Is It Worth Being A Member Of The American Academy Of Pediatrics?

I asked a newly graduated pediatrician if she was going to renew her membership with the American Academy of Pediatrics.

Her response did not surprise me. She said, “…probably not. I see no point in being a member.”

As far as she was concerned, there wasn’t an upside ( or value ) to belong to the Academy. I knew what she meant because I share her feelings.

Screen Shot 2016-06-05 at 10.48.49 AMRecently I came across an email that challenged my stance regarding the value the American Academy Of Pediatrics provides to pediatricians.

I wanted to share the email just as I read it. Below are the unedited comments from Dr. Suzanne Berman and Dr. Christoph Diasio regarding the meeting.

I had the privilege of attending the 3rd Immunization Congress in Washington DC with some of your favorite SOAPM types: Rich Lander, Geoff Simon, Christoph Diasio, Drew Hertz, Joel Bradley and uber-awesome AAP staffers Lou Terranova and Elizabeth Sobcyzk.

We had an opportunity to describe what works and doesn’t work with pediatric vaccinations, and lessons that can be applied in the adult world (where they do not vaccinate like we do).

Rich Lander spoke eloquently about the need for calling it PAYMENT not REIMBURSEMENT and people listened!

He presented the business case for vaccines. For the whole rest of the time, people would start to say “reimbursement” and then caught themselves and said: I should call it payment! I need to update my slides!

Geoff Simon and Drew Hertz spoke about some of the practical aspects of immunization delivery in large health systems and the implications of alternate payment models in vaccine delivery.

Geoff also talked about the challenges of providing vaccines across state lines (PA/DE).

Joel talked about the need for VFC to turn on 90461 and the need for local Medicaid and VFC programs not to do their little unsupervised strange things.

Suzanne Berman, MD

Dr. Diasio chimed in and added this:

There’s so much the AAP in general, and SOAPM, in particular, does quietly in the background- it is important to share this.

I am sure it will surprise none of you that I was continuing to beat the drum for removing the VFC flu vaccine delivery disparity.

Suzanne is humble- her talk on “the stupid things insurance companies/Medicaid agencies do re: vaccine payment” was terrific and included descriptions of dysfunction that I had never heard!

We touched on 2D barcoding uptake, but this was more related to trying to fix registries and increase communications.

We did discuss trying to create incentives/funding for EMR companies to support barcode readers

Christoph Diasio, MD

I have been particularly vocal about the Academy’s presumably disregard towards the numerous challenges pediatrician face in light of the AAP’s recommendations and children’s advocacy initiatives.

When I read this, the first thought that came to mind was, I think I am misinformed. Then I thought, so are numerous pediatricians, like the newly grad I mentioned.

I then thought to myself, the word needs to get out. Pediatricians need to know what the AAP and committees such as the Section on Administration and Practice Management (SOAPM) are doing on behalf of pediatricians, not just children.

Reached out

I immediately emailed Dr. Suzanne Berman and asked her permission to publish her email. I then spoke to Dr. Christoph Diasio – SOAPM Chairperson – and also asked him if I could add his commentary.

They responded with a resounding:


I am kidding, I am kidding. It was the opposite. They replied within minutes saying yes.

Times are indeed tough

I am preaching to the choir when I say that independent pediatricians are facing difficult challenges. However, it is reassuring to know that people are working behind the scenes advocating for children by advocating for those that provide for children.

It is my understanding that highly influential people attended the meeting. There were high ranking AAP representatives as well as influential people from the CDC.


So, not only did I want to inform those that are not fully aware of what type of initiatives their AAP membership dollars go to support, but also wanted to give a big thanks to all that attended the meeting and all those that worked behind the scenes.

Thanks for looking out for us. And keep up the good work.

For the rest of you, go and renew your AAP Membership.

10 CPT Codes You’re Most Likely Under-utilizing

I found myself sitting next to four pediatricians during the hospital’s pediatric departmental meeting. The four docs were engaged in conversation by the time I sat down at the round table.

They were talking about coding. Specifically about 99213 and 99214. “Do any of you bill level 4s?” asked the one sitting across me. ” I can’t remember the last time I coded a level 4. I just don’t have that many emergencies,” replied the doc next to me.

