Expanding Reimbursement for Community Agencies - A Health Plan Colaboration

Background: In the late 1990s two conflicting goals emerged related to immunizing Medicare beneficiaries.  Medicare health plans aggressively recruited new members to join a plan, and community agencies were encouraged to increase their immunization programs. As a result, an increasing number of claims submitted to Medicare for reimbursement by community agencies were denied due to beneficiaries being members of a health plan.

Setting: Community agencies

Population: Medicare beneficiaries who are members of a Medicare health plan

Project Description: Agreement was reached with the health plans in the state that allowed community agencies to submit claims to the plans for all Medicare plan members they immunized.  The community agencies agreed to attend a training workshop prepares and submit a claims form to each of the plans once a year. The plans agreed to review the claims, return all denied claims for submission to Medicare, and reimburse the agencies for appropriate claims at the current Medicare rate.

Results/Lessons Learned: From a pilot of eight agencies the program has expanded to over 140 agencies, with an annual reimbursement level of over $200,000 to community agencies. The presentation will describe the steps in the process and the benefits and barriers to the project from the perspective of the health plans and the community agencies. This project was able to show that it can be of mutual benefit to community agencies and health plans to work cooperatively and develop a voluntary program that is beneficial to all parties. The relative simplicity of the program demonstrates that it could be a model for other states and health plans that would like to expand access to immunizations. Finally, underlying the success of the program has been the ongoing collaborative relationship between a QIO (Masspro), a state trade association, and the state’s Department of Public Health.