A key element of
AAP private payer
advocacy are chapter
pediatric councils, which meet with local payers on
pediatric coverage and payment issues. Antitrust
laws prohibit the Academy and chapters from negotiating payment or collective bargaining. However,
engaging payers in discussions on access, quality,
cost and coverage has resolved carrier-specific issues
and enhanced covered benefits and payment.
Following are recent successes reported by chapter
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 using the new Current
Procedural Terminology code 96161. The decisions
came after the chapter’s pediatric council had been
making the case for coverage under the baby’s claim
over the last several years. Bright Futures Guidelines
recommend assessing for maternal depression at the
1-, 2-, 4- and 6-month visits.
“This is a huge win for babies,
new mothers and Alabama pedi-
atricians,” said chapter President
Catherine L. Wood, M.D., FAAP.
“This will allow us to rightfully
screen the mother in an effort
to ultimately protect the baby’s
health and direct her to the help
Recent advocacy with commercial carriers and
Medicaid managed care plans in Tennessee led to
improved payment for adolescent risk screening,
fluoride varnish application and instrument-based
vision screening. In addition, when the state rolled
out a medical home payment initiative, the chap-
ter/pediatric council provided input to enhance the
program for pediatrics.
Vermont also has seen improved payment for adolescent risk screening and fluoride varnish application after discussions with payers.
Not all chapters have a pediatric council. A few
chapters have a key member as the primary contact
for insurance plan presidents and medical directors
and/or local accountable care organization members
to discuss pediatric issues.
The Minnesota Chapter, for example, uses work
groups and its executive committee to work
directly with health plans. The chapter’s re-
cent successes include improved payment
for adolescent depression and obesity screenings. A
key strategy used by the chapter is to utilize provider
data and partner with health plans to support its
efforts to address an issue that is a statewide priority.
Not all advocacy bears immediate benefits and al-
most always requires sustained effort and continuous
monitoring. After more than two years of advocacy
for coverage of donor breast milk for premature ba-
bies, AAP New York Chapters 1, 2 and 3 recently
were successful in securing Medicaid coverage. This
was included in the governor’s budget, which was
passed in April. With Medicaid now paying, the
chapters are hoping private carriers will follow suit.
The New Mexico pediatric council gave multiple
presentations and data to managed care organiza-
tions to obtain coverage for instrument-based vision
and hearing screening. The payers agreed to increase
payments, but not all pediatric practices are seeing
the higher rates in their fee schedules. This illustrates
the business reality that practices need to monitor
their own fee schedules and negotiate for appropriate
Dr. Lander is chair of the AAP Private
Payer Advocacy Advisory Committee.
Advocacy leads to improved payments for screenings, varnish application
by Richard Lander, M.D., FAAP
• The AAP Private Payer Advocacy Advisory Committee
(PPAAC) is available to help chapters start a pediatric
council or to provide technical assistance and support
to existing councils. For more information, contact Lou
Terranova, in the AAP Division of Health Care Finance,
at 847-434-7633 or firstname.lastname@example.org.
• A Pediatric Council Forum will be held from 2-4 p.m.
Sept. 16 at the AAP National Conference & Exhibition
• AAP members are encouraged to report payer issues
using the Hassle Factor Form at http://bit.ly/2vsL7hd.
Pediatric councils and PPAAC can use the information
reported in discussions with payers.