Processed with VSCOcam with t1 preset

The pediatrician that sat across from me followed up in a justifying manner stating, “I keep it simple… level 3 all across the board. I don’t want to raise any red flags with the insurance companies.”

Judging by their nods, all four pediatricians seemed to agree.

Except for me, of course. But I couldn’t say anything because I was recovering from the feeling you get when somebody scratches their nails across a chalkboard.

You’d be hard press to find a cardiologist or orthopedist say; I keep my coding simple so that I can stay under the radar. But pediatricians are, well, pediatricians. And because of who they are and what they do, they are notorious for under-coding (most of them).

But that doesn’t mean we should give up on pediatricians. If anything, we should be motivated to work extra hard to get the word out on proper coding.

Below I’ve highlighted commonly underutilized codes in pediatrics; including level 4 and yes, level 5 (did you even know there was a level five?) in the hopes you or your staff will become aware of these codes and remember to use them.


According to the AAP, 99214 and 99215 (established patient office or other outpatient services) represent only 20% and 5%, respectively, of all evaluation and management codes submitted in pediatric claims.

What does this mean? That most pediatricians don’t code/bill for level 4 or 5s despite having done the appropriate work.

Don’t be afraid of coding level 4 and 5s. If you follow the requirements set forth by CPT and document the chart accordingly, you’ll realize levels 4 and 5 reflect your work with the patient more than a level 3.


If so, you can bill for consult codes 99241, 99242, 99243, 99244, and 99245 ( office or other outpatient consultations)

You may overlook consult codes because pediatricians are not specialist. However, a surgeon, for example -with all their specialized training – won’t even give a kid Tylenol without clearance from their primary doctor. Thus, pediatricians are indeed consultants.

There are a few requirements to bill this code. For example, follow-up with the requesting physician (i.e., the surgeon) with a written report or a hospital’s standard pre-op form.


As the doctor places her hand on the doorknob after completing an exhausting well-visit, she ask the parent, “…is there anything else?”

The phrase, is there anything else? is doctor code for, we’re all done here, I got to go. For the parent, it’s an invitation, of course. What else would it be?

“There is,” says the mom. ”

If you decide to address the issue right then and not ask the parent to come back, you are performing two significant, separately identifiable evaluation, and management services during the course of a single visit.

Therefore, you should attach modifier 25 to the office or other outpatient service code and list that in addition to the preventive medicine service code.

An example of this is preventive medicine service with an acute swimmers’ ear.The preventive medicine service may be linked to Z00.129 while the office or other outpatient service may be linked to H60.339 (swimmer’s ear, unspecified ear).


Do you see patients on a scheduled holiday? Do you see patients late into the evening? How about on Sundays? Do you see patients on Sundays? If you answered yes to any of these questions, you could code 99051 for every visit in addition to the E&M code.

CPT defines this code as service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic services.


Nursemaid’s elbow is a common occurrence in the pediatric population. Do you know that you can code for the treatment of it?

Code 24640 (closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) may be reported as well as an evaluation and management code if a significant, separately identifiable evaluation and management service is provided.

If this is the case, attach the modifier 57 (decision for surgery) or the modifier 25 (significant, separately identifiable E/M service) to the associated evaluation and management code.


Case management is a process whereby a physician is responsible for direct care of a patient and for coordinating and controlling access to or initiating and/or supervising other health care services needed by the patient.

Sounds complicated. But it isn’t.

Do you spend time on the phone with parents? How about emails or portal messaging?

If you spend a lot of time communicating with parents, either on the phone, email, portal or phone app, you can bill for case management codes.

Although the chances the practice will receive payment for these codes is slim, coding experts and practice management consultants insists it is still a good idea to bill for what you do.

Therefore, whether you communicate with the patient via phone (99441-99443 or e-mail 99444), you are providing care for the patient and should bill for your services.


Let’s say a mom brings her daughter in because she suspects she is a victim of child abuse.

According to the APP, the pediatrician is required to perform a complete evaluation and management service in addition to an anogenital exam with colposcopic magnification.

