Payer Contract Negotiations and Payment Resources

A viable pediatric practice needs to be able to analyze and effectively negotiate healthcare payer contracts. Practices should have a clear understanding of business principles, current market trends, and the cost of delivering quality healthcare. The AAP has provided some resources below related to payer contract negotiations and payment. 

The Business Case for Vaccines
It is essential to remove barriers to children receiving vaccines and support pediatricians in their vital role of vaccinating children. To support and sustain administering vaccines in the medical home, providers must be adequately paid for vaccination.

Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults 
Managed care plan can minimize patient under- and overutilization of services, as well as enhance quality of care. The AAP urges the use of the key principles outlined in this policy statement in designing and implementing managed care programs.  

Essential Contract Language for Medical Necessity in Children 
Health care contracts should include essential language that reflects the unique needs of children and promotes equitable care for children. 

Identifying and Responding to Downcoding
Downcoding is the practice of paying based on a lower-level code than what was submitted on the claim. In addition to the steps outlined in the checklist, consider working with your AAP Chapter and/or Pediatric Council to better understand regional impact to other pediatricians and explore opportunities for broader advocacy.

Preparing for a Payer Audit 
In an effort to control costs, carrier claims processing and Special Investigative Units are conducting audits of claims to prevent improper payments and overpayments. 

Additionally, see Fraud, Abuse, and Compliance for information on protecting from fraud and abuse and complying with payer requirements. 

 Additional Resources

 For more detailed information on negotiations and payment resources, see Coding for Pediatrics. This book is published annually and provides information on contracting and negotiating with payers, submitting clean claims and monitoring payments for accuracy, and conducting documentation and coding audits.