AAP advocacy leads to appropriate payment for members
Susan J.Kressly, M.D., FAAP
Private Payer Advocacy
Almost every practice, institution and organization can cite examples of when they
have encountered barriers to appropriate payment for care delivered to patients. The
AAP Payer Advocacy Advisory Committee (PAAC) was formed to address pediatric issues
with payers in both the public and private sectors.
In order for PAAC to assist AAP chapters and members, it is vital for them to report
their payer issues. Problems with payment can come to PAAC through many channels,
including subspecialty sections, group email lists and the AAP Hassle Factor form.
PAAC then seeks additional data or examples from the reporting AAP member. It often
is helpful to include billing or office management staff who can provide detailed
information about the claim. Also, patient de-identified explanations of benefits
(EOBs) or electronic remittance advice (ERA) are useful examples to show how the claim
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.
After further investigation, PAAC sometimes discovers that particular payers have
nuanced requirements for claims processing that include specific modifiers or coding
patterns. That information is passed on to reporting members to assist them in appealing
claims and changing coding patterns for better payment.
In some cases, PAAC leverages relationships with national payers to advocate for appropriate
payment. Some recent successes include:
Anthem rescinded its proposed policy to reduce payments for evaluation and management
services reported with modifier 25 when submitted for the same physician and on the
same date as a minor surgical procedure or wellness exam.
After discussions with UnitedHealthcare, the nation’s largest carrier is paying for
after-hours care and vision screening. For after-hours/weekend care, CPT code 99051
will be paid for when billed with acute care services (e.g., 99213) and provided by
primary care providers. For vision screening, codes 99173, 99174 and 99177 will be
paid for when reporting with a preventive medicine service code.
In response to a member’s report that Cigna incorrectly denied claims for a patient
who has Cigna as both the primary and secondary carrier, the AAP utilized its Cigna
contacts to resolve the denials.
AAP payer advocacy worked with Humana Military to facilitate more timely payment processing
on pended claims across several pediatric practices in several states.
Your AAP member benefits include PAAC advocating with you and on your behalf to receive
adequate and appropriate payment for the care you provide to children.
How can you help PAAC help you? Instead of complaining to your partners or on email
lists, submit a Hassle Factor form at http://bit.ly/AAPHassleFactorForm (login required). Include as much specific information as you can as well as the
name and contact information for someone in your organization who can provide details
and examples of EOBs and/or ERAs where applicable.
We are able to accomplish more when we work together.
Dr. Kressly is chair of the AAP Payer Advocacy Advisory Committee.