With an example like this one, you should report both the evaluation and management service and the colposcopy. For the anogenital exam, use code 99170.

Don’t forget to add modifier 25 to the evaluation and management code to “alert” the insurance processing the claim the fact that you performed a significant, separately identifiable evaluation, and management service in addition to the colposcopy during a single visit


Have you received a call from a parent at the end of the day asking if her child can be seen? And because you can’t bare the thought of the child suffering for another 12 hours or feel guilty telling the parent to go to the ER, you and a few staff members end up staying after regular office hours to see the child?

If it has happened to you, make sure that you are billing for 99050 in addition to the E&M code

This code is for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed.


Imagine for a moment that instead of a mom calling your office at the end of the day, she shows up mid-morning with a wheezing kid.

Do you see that patient right away, essentially on a “walk-in” basis and make all other patients wait?

If you do, you should be billing for “service(s) provided on an emergency basis in the office, which disrupts other scheduled office services” (99058) in addition to the evaluation and management code.


Do you screen or ask parents to complete forms that aid in the assessments of a child’s development? For example, manage developmental screening tools such as Developmental Screening Test II, Early Language Milestone Screen, PEDS, Ages and Stages, and Vanderbilt ADHD rating scales?

If so, you should be reporting it using CPT code 96110 (developmental testing; limited) or 96127 (brief emotional/behavioral assessment)

Keep in mind that the purpose of this post is to bring to your attention a handful of codes that pediatricians don’t use as often as they should. I’d suggest finding coding and billing resources that go in depth into each of the codes supplied in this post, as well as provide a plethora of other underutilized code.

Do You Know About The Section On Administration and Practice Management ?

The Section on Administration and Practice Management (SOAPM) is the home at the AAP for pediatricians who want to improve the efficiency and profitability of their practices and the care that we provide our patients.

You know that feeling you get when you visit a great restaurant, vacation at an awesome resort or perhaps see a great stage show and you can’t help but to tell everybody you encounter they have to check it out too?

I get that feeling with SOAPM.    I’ve mentioned SOAPM before on the blog, but for those that know, SOAPM is one of the best – if not the best – resource for pediatricians that have an interest in learning the ins and out of practice management.

One of my favorite SOAPM member is Dr. Christoph Diaso. Recently Dr. Diaso became chairman of SOAPM. So I thought, why not have him tell PediatricInc readers about how great of a resource SOAPM is.

I reached out and he agreed. Enjoy.

Q – What is SOAPM? 

The Section on Administration and Practice Management (SOAPM) is the home at the AAP for pediatricians who want to improve the efficiency and profitability of their practices and the care that we provide our patients.

Q – Did you just say the P word, profitability? 

No margin is no mission! It’s fun to have the financial strength to be able to improve your technology or add additional services that are desperately needed.

Q – And what might those services be?

Depends on the practice, but integrating mental health or lactation consultants into your practice is at the top of my list!

Q – What is it about SOAPM that makes it so interesting for you?

We have an incredibly active and passionate listserv that provides outstanding education about real world problems.

Q – Can you provide a few examples of real world education topics that are discussed on the listserv?

Sure! We discuss things like how to improve employee performance, which CBC machine to use, how to negotiate with payers and deal with regulatory oversight.

Q – Sounds like you cover a lot of topics? 

Every day incredibly valuable practice management tips worth thousands of dollars are dispensed for free! Our listserv is the heartbeat of the AAP.

Q – So how does SOAPM distribute all this valuable educational material?

SOAPM provides this education through the listserv, webinars, and through our excellent section programs at the NCE.

Q – You recently became chair of SOAPM, what are your goals for the section? 

SOAPM has a wealth of knowledge to offer Pediatricians in all arenas, whether practice owners or employed doctors. My goal as chair is to continue to expand the SOAPM membership and to improve the practice of pediatrics.

Q – You mentioned employed physicians, SOAPM isn’t just for practice owners?

SOAPM currently has members in every possible employment situation and is not just for private practice doctors!

Q – Besides private practice doctors and employed physicians, are there any other groups that can benefit from SOAPM?

