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AAP sees success in efforts to secure payment for pediatric services :

October 4, 2016

The AAP Private Payer Advocacy Advisory Committee (PPAAC) has made gains recently in its charge to advocate for coverage of pediatric services and appropriate payment to primary care and specialty pediatricians by private payers.

Several national health plan carriers have responded to the Academy’s calls for payment for smoking cessation and fluoride varnish application. In addition, Anthem will be revising its policy on reporting evaluation and management (E/M) services.

Anthem’s policy required medical decision-making to be one of two factors in reporting E/M services. However, CPT guidelines state that two of three components (history, examination or medical decision-making) must be met to report a particular level of an E/M service for an established patient, but none of the components is required.

Anthem is revising its policy following discussions by pediatricians on its Physician Advisory Committee, as well as PPAAC members and AAP staff. The payer agreed to revise its policy and eliminate medical decision-making as one of the requirements to report E/M services for an established patient. Once approved by Anthem, the policy change will be communicated to Anthem providers.

While there are coverage benefits for smoking cessation counseling, PPAAC wanted to ensure that the service would be paid separately. Aetna, Health Care Services Corporation (Blue Cross Blue Shield of Illinois, New Mexico, Montana, Oklahoma and Texas) report that this is a separately paid service. In addition, Humana and UnitedHealthcare pay the CPT codes for smoking cessation counseling (99406 and 99407) separately from an acute care E/M visit with the use of modifier 25 but do not pay separately when reported with the preventive care E/M service.

PPAAC also has worked with the AAP Section on Oral Health to advocate for payment for fluoride varnish application. To date, Aetna, HealthNet and UnitedHealthcare have responded to the Academy saying they will pay for CPT code 99188 apart from the office visit when reported by pediatricians.

PPAAC is available to AAP chapters, committees, sections, councils and task forces in advancing payment and benefit coverage issues germane to their constituencies. PPAAC also is available to assist AAP members with their private payer issues and works with private payer advocacy staff to develop resources to strengthen pediatricians’ financial standing with private payers.

The Academy has nurtured contacts with the largest national private health plan carriers. PPAAC members are assigned to the following carriers to serve as a resource for AAP members having issues with that carrier: Eugene R. Hershorin, M.D., FAAP (Aetna); Mark L. Hudak, M.D., FAAP (Anthem); Susan J. Kressly, M.D., FAAP (Cigna); Gail A. Schonfeld, M.D., FAAP (Humana); Norman “Chip” Harbaugh Jr., M.D., FAAP, and Richard Lander, M.D., FAAP (UnitedHealthcare); and Elizabeth M. Peterson, M.D., FAAP (Blue Cross Blue Shield Association regional plans).

Mary L. Brandt, M.D., FACS, FAAP, is the liaison to PPAAC from the Section on Surgery and is available to assist with coverage/payment issues related to pediatric surgical and medical specialties services and administrative practices affecting pediatric services.

AAP members also can use the Hassle Factor Form at to report private payer issues for follow-up by PPAAC and private payer advocacy staff.

Dr. Lander is chair of the Private Payer Advocacy Advisory Committee.

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