Payment & Finance

Implementing medical home makes a practice better positioned to advocate and negotiate for improved and appropriate payment. As a "work in progress" these contract and other negotiations will be specific to the unique nature of your practice—whether you are a small/large independent group, a community health center, or an integrated delivery network. Please note that this page provides additional resources as to what is provided in the Payment & Finance section of the Building Your Medical Home toolkit.

Medical Home Interview Videos New
Developed by the National Center for Medical Home Implementation

AAP Coding Fact Sheets

Medical Home Coding Fact Sheet
This coding fact sheet highlights most of the commonly reported codes for the medical home. This resource is updated annually to provide you with the most current coding information.

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Pediatric Code Crosswalk: ICD-9-CM to ICD-10-CM
This new reference from the AAP includes the basic guidelines for selecting appropriate codes for commonly encountered pediatric diagnoses and diseases. Includes updates to the current ICD-9-CM code set and a crosswalk to the relevant ICD-10-CM code that will be reported after the ICD-10-CM implementation date.

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Coding for Pediatric Preventive Care
This coding resource contains comprehensive listings for all CPT and ICD-9-CM codes commonly reported for providing preventive care services.

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Coding Telephone Care

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Developmental Screening Coding Fact Sheet
(Available to AAP Members)
This resource, developed by AAP Committee on Coding and Nomenclature and the Section on Developmental and Behavioral Pediatrics, provides guidance on how pediatricians can appropriately report developmental screening and testing services.

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Early Hearing Detection and Intervention (EHDI) Coding Fact Sheet
While coding for hearing screening is relatively straightforward, ensuring that appropriate payment is received for such services is a more complicated matter. This Coding Fact Sheet will provide you with a guide to coding for pediatric hearing screening. While it provides suggested codes, it should be noted that payer recognition of codes might vary.

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New CPT Codes Cover Care Coordination
The American Medical Association added codes 99487-99489 to the CPT 2013 Professional Edition for care coordination that patients with complicated, ongoing health issues receive within a medical home, accountable care organization or similar delivery model. The codes were created so providers could bill for time spent connecting patients to community services, transitioning them from inpatient to other settings and preventing readmissions. Refer to the Medical Home Coding Fact Sheet for more information.

 

For more resources on coding, please visit AAP Practice Support—Coding Resources or contact the AAP Coding Hotline at 800/433-9016 extension 4022 or aapcodinghotline@aap.org.

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Promising Practices

About Half of the States Are Implementing Patient-Centered Medical Homes for their Medicaid Populations
This November 2012 Health Affairs article focuses on trends in patient-centered medical home payment that can inform public and private payment strategies more broadly. The article also discusses the wide variety of approaches that Medicaid programs are taking to implement payment reform.

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Catalyst Center: Financing Care for Children and Youth with Special Health Care Needs (CYSHCN) and Medical Homes
The Catalyst Center seeks to promote adequate financing for comprehensive, family-centered care of CYSHCN. The Center works with a broad range of stakeholders in financing and coverage issues including government agencies, parent groups, health and social service agencies, employers, payers and other stakeholders to determine family and community needs, identify gaps in current funding to meet those needs, and develop creative funding strategies. As researched by the Catalyst Center, states are developing innovative ways to finance initiatives that strengthen the existing health care system. For example, states have developed strategies to procure services in ways that improve quality or delivery of care, whether it be through medical home supports, youth transition services, or primary care case management. States are developing strategies to fund new services for CYSHCN that are not typically covered by health insurance, including care coordination (by blending state Title V and Medicaid funding, or by blending Title V and private insurance funding) and integrated care for children with specific diagnoses (by blending funding from multiple state agencies).

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CDPHP Pilot Program Shows Good Results
This article in The Business Review discusses how the Capital District Physicians' Health Plan, based in Albany, NY, is saving $32 per member, per month, at the three primary care practices that made up the first phase of its medical home pilot. The health insurer is working with 21 other area practices for the second phase, and it will select the third-phase practices by the end of May 2011.

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For Hospitals and Insurers, New Fervor to Cut Cost
New York Times, May 2012

This article provides examples of hospital and insurer driven strategies to reduce costs including the medical home concept and collaborative learning across institutions.

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How Can States Get Federal Funds to Help Pay for Language Services for Medicaid and CHIP Enrollees? PDF
National Health Law Program
This resource aims to assist states in evaluating best practices for setting up language services reimbursement. The report details federal funding available to states to pay for language services and describes technical requirements that vary from state to state.

