Payment Agenda Achievements

Broadened relationships with new national and regional payers (e.g., Aetna), strengthened existing partnerships, and increased engagement in national payer forums, including America’s Health Insurance Plans (AHIP), to elevate pediatric priorities.[

Advanced direct engagement with payers on downcoding, prior authorization, immunization coverage, RSV immunization access, and coding/payment policies, translating frontline issues into coordinated advocacy and measurable payer dialogue.

Expanded coding companion development aligned with Clinical Practice Guidelines, addressed emerging payer issues through coordinated channels through payer discussion and the Coding and Payment Hotline, and elevated Pediatric Council visibility to reinforce pediatric input in payer decision-making.

Progressed the APM policy through review and refinement, incorporated key design elements and initiated development of a technical report, Assessing Pediatric Risk Adjustments and Stratification in Payment and Financing, to strengthen the evidence base for VBC models.

Engaged directly with payers to evaluate incentive structures, attribution methodologies, and practice engagement strategies, while exploring opportunities for behavioral health integration within pediatric VBC arrangements.

Advanced partnerships with the National Committee for Quality Assurance (NCQA) to address gaps in pediatric quality measurement, elevated national visibility through policy panels and convenings, and expanded provider readiness through targeted VBC education and training, such as the Business Essentials course.

Published and disseminated a comprehensive pediatric VBC overview resource, equipping pediatricians and stakeholders with practical guidance and accelerating alignment toward scalable adoption of alternative payment models.

Delivered targeted education through Medicaid 101 webinars, price transparency trainings, Managed Care Contracting webpage, SOAPM Practice Essentials, and national presentations. The end goal is strengthening member understanding of payment systems, advocacy opportunities, and payer engagement.

Upgraded coding infrastructure, including enhanced downcoding resources, coding fact sheets, and a redesigned coding library, and provided real-time support to members and chapters on payment barriers and payer policies through coordinated advocacy and tool dissemination. 

Modernized payment tools, including enhancements to the price transparency platform, to strengthen usability, improve accessibility for members, and support long-term scalability and impact.

Advanced engagement with Current Procedural Terminology (CPT), the Relative Value Scale Update Committee (RUC), and International Classification of Diseases, Tenth Revision (ICD‑10) processes; secured a positive Centers for Medicare & Medicaid Services CMS coding adjustment (96127 MUE), and expanded member participation through travel scholarships supporting attendance at American Medical Association meetings. 

Equipped chapters with AAP advocacy toolkits, template letters, and technical assistance, while developing targeted state work plans to address evolving policy changes in eligibility, benefits, and payment rates and mitigate the impact on pediatric care.

Collaborated with national and state partners and engaged policymakers to address administrative and regulatory barriers, including prior authorization, claims delays, while monitoring state-directed payment (SDP) opportunities to preserve and strengthen pediatric payment approaches.

Responded to federal policy changes (e.g., HR 1) by protecting Medicaid/CHIP payment and delivery structures, tracking rulemaking and state implementation, and advocating for stable eligibility and sustained access to care for children.

Continued leadership on continuous Medicaid eligibility and payment adequacy (including parity) through research, policy development, and regulatory engagement, reinforcing the link between stable coverage, access to care, and sustainable pediatric financing.

Initiated partnerships with national employer business coalitions, established recurring engagement cadence, and expanded outreach to additional groups, supported by a formal outreach plan and targeted communications to scale relationships. Focused on influencing employer-sponsored coverage to improve pediatric benefit design, coverage, and payment alignment.

Progressed an AAP employer engagement plan through iterative development and leadership review, creating a more structured and scalable strategy to guide partnerships and position pediatric health within employer-focused initiatives.

Deepened collaboration with Purchaser Business Group on Health (PBGH) and established new relationships with Midwest Business Group on Health (MBGH), while continuing targeted outreach to broaden employer partnerships and identify opportunities for alignment on pediatric priorities.