Pediatric Council, September 2015

Quarterly Report, September 2015
ICD-10 is just around the corner, and those of you requiring further guidance should check the Chapter and District’s previous emails about resources for understanding and making the transition. The CMS and AAP websites are another great source for guidance.

The mission of the Pediatric Council is to act as a liaison between the Chapter’s members and insurers to create a forum to resolve coverage issues, advocate for access to services and quality pediatric care, foster discussion when managed care decisions adversely affect the provision of care, and enhance communication between pediatricians and payers. The development of a network of contacts at the local, state and national levels with government and insurers helps speed the resolution of issues that arise.

Recently, Amerigroup, the Medicaid Managed Care Plan of Empire Blue Cross sent out recoupment notices for those physicians that received payment for immunization administration code 90461. 90461 is the add-on code for vaccine administration involving counseling and education by a qualified provider when a vaccine has more than one component. The VFC program does not recognize this as a required code for payment, and work at the national level is in progress to rectify this situation. Amerigroup paid many physicians for this code between 2013 and 2015, although it was not required to do so. Some practices with multiple practitioners received requests for a large recoupment. There is an ongoing dialogue with Dr. Sajidah Husain, the Medical Director of Amerigroup, to resolve this issue. Our last request was to postpone recoupment until the issue is resolved, and I am waiting for a response. Some of you may remember when Americhoice, the United HealthCare Managed Medicaid Care Plan asked for return of fees going back two years, and we were able to resolve that issue. I am optimistic that this issue can be resolved.

Amerigroup is changing its name as of October 1st, 2015 and will be known as Empire BlueCross BlueShield HealthPlus.

I believe that the Pediatric Council’s work creates value for our members by its actions and advocacy with insurers. Chapter AAP backing helps ensure that insurers consider the concerns of our members. Resolution of even a small matter by our intervention can pay for AAP membership many times over. Please continue to inform me of your concerns and payer issues—and let others know about our work on behalf of children and pediatricians.
Respectfully submitted,
Steven J. Goldstein, M.D., F.A.A.P.
Chair, Pediatric Council, Chapter 2, District II