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National Academy for State Health Policy (NASHP) Resources

  • Evaluating the Patient-Centered Medical Home: Potential and Limitations of Claims-Based Data
    This State Health Policy Briefing summarizes the advantages and disadvantages of using claims-based data to evaluate patient-centered medical home initiatives and highlights pilots in Oklahoma and Rhode Island using claims-based data in part to evaluate their medical home programs. Understanding the potential uses and limitations of both claims data and other data sources that can aid evaluators will help states to design appropriate evaluative criteria for their medical home programs.
  • Evolving Medical Home Payment Models to Better Support Triple Aim Goals
    Innovative payment models can support medical homes by decreasing the cost of care, incenting and rewarding quality over quantity, and enabling practices to invest in infrastructure and supports. Many leading states have learned from early initiatives and are moving forward with new payment models that to further drive system goals, including lowered costs, improved quality and increased patient satisfaction. Program leaders in Colorado, Rhode Island, and Vermont describe advances in their medical  home initiatives during this webinar recording. 
  • Supporting the Patient Centered Medical Home in Medicaid and SCHIP: Savings and Reimbursement PDF
    This brief explains the Patient Centered Medical Home model of care and explores reimbursement strategies states are using to help medical practices become medical homes.

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Patient Centered Primary Care Collaborative (PCPCC) Resources

  • Payment Rate Brief PDF
    Although the PCMH is taking hold in dozens of demonstration projects across the nation, there is a wide range of payment methodologies and rate arrangements with providers within those projects. This brief provides a detailed look at the payment arrangements and dollar value of a sample of 12 PCMH initiatives that represent a diverse mix of initiatives, including those involving a single commercial payer, multiple payers and a state Medicaid agency acting alone. The brief is a reference for primary care practices and payers interested in creating new PCMH initiatives, or to refine existing ones. 
  • Payment Reform to Support High-Performing Practice PDF
    This report was represents the work of a diverse group of PCPCC stakeholders and collaborators interested in exploring payment reform as a means of supporting the PCMH and transforming primary care in the US. Many other organizations are examining payment reform proposals; the PCPCC's task force is focusing on them from the unique perspective of their impact on the PCMH. The task force's goal was not to identify a "best" payment reform proposal, but rather to point out the strengths and shortcomings of available models so that PCMH advocates could choose the model that best suits their needs and circumstances. 

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Paying for the Medical Home—Payment Models to Support Patient-Centered Medical Home Transformation in the Safety Net PDF
Safety Net Medical Home Initiative
Operating as a medical home requires increased non-reimbursed activity (eg, care team meetings, patient self-management education, care coordination, data analysis, communication with other clinicians) and care management. In order for patient-centered medical home (PCMH) practice transformations to be sustainable, there must be payment reform to incentivize high-value, first-contact, primary care, and support medical home costs that are traditionally not reimbursed (eg, non face-to-face encounters). This publication provides an introduction to a series of policy briefs focusing on payment reform opportunities to support and sustain the medical home.

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Who Pays? Taking the Maze Out of Funding Manual
Minnesota Children and Youth with Special Health Needs (MCYSHN)
This manual is designed to inform both families and professionals about a wide range of potential funding sources. The goal is to help persons know what programs and resources exist in order to improve access to health care and more effectively advocate for children, youth, young adults and their families. The content in the manual is geared towards all children and youth, including but not limited to those with special health needs. It includes major funding programs, other possible funding options, and "tools" to help in identifying funding resources.

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Cost Savings

The Medical Home's Impact on Cost and Quality (2013)

Impact of a Patient-Centered Medical Home on Access, Quality, and Cost (2013)

The Landscape of Medical Care for children with Medical Complexity (2013)

Integrated Complex Care Coordination for Children with Medical Complexity: A Mixed Methods Evaluation of Tertiary Care-Community Collaboration (2012)

How Patients View Your Medical Home (2012)

Benefits of Implementing the Primary Care Patient-Centered Medical Home: Cost and Quality Results (2012)

Analysis of Community Care of North Carolina Cost Savings PDF (2011)

Medical Home and Out-of-Pocket Medical Costs for Children with Special Health Care Needs (2011)

Effect of Hospital-Based Comprehensive Care Clinic on Health Costs for Medicaid-Insured Medically Complex Children (2011)

Benefits of Care Coordination for Children with Complex Disease: A Pilot Medical Home Project in a Resident Teaching Clinic (2010)

