Payers may implement programs and policies based on adult-based recommendations that may not be appropriate or follow best practices for children.

Pediatric councils and the Coding Hotline are among the resources AAP members can access when payer policies impact their ability to provide high-quality care to patients.

Recently, payers have been “accepting” a higher-level E/M code but paying at a lower level. This frequently goes undetected by busy medical practices.

Seven in 10 pediatricians who participated in a 2018 PLACES survey reported they do work at home, such as patient charting, at least once a week.

Payments to physicians increasingly are shifting from fee-for-service (volume-based) toward value-based and other alternative models.

The 2019 resource-based relative value scale final rule established a framework for future changes to office/other outpatient E/M services provided under Medicare.

PAAC is having conversations with AAP leadership about value-based payments and consequences of focusing on cost containment in the “value” proposition at the expense of quality.

Advocacy efforts by the PAAC and staff, including a letter from the AAP, prompted Aetna to change its policy that limited coverage of CPT code 96127 to one instance per year.

PAAC often reaches out to the pediatric council in the state/region where the report was generated to capitalize on reported trends, to get additional information about the scope/depth of the problem and often to take advantage of relationships that pediatric councils have with regional payers.

Payer credentialing requires periodic updates of information including but not limited to the following: state licensing, Drug Enforcement Administration licensing, malpractice information with adequate coverage, demographic information, disclosures and attestation, and provider affirmation of what information payers are permitted to access.

Changes to UHC reimbursement policies impact vision screening, after hours/weekend care and new patient visits.

With new models promoting value-based payment and evidence-based care, the Academy wants to ensure that payment models support the family- and patient-centered medical home.

As 2018 begins, practices should review their documentation, coding and billing processes to ensure they are reporting current ICD-10-CM and CPT codes accurately.

To maintain a financially viable practice, pediatricians need to assess payer contracts and business practices periodically.

TRICARE will be going from three to two U.S. stateside regions, and the TRICARE regional contractors will change.

Alabama Medicaid, Blue Cross Blue Shield of Alabama and the state Children’s Health Insurance Program (ALL Kids) have added coverage for maternal depression screening.

Good business policies are crucial to ensuring that your practice can serve your patients and families for the foreseeable future.

Building and sustaining lines of communication and nurturing productive relationships with private payers are more important than ever as health care delivery and financing evolve to value-based payment.

The Academy has facilitated review of the nation’s largest private carriers’ clinical policies to incorporate pediatric perspective.

In a value-based contract, ensure the carrier thoroughly and clearly identifies the care delivery or quality performance metrics and how the physician(s) and practice are measured