Immunizations are one of the biggest revenue growth opportunities for pharmacies, and learning to successfully navigate the world of vaccine billing can bring tremendous value to a business. Unfortunately, vaccine billing can be intimidating, which may cause many pharmacies to miss out on this revenue opportunity. Much of the confusion is because of the different ways that vaccines are covered by insurance; however, once the basics of vaccine billing are understood, pharmacists can easily take advantage of this growth opportunity.
PHARMACY COVERAGE VERSUS MEDICAL COVERAGE
Vaccines can be covered under the pharmacy benefit, medical benefit, or in some cases, both. Before reviewing vaccine coverage specifically, it is important to understand the differences between pharmacy coverage and medical coverage in general, including how claims are processed and reimbursed under each type of benefit.
Transactions covered under the pharmacy benefit are processed between the pharmacy and the pharmacy benefits manager (PBM). Claims submitted under the pharmacy benefit are adjudicated in real time, and the PBM provides paid responses based on their contracted rates with the pharmacy. Although the PBM may later apply clawbacks or direct and indirect remuneration (DIR) fees, the amount paid on a transaction will not change from what is shown during the claim adjudication.
Medical coverage accounts for a smaller percentage of a pharmacy’s overall transactions, but claims covered under the medical benefit are generally higher-value transactions such as specialty drugs, clinical services, durable medical equipment (DME), and, of course, certain vaccines. Medical benefit transactions occur between the pharmacy and the payer directly, as opposed to the pharmacy and the PBM. These claims must be submitted in batches and must use the required American National Standards Institute X12 837 batch standard or a CMS 1500 form. With medical claims, it is still possible to receive a denial days or weeks after a claim has been adjudicated, since the batch submission process does not occur in real time. A pharmacy can mitigate their denials by incorporating claim adjudication technology into their work- flow (see “Leveraging Technology”).
When it comes to vaccines, the simplest answer on how they are covered is that it depends on both the payer and the type of vaccine. Included above is a high-level summary of major payers, vaccines, and coverage types (see table).
DISPELLING THE MYSTERY OF THE MEDICAL BENEFIT
There is a common misconception that not all pharmacies can bill vaccines under the medical benefit. Any pharmacy can bill medical benefit claims, but there is one important dependency. Because the relationship for medical coverage is between the pharmacy and the payer directly, the pharmacy must be contracted with the payer in order to bill under the medical benefit.
To bill claims to Medicare Part B, pharmacies must complete a CMS 855B application and be enrolled as a mass immunizer. The application approval process takes about 8 weeks, and once the application is complete, the pharmacy receives a Provider Transaction Access Number (PTAN) and is able to bill flu and pneumococcal vaccines covered under the medical benefit to Medicare Part B.
To bill claims to commercial payers, pharmacies must be contracted with each commercial payer that they wish to bill. For independent and smaller retail pharmacies, contracting with individual commercial payers can prove difficult, if not impossible. For those pharmacies that fall into this category, it is important not to be discouraged and abandon vaccines covered under the medical benefit altogether. There is still a lot of value in billing vaccines to Medicare Part B, and setting up to bill this way is worth the investment.
LEVERAGING TECHNOLOGY TO SIMPLIFY VACCINE BILLING
Good technology makes life easier, and the world of vaccine billing is no exception. Although claim submission under the pharmacy benefit is pretty straightforward, medical claim submission is more complex. A good medical claim billing solution will handle the complexities behind the scenes, automating the process and allowing operation within an existing workflow.
During the claim adjudication process, an effective technology solution will have a built-in set of rules (eligibility, coverage, etc) for each payer and apply those rules to the claim in real time. This reduces some of the risk around medical claim reimbursement by ensuring that the claim includes all of the required information and increasing the likelihood of receiving the expected reimbursement.
Technology should also allow providers to submit both pharmacy and medical benefit claims the same way, within the existing workflow of the pharmacy management system. If a technology solution requires an already busy pharmacist to change their workflow, it is not likely to be effective. Technology solutions should seamlessly integrate into an existing workflow and accounts receivable processes.
BILLING BEYOND VACCINES
Navigating the world of vaccine billing is not as difficult as it may seem at first. Finding the right technology partner can help ensure success. Investing in a solid foundation for medical claim billing will have a positive impact beyond just immunizations. As provider status for pharmacists expands, a growing number of clinical services covered under the medical benefit (eg, oral contraceptive prescribing, health assessments, point-of-care diagnostic testing, smoking cessation counseling, etc) will create new ways for pharmacists to serve their patients and grow their business. Understanding how to effectively bill for these new services will be essential for pharmacies to differentiate their brand in today’s competitive market.
JOHN KING is the chief executive officer of OmniSYS. He focuses on driving innovation and delivering high-impact solutions that enable customers to grow their businesses profitably.
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