical home.
- The Maine, Pennsylvania, Rhode Island and Tennessee Chapter pediatric councils successfully advocated for private payers to cover fluoride varnish application.
- The Massachusetts, Mississippi, Pennsylvania and Utah Chapter pediatric councils are working with payers on coverage of vision screening. In Oregon, a regional plan provider (Providence) has started paying separately for vision screening.
- The Pennsylvania Chapter pediatric council uncovered and resolved an incorrect International Classification of Diseases, 10th Revision coding/processing issue that resulted in well-child visit claims being rejected by Highmark Blue Cross Blue Shield (BCBS).
- The Tennessee Chapter pediatric council successfully advocated to its BCBS carrier to pay for the 9-valent human papillomavirus vaccine for males ages 16‐18 years. It also stopped improper payment recoupments from a Medicaid managed care organization.
Dr. Lander is chair of the AAP Private Payer Advocacy Advisory Committee.