We particularly welcome young physicians who are interested in learning about practice management since that is usually a knowledge gap for most trainees.

Q- Can practice managers join?

We recognize the amazing contribution of our practice managers and have an outstanding practice manager section with their own listserv.  Every PM ought to belong!

Q – The AAP seems to be more academically focused, completely opposite to SOAPM’s “no margin, no mission” mantra. How does the leadership of the  AAP view SOAPM? 

I agree that some perceive the AAP this way, although I disagree with that perception.  The AAP has become much more responsive to practice issues in the last several years and much of that is due to SOAPM’s advocacy and increasing membership. No margin is no mission is no Pediatricians for children!

Q – What types of advocacy initiatives are you referring to?

We are working on a number of projects currently such as improving VFC flu vaccine delivery, representing pediatric concerns to NCQA PCMH and trying to improve the ABP MOC process.

Q – Any final words?  Please join us and participate in improving the practice of pediatrics!

Pediatric Practice Management Seminar You Don’t Want To Miss

The content in many practice management seminars or conferences are either too generic (the one size fits all medical specialty approach) or too specific (subspecialty focused) in my view. As a result, it makes it difficult sometimes to figure out how to apply the lessons from other medical specialties to pediatrics.

If only there was pediatric specific seminar, where everybody in attendance speaks yScreen Shot 2014-11-21 at 10.10.07 AMour language (the language called Pediatrics), are aware of my specific challenges and when I receive advice, tips, suggestions or recommendations, it is provided with in the context of pediatrics. Wouldn’t that be great?

Well, our prayers have been answered.

My friends at the Pediatric Management Institute have put together an awesome line-up of speakers (Disclosure: I’m one of the speakers. But I’m not including myself among the awesome ones), presentations and case studies for a one day seminar in the San Francisco/Oakland area that you will not want to miss.

This one day seminar packs a lot of information. Here’s a glimpse of the topics that will be discussed:

  • Coding, The Basics and Beyond
  • Set Your Practice Prices Fairly and Easily
  • Brave New World: Future Pediatric Models
  • Key Performance Indicators for Pediatric Practices
  • Easy Methods to Collect Patient Balances
  • The 5 Legal Issues To Watch Out For In a Pediatric Practice
  • Top 10 Coding Lost Opportunities
  • Five Concepts to Maximize Your Marketing
  • When to Add Another Provider to Your Practice
  • ICD-10, Ready or Not!
  • Patient Recalls
  • Budgeting for a Pediatric Practice

Whether you are an expert in practice management, employed by a large health organization or just starting to learn about how to properly manage a medical office, this seminar offers a valuable learning opportunity.

But wait… there is more!

The PMI team is holding the seminar at the Holiday Inn & Suites Oakland Hotel Airport , which as the name implies, is right next to the Oakland airport. No need to rent a car or arrange for additional transportation. You’ll be right there. Fly in. Attend the seminar. Fly out.

For a PDF on the topics, speakers, location and date (Saturday January 24, 2015)  click on the link: Pediatric Management Institute Seminar

Psst…. one more thing.

If you use the code “PediatricInc” when you register, you will receive $75 off your registration. How cool is that? This offer is exclusive to PediatricInc readers. Now you can bring someone along and save $150.00. If you bring one more person, you’ll save $225.00… it’s like the gift that keeps on giving. 🙂



Thoughts On The AAP NCE 2013 – Orlando

photoIf you follow me on social media, you probably know I was in Orlando at the AAP NCE this past week.

Every year right before the date of the convention, I start to dread going. Leaving town is always hard when you have a million things to do. And since we still have little ones, and I don’t travel often for business, I feel a hint of guilt leaving my wife behind fending for herself.

But once I arrive, the anticipation, excitement, and nervousness starts to settle in. I like the feeling.

The Disney Institute

The highlight of my trip was attending a class lead by the Disney Institute. That class was probably one of the most fascinating classes I have attended this year (I say this year because I go to the Global Leadership Summit and those sessions are hard to beat).

