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Private Vaccine$: Purchase, Coding and Billing

Private Vaccine$: Purchase, Coding and Billing






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    Private Vaccine$: Purchase, Coding and Billing Private Vaccine$: Purchase, Coding and Billing Presentation Transcript

    • Private Vaccine$ Purchase, Coding, and Billing Christoph Diasio MD FAAP Sandhills Pediatrics NC Pediatric Society Meeting Myrtle Beach, SC 7-30-2010 [email_address] I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
    • Disclosure!
      • I h ave no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
    • History
      • At the time the UCVDP was created, most insurance programs (including the state employees plan!) did not pay for any childhood vaccines
      • Practices paid to immunize children out of the “generous” payments from insurers for well child care
    • History
      • NC Pediatric Leaders succeeding in getting the NC state legislature to fund the program so that the state would buy the vaccine, ship it to the practice for “free” and we would administer the vaccine for only admin. fee
        • Also, prohibited billing more than 2 vax admin if uninsured/cash pay
    • Slow death /budget cuts & HCR
      • The UCVDP has slowly died, as more expensive vaccines (Var, PCV7, Rota, MCV4, HPV, PCV13) were not paid for by the state
      • NC was a “universal select” state, so all practices should be experienced in buying at least some vaccines currently!
      • Over time, more private insurance plans paid for vaccines
      • State budget cuts in 2010 led to death of program
      • Health care reform mandates first-dollar coverage for Well child care and vaccines
    • How to buy?
      • Always, always, ALWAYS use a GPO! (Group Purchase Organization)
      • They “group purchases” together and you get a cheaper cost per dose on vaccine at no risk to you- only obligation is usually must pick a Sanofi-Merck group of vaccines or GSK
        • Still go to the website and order- just a cheaper price!!
        • Some also have discounts on Rocephin, other supplies
      • Don’t pay the “rack rate” at hotels or to vax manufacturers! (not a huge dollar difference, but this is the # 1 most frequent service you provide)
    • You decide now!
      • Model out which vaccine schedule you want to follow compared to what the ins. cos. will pay- GSK gives you rebates quarterly for using multiple GSK vax
      • Sanofi-Merck in GPOs have a cheaper “up front” price than list price from a distributor
      • Both options end up with discounted costs at the end of the year!
    • Take home message….
      • JOIN A GPO!!
      • Many of them are next door in exhibit hall!
    • Storage
      • Vaccines are worth a lot of money!
      • Need a temp. monitor/alarm system that measures liquid/glass bead temp in fridge (less swing than air temp c opening door)
      • Consider a “purpose built vaccine fridge/freezer” non-household fridge
      • - you get what you pay for!
      • Need insurance to replace loss in case of fire, fridge death, fridge freezes vax, or HUMAN ERROR (door left open)
      • -ask insurance co rep. “what could happen to make your company not pay my claim” and file that email away somewhere safe….
      • -may need a fridge maintenance contract!
      • Household
      • Vaccine fridge
      • Vaccine temp monitor
    • Administering vaccine
      • Use appropriate codes to bill
      • Have an EXCELLENT superbill (mine is on USB)
      • 90465/6/7/8 for vax for kids < 8 yo with Physician/NP/PA counseling risk/benefit
        • (create a line on WCC form above signature “I the MD/NP/PA counseled re: risks/benefits from these vax)
      • 90471/2/3/4 for vax kids any age no counseling
      • Note new vax admin. codes are arriving in October to cover multi-antigen vaccines (Pentacel/Pediarix/Kinrix)
        • Currently we “lose” admin fees in order for child to get fewer sticks
    • New admin fees in 2011
      • AAP Coding Hotline:
      • While we are not able to share the actual code descriptors prior to their release via the AMA's CPT 2011 manual (which is scheduled to be published in October 2010), we can tell you the following about the new immunization administration codes:
        • Two new immunization administration (IA) codes will replace codes 90465-90468
        • Codes 90471-90474 will not be affected
        • The new codes will be through 18 years of age, include all forms of administration, and require counseling by the physician or other qualified health care professional
        • The new codes will also allow the provider to report each vaccine component separately
      • RBRVS values are expected to be published for 2011 (around November 2010) and go into effect Jan 1, 2011
    • Payment
      • How to negotiate?
        • Use CDC private sector cost to base negotiations! AWP/ASP are funny numbers and some versions are only available by subscription
        • CDC price is transparent, free, and emails you if price changes!
        • http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm
        • Analogy is to negotiating on percent of Medicare
    • Payment
