PPA Vision and Opportunities

2. PPA Vision and Opportunities • Advocate for coverage for pediatric services and payment for primary care and specialty pediatricians • Engage payer support of the pediatric medical home model and Bright Futures Guidelines for preventive care • Work with key groups within the Academy on strategies to address new payment models by private payers • Develop education programs and tools to strengthen member's  negotiation & contracting with payers  • Strengthen chapter pediatric councils in engaging carriers on pediatric issues

3. Headlines from AAP News articles on AAP Private Payer Advocacy activities CIGNA to increase vaccine payments AAP helps physicians get paid appropriately for PCV13 vaccine Pediatric councils help secure coverage for developmental screening Humana to pay for the new telephone care CPT codes AAP efforts pay off: UHC to update vaccine fee schedule Aetna, CIGNA & UHC pay for both preventive E/M & problem oriented E/M services Physicians see results after filing disputes against insurers Aetna to pay for claims appended with modifier 25 AAP making impact on UnitedHealthcare pay-for-performance programs

4. New Challenges and Opportunities • ACA Implementation * Coverage and Payment for Preventive Care Services * Grandfather status of plans * Insurance Exchanges • New Payment and Delivery Systems * ACOs, Integrated Delivery Systems * Global fees, shared savings/risk, etc.

5. AAP Private Payer Advocacy (PPA) is a Multi-level approach • National/Regional Dialogue with payers on AAP policy and specific carrier issues; Member Center PPA resources; Assistance to Chapters, Committees, Sections,Councils, and members • Chapters Pediatric Councils meet with payers on regional issues: Hassle Factor Form Reports to identify member concerns • Members Technical assistance by AAP Coding Hotline staff; Appeal Letter Templates; Resources on coding, contracting, appeals, etc. Members can report issues on the AAP Hassle Factor Form on MyAAP, private payer advocacy page

6. Private Payer Advocacy Advisory Committee (PPAAC) PPAAC is a sub-Committee of the AAP Committee on Child Health Financing (COCHF) Charge: Advise the AAP and its leadership on a payment strategy, including specific goals and action steps, to improve pediatrician’s economic and organizational position in the private marketplace and collaborate with other AAP Committees, Sections, Councils, and Task Forces in advancing the payment and benefit coverage issues germane to their constituencies

7. AAP Activities to Sustain Payer Relationships • Meetings with national carriers • Letters to carriers on specific issues • Pediatric representation on carrier physician advisory boards • Review process for WellPoint and UHC clinical policies to incorporate pediatric perspective • Chapter pediatric councils to meet with payers on regional issues

8. AAP Endorsed Principles on Benefit Plan Coverage and Payment The AAP approved a listing of benefit plan coverage and payment principles to serve as an advocacy agenda for discussions with payers.  The principles represent existing AAP policy and strategic plan concepts. Available at: http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Documents/Private/PaymentPrinciples.pdf

9. AAP Chapter Pediatric Council • A forum for chapters to meet with payers to discuss issues impacting access, quality, cost, coverage and payment • A means to address payer policies, covered services and administrative practices affecting pediatric services • A collaborative effort to discuss ideas for resolving issues between pediatricians and payers • It is not a means to discuss or negotiate fees, payment, or any collective action by pediatricians

10. Resources for Chapter Pediatric Council Development • Pediatric Council Guidebook (featuring tips and strategies of successful pediatric councils) • Pediatric Council E-mail List • Pediatric Council Web Site on the AAP Member Center • Powerpoint presentation templates and talking points to use with payers • Hassle Factor Form Reports provided quarterly or as needed to chapter pediatric councils

11. Resources for AAP Members • Private Payer Advocacy Web Site on the MyAAPMember Center at http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Private-Payer-Advocacy.aspx • Powerpointpresentation templates and talking points to use with payers • Hassle Factor Form Reports to report payer issues to PPAAC and pediatric councils • Template letters and appeal letters to send to payers • Managed Care contract resources

12. Enhance PPA Communications to Chapters and Members • Monthly PPA updates to AAP Chapters • PPA articles in AAP News, AAP OnCall, Chapter Connections • PPA link on the MyAAPMember Center • Promoting the Value of Pediatrics

13. AAP Hassle Factor Form • AAP Members can report insurance administrative and claims processing concerns. • The information provided will be used to assist the AAP and chapters in identifying trends and facilitating public and private sector advocacy related to health plans. • Members can report issues on the AAP Hassle Factor Form at http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Hassle-Factor-Form-Concerns-with-Payers.aspx

14. Contact Information National AAP: 800/433-9016 Pediatric councils, coverage/contract issues: Lou Terranova (7633) or at lterranova@aap.org Medicaid: Dan Walter (4086) or dwalter@aap.org) Coding: aapcodinghotline@aap.org Immunizations: Elizabeth Sobczyk (4271) or at esobczyk@aap.org