The Disney’s Institute class gives you a behind the scene sneak peak at Disney’s stellar approach to customer service. Part of the class was in the classroom, while the other half was at the Magic Kingdom where we toured parts of the park, including going “back-stage” to see first hand how they manage the operations.

Meaningful & Fulfilling Dialogue

The best part of NCE is the people you meet and see. This year, I met up and chatted with more people than ever before.

Many were old friends, others were strangers that came up to me after my talks, while others became new acquaintances. I even got to meet a couple of long time online-virtual friends IRL, which is always fun.

Topics & Trends

You know that observation that many of us make when we buy a car or a phone and right after, we start to notice all the people around us that also have the same car or phone? Well, I don’t know if that applies to the trends I observed during the conferences, but what I heard over and over were two things:

Patient Engagement & Data

PE is always been an important topic, but this time, it seems there was more emphasis on finding different ways to involve the parents/patients into one’s practice.

Speakers emphasized that PE will not only be important to remain relevant in a tectonic-shifting, healthcare landscape kind of scene, but parents are/will demand it.

And the data discussions had to do with implementing systematic studies that will help physicians/managers establish facts and reach new conclusions on how to work in a pediatric practice more effectively and efficiently.

However, the narrative went beyond the clinical and addressed data analysis in the practice management side of things too in an effort to understand the needs of our parents, thus provide meaningful “engagement.”

Thus, the data, the research and the analysis is fundamentally going to help us with the PE portion of this more prominent trend.

I came away with lots of ideas.

Going to something like the NCE  is expensive, consuming and tiring. But just like vacations or time off is needed to replenish one’s soul, reduce stress, and recover emotional balance, attending AAP’s NCE is a needed activity to replenish our minds and share experiences with other like-minded-people.

Look forward to see you in San Diego next year.

Leaving a Hospital Job to Start a Solo Practice

Dr. Lois Freisleben-Cook is a pediatrician that started her practice after completing a two year contract with the local hospital.

These days, you don’t hear about too many docs leaving hospital jobs to open up solo practices, so I wanted to learn amount what many consider to be a rare, dying breed of doctors.

I reached out to Dr. Freisleben-Cook and asked her if I could ask some questions regarding her experience as a solo rural doc. She was gracious enough to allow me to post her responses.

The post is a little long. Certainly longer than usual for PediatriInc; but Dr. Freisleben-Cook provided SO much information that I couldn’t pass it up.



Tell me about your experience making the transition from clinic practice at a local hospital to a solo doc.

I left a clinic practice at a local hospital after my two year contract was up and over 2500 patients came with me.  By the fourth year I was up to 4000 and now over 6500.  The population of this town is expected to triple by the end of this year and do it again in another year. I have been the solo pediatrician here for the past twelve years with the nearest pediatric care over 120 miles away to the east and over 500 miles to the west and south.  Canada is to the north and there is nothing between us and Canada.

Holy Cow. That is a lot of patients

I can’t stop taking new patients because the rest of the community docs are also full.  I am especially obligated to take all the CSHCN as they have no one else to see for over 120 miles.

Before you started, what resources did you use to gather information about starting a practice?

Before starting I used what I had learned over the years managing developmental clinics for the Department of Defense. I had no experience with the financioal side of things and foolishly thought I could learn as I went on. The clinic had a huge cash buffer provided by my husband and myself so we were able to make a lot of mistakes and survive financially.

Now I would suggest the AAP practice management resources. It is excellent for setting up the logistics of a new practice.  I did not use them ‘till I was five years into practice thinking I already knew it all.  Boy was I wrong.

Life would have been a lot simpler if I had used those wheels instead of trying to invent my own.   Another source of good and practical advice offered with no strings attached is the PCC site.

There is a lot of information out there and much of it can be confusing and wrong.  You can’t go wrong if you start out with just these two sources.

Since there is so much information out there, where should one begin in terms of  preparation?

Learn all you can about coding and documentation as that drives your revenue stream. The biggest mistake most new docs  make is to under code and undervalue their services. Although it was forced on me, I took a coding class in California that more than paid for itself.

Anything else you would add to a doc that is preparing to open up their own office?

