Over the past few years, the American Academy of Pediatrics has increased its advocacy efforts in response to the membership's growing frustration with inequities in both the public and private sectors. Initially, work focused primarily on Medicaid issues. That work continues and the Private Payer Advocacy Advisory Committee was formed to more aggressively address pediatric issues in the private payer sector.
If you have any questions or would like information on the Academy's private payer advocacy activity please contact Lou Terranova at firstname.lastname@example.org
or at 800/433-9016 ext. 7633.
Medical Home Financing
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.
AAP Private Payer Advocacy Resources
Managed Care Contracts
Promoting the Value of Pediatrics
Pediatric care must be adequately paid in order to ensure access to care for patients. In addition, children’s health care should not be fragmented—it should be provided through a medical home to ensure quality care and to prevent costly illnesses and injuries. The AAP has developed these materials to assist our members in communicating to the media about one of the greatest values in healthcare today: preventive pediatric care. These materials focus on primary care provided in a medical home model.
Pay for Performance
Several states have enacted legislation known as prompt pay laws to regulate timely payments by health plans to physicians. Depending on the state, ERISA plans may be exempt from the state prompt pay law. However, the US Department of Labor (DOL) enacted a claims regulation in 2003 that requires that plans must make a decision about a claim within 30 days after receiving the claim. The DOL regulation states that once a plan has made a decision to pay a claim, it needs to pay within a "reasonable amount of time", but does not provide an actual timeframe. You may use your state prompt pay law as the benchmark for a reasonable amount of time.
Resources for Families
Families may need assistance in appealing to their health plan or employer over coverage issues and often may turn to their pediatrician for assistance. Below are some resources to share with families.
Retrospective Audits and Repayments
The Academy has produced guidance for members on factors to consider in evaluating an opportunity to participate in an ACO.