Incremental Cost Estimates for the Patient-Centered Medical Home (2009)

Looming Financial Issues for Medical Homes in Healthcare Reform PDF (2009)

The Medical Home, Access to Care, and Insurance: A Review of Evidence (2009)

Patient-Centered Medical Home Demonstration:  A Prospective, Quasi-Experimental, Before and After Evaluation (2009)

The Medical Home Gets Updated Improving Outcomes While Reducing Costs (2008)

A Review of the Evidence for the Medical Home for Children With Special Health Care Needs (2008)

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Funding Opportunities

 

Many funding opportunities exist for supporting community-based projects for medical home implementation, or for targeted patient populations. Visit the Funding Opportunities page for more information.

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Additional Resources

AAP Resources

  • Policy Statement—Principles of Health Care Financing
    Pediatrics. 2010
    This policy statement discusses how access to care depends on the design and implementation of payment systems that ensure the economic viability of the medical home, as well as other factors including the support and grow the of the professional pediatric workforce, and the promotion of the adoption of health information technology. Health insurance plans must be affordable and have cost-sharing policies that protect patients and families from financial strain and are without risk of loss of benefits because of plan design, current illness, or preexisting condition
  • Chapter Pediatric Councils (AAP Members Only)
    Pediatric councils serve as forums to address pediatric issues with payers involving covered services, plan policies, and payer administrative procedures that impact access, quality, and cost. For more information, contact Lou Terranova at lterranova@aap.org.
  • Child Health and Medical Home Financing Slides PPT
    (Available to AAP Members)
    These powerpoint templates are available for AAP leadership, chapters, and/or members to provide information on child health and medical home financing, which can be used for presentations given during District meetings, chapter meetings, pediatric council meetings, etc.
  • Committee on Coding and Nomenclature (COCN)
    The COCN is responsible for reviewing all proposed changes to CPT and ICD-9-CM coding structures to determine whether the Academy will endorse the proposal; participates in the American Medical Association/Specialty Society Relative Value Scale Update Committee's (RUC) survey process by validating clinical vignettes, evaluating survey data, and deciding on physician work and practice expense relative value units (RVUs) to recommend to the RUC; and serves as a review panel regarding other activities such as identifying Academy positions on the RBRVS. The COCN also monitors the Medicare RBRVS physician fee schedule and its adoption by private and public payers.
  • Pediatric Coding Newsletter Online
    Developed by the AAP, with careful review by the COCN, this monthly newsletter provides broad coverage of coding for both pediatric primary care and subspecialty services. Look here for peer-reviewed, AAP-endorsed coding solutions, alerts on upcoming coding developments, and exclusive insights from experienced practitioners, all custom-built for ready access and easy comprehension by physicians and office staff alike.
  • AAP News Coding Corner (monthly column)
  • The Medical Home for Children: Financing Principles PDF
    Prepared by the AAP Committee on Child Health Financing, which monitors and makes policy recommendations to the AAP Board of Directors on various aspects and sources for financing health care for children, both private and public, and in all modes of delivery. This white paper is intended to provide guidance on the financing of medical home programs at the federal, state, and health plan levels.
  • Medicaid Reimbursement Report for Commonly Used Pediatric Services, 2007-2008 PDF
    As part of its effort to monitor the impact of the Medicaid program on pediatrics, the AAP conducts its Medicaid Reimbursement Survey periodically. The Survey, which collects state-level data on Medicaid programs and Medicaid fee-for-service payment rates for most commonly reported pediatric CPT® (Current Procedural Terminology) codes and dental codes, is mailed to state Medicaid Directors in the 50 states and the District of Columbia.
  • Pediatric Cost Model
    (Available to AAP Members)

    To support child health and medical home advocacy in ongoing health reform discussions, the AAP launched the new Pediatric Medical Cost Model in September 2009. Based on an actuarial analysis of physician fees paid by insurers for children's services during 2008, this cost model provides state-by-state data for both public and private insurers for pediatric service categories such as well visits, sick visits, lab, immunizations, psychiatric visits, allergy tests, and others. Overall Medicaid/CHIP physician payment for children's services was 72% of Medicare payment during 2008, compared to commercial payment estimated at 113% of Medicare. Wide variations in Medicaid and CHIP fees were observed among states.

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The Care Coordination Toolkit PDF
Cincinnati Children's Hospital Center for Infants and Children with Special Needs
This tooklkit outlines billing for the care coordination through a review of individual codes, proper documentation, and an easy to follow billing slip. 

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