Remember everything you do that requires thought and knowledge is valuable.  Even things that are obvious to you are important to patients and are valid billable services.  If your see a newborn and spend time counseling about breastfeeding to solve a feeding concern document it and charge for the time.

I have learned that there are ways to be compensated for my time even if providing an “uncovered service”.

Some of our insurers, for example, do not cover asthma education.  I simply document the elements we discussed and code for time spent in the chart.

As Herschel will say, do not give away the talents and information you have earned.  Remember you are valuable and do not let insurance company or anyone else say otherwise.

Editorial Note: Dr. Herschel Lessin is a regular contribution to Survivor Pediatrics and a very passionate member of the pediatric community. Dr. Lessin has posted on PediatricInc before

What else?

Learn the Medical Home standards and start off with the structure you will need to meet them using the ample free on and off site support available too you from the AAP and a number of other medical home agencies.

Speaking of uncovered services, many docs find out very quickly that what you learn in a coding class in terms of appropriate ways of billing, doesn’t always fall in alignment with how insurance companies pay for services. What do you think about that?

Follow CPT guidelines and bill even if the insurance company says it will not cover.  For example an insco may say it does not cover after hours codes. Document and bill them anyway and track the refusal to pay so you can later take it higher.

If something is in the CPT as a billable service, don’t leave it out because they never pay.  That is a reason to keep it in.

Make sure your payment data is in a format that is conducive to searching who pays for what and what refusal codes they use and what services they illegally bundle.  In a few years you will want to analyze and act on that data.  Encourage families to update their insurance policies to take advantage of the ACA. If a policy is grandfathered, have them consider making a small change that will put it into the newer eligible for ACA category.

Those are great tips on the billing side, what about staying up to date on the clinical side?

Learn and keep up with Bright Futures and use it as the model for preventive care.  Assign one of your staff to use that to design all well child visits and documentation and remember everything in the Bright Futures preventive model is covered under the ACA; so bill for the hearing and vision screens, developmental screens, the depression screens as separate and not bundled services.  Record the refusals to cover and the bundling.

What about billing staff, what should you instruct them to do as you get started?

Make sure your billing person gets current literature i.e. AAP coding bulletin etc and attends continuing education activities. The return will more than pay for the classes.

Make sure your clinical staff have opportunities to learn new skills and advance in their own careers.  They will eventually grow out of their jobs but will be sure you have what you need in new hires.

Managing employees is no easy task. Any words of wisdom? 

Value everyone who works for you and show that your value them.  Don’t set up a hierarchy but instead use the team model including the 180 degree evaluation process.

You seem to have a lot of great ideas. Can you think of one (maybe two) that isn’t as common to the rest of us that would help our practices?

Recruit a parent to be a consultant to the practice, reviewing how you do things and giving input on what would work better from the parent perspective. Include that person in staff meetings .

OH  YES  never forget to have regular staff meetings.  That was one of my biggest mistakes.  Ask the parent consultant to interview families leaving the practice. That will be more forthcoming with their reasons with the “parent consultant” than with a member of your staff.

Do satisfaction surveys early on and often to identify ways to better meet the needs if families. You will get enormous PR capital by taking the information in these surveys, sharing it with families, and having them help you brainstorm improvements.

Many pediatricians have a tendency to want to do everything. What do you say to those docs?

Do not be penny wise and pound foolish.  If you are spending time doing something you can train an employee to do then do it and give it up.  If you can hire someone to do it for ten dollars an hour that frees you up to make a lot more than her salary.

Can you give me an example?

Hiring a scribe is a really good investment.  You will be a better doc if you delegate things you do not need to be doing yourself. Remember to follow up on tasks you delegate.

You need time to think, have a life and sleep. Your family needs you to spend time with them when you are not exhausted.  Just like a marathon, you can start up with a slow pace and little work and build up to more and more as you find yourself able too handle the flow.

On the SOAPM listserve you’ve shared some pretty scary circumstances that have added stress to your private practice endeavor. I’m not going to get into those challenges, but would you speak a little bit about why you do what you do despite those challenges?