      • Contact insurance companies
        • Be sure to remind them that vaccines are the greatest cost-saver ever invented and we should be paid handsomely to encourage us to vaccinate their customers!
          • Just like toddlers&teens- Align incentives with good behavior
        • Product cost is different than admin !
          • 100 % of reps will claim you are getting a good deal because they pay for admin fee separately- Silly!
    • Tire Shop Analogy
      • No one goes to the auto shop and buys tires (vaccine product) for the same price as the tire shop (peds practice) did (excise tax, staff time to order/inventory, insurance, alarm, cost of money in fridge, expiration/wastage/unpaid claims)- need a percent above cost because HPV is more “dollars in fridge” compared to DTaP!
      • You also pay labor to balance and put tire on the car (admin. fee)- MD counseling/ Jenny McCarthy time, nursing time, data entry to registry, table paper, syringe, alcohol swab, contribution to overhead for office rent, HVAC, phones, etc
    • Avoid invoice pricing
      • Try not to share invoices with payors
        • “ None of their business”
        • If the tire shop (peds practice) finds a better supplier and gets the same tire (vaccine) for 10 dollars less, is the customer (ins. co.) entitled to know that? Do you pay your employees less when they use coupons at the grocery store?
        • ALL of pediatric care is budget dust to ins.cos.!
          • ALL dollars to ALL primary care is 6% of US healthcare$
        • Say it with me- “CDC Private Sector Cost List”!
    • How to price vaccines
      • We can not engage in price fixing! But….
      • Be aware some payors pay 70-80% of your billed charge, so price accordingly
      • You want to be paid 17-28% above your hard dollar cost to break even per AAP Business Case on Vaccines (USB drive)
      • (Simpler for payors to understand if you reference the CDC private sector cost for vaccines)
    • Is this the switch to private vaccines in NC terrible?
      • NO!
      • This event is actually an opportunity for us to start making margin on the incredibly valuable service we provide to society in general and our patients in particular
        • We ought to be paid like orthopods for this !
      • Not any fun to see all those dollars in fridge– but EOBs back with positive margin is not bad!
    • You are a scientist- Data isn’t just for drug studies!
      • Simple spreadsheet on thumb drive- EXCEL nerd session!
      • List all vaccines in column A&B
      • # given in 2009 (from your PM) column C
      • CDC price in column D
      • Your price in column E
      • Payment from ins co column F
      • C * E = cost to acquire
      • C * F = your total payment by vaccine
        • (this is not a strict ROI analysis if your are an MBA)
    • Best practices
      • GPO, GPO, GPO!- watch for specials!
      • Charge to AMEX Plum card and get 2% cash back! (or similar incentive card)
        • (also all medical supplies, CME, esp. Annual Peds meeting at beach….)
      • Audit RN/MD code selection & charge posting
    • Best practices
      • Inventory of vaccine
        • Track wastage rate using state registry or on fridge piece of paper!
        • Compare invoices (what comes in) with what is billed (what goes out)
      • Close the loop= watch the EOBs come back! (make sure the Ins. Co. rep told the truth)
        • Simple grid for EOB posters to reference
        • Program “expected” amount into PM system
    • Worst practices
      • Story courtesy of Graham Barden (not his practice) –Someone plugged in a refrigerator to a standard computer UPS - the power blinked over a weekend, which tripped the UPS since NONE are designed to pull a load as big as a refrigerator compressor - and the UPS &quot;kicked out&quot; and killed the power. So because the refrigerator was plugged in to an inappropriate device, a simple power burp that lasted just a few seconds killed an entire refrigerator!
      • Another practice did not pay attention to temps and faithfully documented freezing vax in fridge and gave compromised vax. Had to recall all patients post VFC audit! - I like the IAC temp graphs as a result
    • Neat ideas
      • Add on form for sibs in exam room who need flu vax (on USB)
      • Use call-em-all.com to robo-call patients in for vaccines (upload list of names & phone numbers in excel spreadsheet from PM/EMR system) eg, asthma/DM patients for flu vax
        • or constant contact to email….
      • Use Flash appointments so patients can make their RN-only flu clinic appts. ( idea from Bill Satterwhite MD)
    • Flash Appts
    • Resources
      • AAP online course: Immunizations: Best Business Practices
      • CDC private sector price list
      • Immunize.org
      • Coding for Pediatrics- buy new one yearly!
      • Email NC pediatric council!
        • [email_address]
        • [email_address]
    • As always….
      • JOIN SOAPM!
        • Attend SOAPM section at NCE!
          • Do you really need to hear your 55 th talk on asthma? Learn something new!
          • Instructions on how to join on USB drive
          • Join with a gmail.com email account for listserv
    • Questions
      • ?????????