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The Pediatric Council is a group of pediatricians from New York Chapters 2 and 3 that has been working behind the scenes for some time representing the pediatric practitioners in our area. The Council has been meeting with insurance companies to make them aware of the coverage, payment and logistical issues confronting our membership and has been negotiating to resolve them.
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To date, we have had meetings with Aetna, Empire Blue Cross, GHI-Emblem and United Health Care. Meetings generally occur about three times per year with each company. To date, our Council has been instrumental in the facilitating the following:
Blue Cross reversing its denials of developmental testing codes
Speaking with United Health Care about its recent bundling of those codes with the office visit. United is reprocessing the denied claims.
GHI has revised its 365 day
rule and well visits now go by calendar year.
Chapter 3
Andrew Racine
Evelyn Ha
Chapter 2
Richard Ancona
Stuart Beeber
Steven Goldstein
Our District II Executive Director, George Dunkel, also attends and has been of great assistance in scheduling the meetings and preparing our agendas and conference calls.
Our task is complicated by the number of insurance companies doing business in the Downstate area; currently, there are twenty seven (27). To address this situation we have devised the following strategy, but this strategy requires manpower and that is why we are soliciting your participation. We would like to identify chapter members to act as a liaison with an individual insurance company and develop an ongoing working relationship with someone in the upper management in that company. These liaisons would act as the Council’s contact with the company and would be invited to attend our meetings with them. If an issue arises, the liaison would be the first to address it with his or her contact at the company. Hopefully those contacts at the insurance companies would communicate through the liaison if they needed a problem brought to the attention of the pediatric community. We would like to have a liaison for each of the 27 companies which is why we need your participation. If you are interested, and we hope you are, please e-mail Steve Goldstein at SJG34@Cornell.edu and we will discuss this opportunity with you.
We can do more, but we need
your help. If you do not feel
comfortable being a liaison, we still need your input and to hear about your
problems. Please forward your
concerns to us so we can add them to our agenda for future meetings with the
insurance companies.
The American Academy of Pediatrics has finally addressed the issue of vaccine administration fees and new codes for administration go into effect in January 2011. Under the old system currently in use, giving combination vaccines rather than single entity vaccines resulted in decreased payment for administration to the physician. The new system takes into account that counseling increases with the number of distinct vaccine components and is much more fair. This is a sorely needed reform.
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Required
ImmunizationsThe Advisory Committee on Immunization Practices (ACIP) develops and adopts recommendations for the routine administration of vaccines for children and adults and promulgates schedules regarding the appropriate periodicity, dosage, and contraindications applicable to the vaccines. Pursuant to Circular Letter No. 13 (2006), covered necessary immunizations for dependent children to age 19 are those vaccines and immunizations recommended by the ACIP. ACIP recommendations are posted to the ACIP website after they are adopted. Later, they are published in the Morbidity and Mortality Weekly Report (MMWR). Once a recommendation is adopted, the vaccine or immunization must be covered in accordance with Circular Letter No. 13 (2006) as of the date of adoption. Insurers and health plans should monitor the ACIP and CDC websites regularly for the most current information on recommended vaccinations. Reliance on information published in the MMWR, should only be utilized in the absence of posted recommendations on the ACIP or CDC Websites, but even in such cases, recommended vaccines must ultimately be covered back to the date of adoption by ACIP.
Provisional recommendations and the federal Vaccines for Children Program (VFC) resolutions are posted on the ACIP and VFC websites and indicate adoption by ACIP. Please see the links below for more information.
ACIP Recommendations and VFC Resolutions (new external link)
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(Posted 1/2/12)The American Medical Association’s CPT editorial panel recently revised the description of code 96110 to cover "developmental screening" rather than developmental testing, as it had been previously described. As Medicare does not pay for screening or preventive services unless such coverage is authorized under the Medicare statute, for Medicare purposes, CMS modified the active status of code 96110 and did not include associated value units in the 2012 Medicare Resource Based Relative Value Scale physician fee schedule (PFS).
This change resulted in many questions and potentially unintended consequences for other payers. We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110. At the request of Medicaid and concerned stakeholders, in the next few weeks Medicare will provide the relative value units for this code.
Revised payment files to reflect corrections and revisions to the physician update amount will be posted on the Physician Fee Schedule portion of the CMS website under the PFS Relative Value Files section, available
here in the near future. In advance of these files, the payment rate for code 96110 will be based on 0.28 total Relative Value Units (0.27 practice expense and 0.01 malpractice).CMS has also created a new code, G0451 (Developmental testing with interpretation and report, per standardized instrument form), and published associated relative value units, to ensure that physicians can continue to bill for the types of services encompassed under CPT 96110 when used for testing and not screening purposes.
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