I love coming to work every day.  I love being able to employ and train and offer the services of care coordinators, parent advocates, clinical and administrative support to local activities such as Head Start, and practicing the way I want to.

I love being able to write off a bill now and then when someone really is in a bad spot financially. I love being able to handle 99 percent of the care from my office.

I love the fact that in twelve years we have NEVER had a bad outcome, not one of my patients has died and the only two deaths we have experienced were inevitable when we first saw the children (a drowning and an end stage neuroblastoma) .

I love that children and their parents feel at home in our clinic and readily bring their concerns and their family members, friends, neighbors to us.

More recently I have had the unimaginable pleasure of hearing parents stay they feel well cared for for the first time and are grateful they came here because their children with special needs are doing so much better than they did in the “big cities” they came from.

I guess what I am trying to say is that in spite of the horrendous medical climate and incessant bullying I experience, I would not go back and change my decision to stay here.  While I could have easily returned to Westwood and had a nice and stressless practice there, I would not have the wonderful sense of purpose and service I find fulfills me.

If you could go back in a time machine (like Marty McFly), what would older Lois say to younger Lois as younger Lois was ready to embark on this long scary journey of opening up a practice?




Even as you value your services, do not overvalue yourself as a person as we are all in this world together and you could never survive without your cleaning lady.

Learn how to make the rest of the world disappear and be infinitely present to the moment when in a room with a family.  They will feel your attention and the time spent with you will feel like it is long enough even if it is only five minutes. Greet the child first when you enter a room and briefly interact with the child before addressing the parent.

Anything else you would say?

Ask questions.  There is no such thing as a stupid question and everyone her and at the AAP loves to answer questions and give advice. Start with SOAPM first.

Insurance Contract Negotiations: 15 Tips From a Pro

Today’s guest blog post comes from David Horowitz MD. Dr. Horowitz responded to a question on SOAPM regarding how to go about negotiating with a payer. I thought his advice was practical, to the point and very useful, so I asked him if he had an issue with me posting his response. He graciously agreed to share his comments with readers of PediatricInc.
By the way, this is not an unusual response on SOAPM. Most comments are this good. Enjoy…

I have done the contract negotiations for my practice for 20+ years. In those dark ages, before Internet and AAP resources, there was no primer for doing this. One of my partners recently asked how she could get up to speed on this, looking to the point where I might retire – which is not anytime soon. So I started thinking about a few essential points to have in contracts. You may not be able to get all of them, but they are all worth fighting for.

