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Billing Standards for Public Clinics. Recommendations of the IPAT Billable Vaccines Workgroup. Kelly F. McDonald, MPH Oregon Immunization Program Billables Project Contractor. March 7, 2013. IPAT Workgroup. Opened to new members in October 2012 23 public clinics, including 21 LHDs

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billing standards for public clinics

Billing Standards for Public Clinics

Recommendations of the IPAT Billable Vaccines Workgroup

Kelly F. McDonald, MPH

Oregon Immunization Program

Billables Project Contractor

March 7, 2013

ipat workgroup
IPAT Workgroup
  • Opened to new members in October 2012
      • 23 public clinics, including 21 LHDs
    • Wide range of positions
      • Billing specialists
      • Immunization coordinators
      • Office managers
      • Administrators
  • Monthly conference calls
  • Subgroup
guiding principles assumptions1
Guiding Principles / Assumptions…
  • LHDs should be assessing immunization coverage in their respective communities and assuring that vaccine is accessible to all across the lifespan
guiding principles assumptions2
Guiding Principles / Assumptions…
  • Health plans should reimburse LHDs for the covered services of their members, with vaccine costs reimbursed at 100%
guiding principles assumptions3
Guiding Principles / Assumptions…
  • LHDs who serve insured individuals should work to develop immunization billing capacity that covers the cost of providing services to those clients
guiding principles assumptions4
Guiding Principles / Assumptions…
  • OIP staff and contractors will work with LHDs and health plans to improve contracting / agreement opportunities and billing processes
guiding principles assumptions5
Guiding Principles / Assumptions…
  • Each LHD is uniquely positioned to determine the best methods of meeting both the immunization needs of its community and how to recover the costs of providing those services
guiding principles assumptions6
Guiding Principles / Assumptions…
  • CLHO is to be kept informed as standards are developed. We hope to add the standards to Program Element 43, effective July 2014
guiding principles assumptions7
Guiding Principles / Assumptions…
  • The billing standards are designed as tiers, with Level One activities laying the foundation for more advanced billing capacity in Level Two, etc.
tiered standards
Tiered Standards

Each new step builds on the last…

level one
Level One
  • The LHD:
    • Identifies staff responsible for billing and contracting activities, dedicating at least a portion of one or more FTEs to meet agency billing needs
    • Identifies major health insurance plans in the jurisdiction, including those most frequently carried by LHD clients
    • Develops relationships with plan contacts to assist with contracting and billing activities
level one1
Level One
  • The LHD:
    • Determines feasibility of separating health plan agreements/contracts for vaccine services from other agency program areas, such as mental health and chemical dependency
    • Determines administration fees based on the actual cost of service and documents how they were determined…
true cost administration fee
“True Cost” Administration Fee
  • Costs Related to:
  • Scheduling
  • Clinical Visit
  • Billing
  • Vaccine Management
  • Supplies
  • Registry
  • $ per injection
    • 1st
    • Successive
  • Private Insurance
  • Medicare
  • Adult Medicaid
  • Private pay (Non-VFC/317)


  • VFC & 317 Eligible
  • max = $21.96/inj.
  • (Cannot turn away due to inability to pay)
level one2
Level One
  • The LHD:
    • Develops an immunization billing policy that:
      • Details the strategies to manage clients who, effective March 1, 2013, are not eligible for VFC or 317 and are unable to meet the cost sharing requirements of their insurance coverage
      • Details the “true cost” administration fee of immunizations provided and the adjustments made to that fee for billing of different groups (i.e., VFC/317, Medicaid adults, and other insurance )
level one3
Level One
  • The LHD:
    • Develops an immunization billing policy that:
      • For those who purchase their own vaccine for insured clients, includes a vaccine management policy that describes the handling of locally owned vaccine for private pay patients, including allowable charges
level one4
Level One
  • The LHD:
    • Develops written billing procedure that:
      • Is updated annually or as changes occur
      • Includes the separation of billing processes between children and adults
level one5
Level One
  • The LHD:
  • Bills appropriately for Medicaid-covered clients:
    • Adults: Bills DMAP for the vaccine and an administration fee that reflects the true cost of providing immunizations
    • Children, birth through 18 years: Bills an administration fee that does not exceed the CMS allowed amount for the State of Oregon, $21.96 per injection
level one6
Level One
  • The LHD:
  • Identifies and documents health plans that consistently under-reimburse for vaccine costs and administration fees, after attempting to negotiate better rates
  • Pays the Oregon Immunization Program (OIP) for billable doses
  • Participates in and supports (i.e., completing surveys, utilizing the listserv, etc.) billable workgroup information exchange with other LHDs
level two
Level Two
  • In addition to all Level One activities, the LHD:
  • Begin establishing preferred provider contracts or other appropriate agreements with top identified health plans serving LHD clients
      • Fulfill credentialing requirements when necessary
      • Determine whether contract should include other public health services—STD, family planning, HIV, etc.
level two1
Level Two
  • In addition to all Level One activities, the LHD:
  • Bills private and public health plans directly for immunization services, when feasible, rather than collecting fees from the client and having them submit for reimbursement
  • Pre-screens immunization clients to determine amount owed for service
  • Develops a procedure for billing for vaccines given offsite
level three
Level Three
  • In addition to all Level 1 and Level 2 activities, the LHD:
  • Assures that Medicare members in the community have access to vaccine, and bills appropriately for immunization services provided by the LHD to Medicare clients
  • If not included in Level 2 contract work, interact with large, self-insured employers in the jurisdiction to recover costs of immunizing their insured members
  • Maintains credentialed status of providers by following re-credentialing guidelines at intervals determined by contracted health plans (i.e., every three years, etc.)
level three1
Level Three
  • In addition to all Level 1 and Level 2 activities, the LHD:
  • Annually evaluate most frequently billed insurance carriers and pursue preferred contracts with those carriers where appropriate
  • Conduct regular quality assurance measures to insure costs related to LHD’s immunization services are being recovered
march december 2013
March-December 2013
  • IPAT feedback
  • Revise standards
  • Present to CLHO-EPI regarding PE 43
  • Health plan progress
  • Online resource guide…
online resource guide
Online Resource Guide
  • Webpage of Resources
    • Contracting
    • Credentialing
    • Coding
    • Example policies
    • Workflows
    • ICD 9/10 resources
    • Health plan-specific information
questions comments
Questions / Comments
  • Kelly McDonald
  • 541-419-0136 (c)