  1. Do a payer analysis so you know ahead of time what % of your practice income comes from each payer and what each payer is paying you for the major E/M codes. This means learn spreadsheet 101 software. Sometimes you need to be prepared to tell a company their offer is not acceptable and walk away. You need to know ahead of time what this may cost you. You also need to know whether you are the only pediatrician for 30 miles or whether there are 3 other practices within 5 miles who would be happy to snap up your cast offs.
  2. Become familiar with RVU valuations. AAP book Coding for Pediatrics issued yearly is an excellent resource for this.
  3. Ask for fee schedules based on a percentage of a given years Medicare, rather than just “we will pay you $x for code y. If you are lucky enough to get them to agree to basing the fee schedule on the current year, be aware that Congress is still playing with something called the SGR, which, if not fixed, may cut payments from Medicare by 30%. Fee schedules based on prior years Medicare are fixed in stone at this point.
  4. Know your area. There are parts of the country where simply getting 100% of Medicare is considered good. There are other parts of the country with rates as high as double that.
  5. Try to get a concession that they will follow CPT coding guidelines. I have been unable to get this in any contracts. But by bringing it up, it opens the door to specific discussions of paying for –25 modifiers for well and sick care on the same day, and bringing up what services are or are not bundled into well care, such as vision, hearing and developmental evaluations and after hours care.
  6. If in office lab is a big part of what you do, insure that what you are paid doesn’t lose money. You can always threaten to send every kid who needs a specific test to the hospital if they don’t at least meet your cost.
  7. VACCINES: know you costs, know your overhead and make sure that you are paid appropriately. These are almost always carved out of every contract and can cost you tons of money. Inscos often try to pay less than your acquisition cost for vaccines. Try to get payment based on the CDC price list. Also check out the AAP information on the Business Case for Vaccine pricing. This one piece of the contract can make or break you.
  8. Try to avoid forever renewing contracts. A good price today is going to look pretty poor in 5 years when it hasn’t changed. 2 years is a reasonable amount of time so you are not forever negotiating.
  9. It takes 6 months to negotiate a contract and they are almost always completed after the actual termination date. Stall is the name of the game for inscos.
  10. When you agree on a contract, make sure the contract they send you to sign is actually the one you agreed to. All the companies have boiler plate contracts. I have had a company agree to give me specific terms, but the contract sent to me was 3 or 4 drafts prior to what we agreed upon. I was told this was an “oversight”.
  11. Once you agree on the big things, like payment for E/M codes, don’t forget the little things. Will they pay for after hours care and in office labs are the main things here. If they don’t pay for a specific service, do they consider it “bundled” which means you can not charge the patient, or do they consider it “not covered” which means you can bill the patient.
  12. Not that I don’t trust people, but once you sign a contract, look at the EOBs that come in and make sure that they are really paying you what they said they would pay you. You’d be surprised how often the insco computers load the “wrong” fee schedule by “accident”.
  13. You may not win even if you think you won. A comeback offer from an insco may take the form, “We will give you 10% more on E/M codes, but pay you 5% less on vaccines.” You have to be able to know that this 2nd offer may actually pay you less than the first. It can only help you in negotiating when you come back to them with something to the effect of how disappointed you are that they think you are so naïve, so how about a real offer, not a trick offer. Know what they mean by “E/M codes”. In my experience, they mean only Office Visit and Preventive Care codes. And even though all the other common codes for hospital care, newborn care, in office counseling, etc. are in the E/M section of the CPT book, they usually are not included in the insco definition of E/M.
  14. Know a ballpark minimum offer that you simply can not go below. If you don’t get it, WALK AWAY. This is the hardest thing to do. But if you are losing money on a payment schedule, you can’t make that up by doing more volume.
  15. Start your 1st negotiation with a payer who is rather MINOR in your income. This way you can learn, get your feet wet, and mistakes (which I still make) are not so costly. Save the big payer negotiations for after you have gotten some experience.

This is a starting place. I’m sure others on this listserve will be happy to offer more critical points that I have over looked. And some of these items can be rather daunting. It can take a while to get proficient at Excel. If you have a spreadsheet wiz in the office, it might be reasonable to delegate this part of the task. And getting the Medicare fee payments for the common codes that you do may be somewhat hard if you are not good at Excel. The AAP and Chip Hart on this listserve have good sources of information about common CPT codes and their valuation.

Survey To Identify Delays in VFC vs. Private Shipments

If your pediatric practice participates in the VFC program, you are aware that VFC generally ships their vaccine later than one’s private vaccines.

As many of us know, this delay becomes a burden during the flu season. For example, in our practice, we often receive our private flu shipment a month, sometimes nearly two months, before VFC vaccines.

I always thought this was an Illinois issue, but apparently, the delay happens all over the States.

There have been variable delivery times with large lags in VFC vs. private stock in recent years. Thus the AAP Immunization Program is conducting a survey on when practices received their influenza vaccine- private and VFC.

I think this is great because the survey helps pinpoint the problem areas.

The AAP was the only one to collect this information last year, and consequently made some significant strides toward identifying where the problems are.

The Immunization Program is conducting a survey again to see if changes have been made for the better this year.

Below is the link to the survey. I encourage you to fill it out. You will need information on hand of what types and quantity of vaccine was ordered, as well as dates and quantity of vaccine received.

Dr. Diaso from Sandhills Pediatrics in North Carolina had this to say:

This is a real opportunity to give input from the front lines and reduce the bureaucratic disparity of care that has been existing in many states for VFC vs private flu vaccine.

They are planning to announce this survey to the broader AAP membership this year in chapter listservs, Smartbrief, etc. So please help the cause by completing the survey. And if you don’t have time, have one of your nurses or office manager complete it for you. They probably have a better idea of many of the answers anyway.