25039 Vaccine Eligibility and Reimbursement Medicare B - D - Commercial for Pharmacies and Physicians

Tuesday, March 29, 2011
Columbia Hall
Andrea Seratte, CPA , VP Development and Specialty Services, POC Network Technologies Inc

Background: Patient  benefit eligibility and knowing if a claim will be reimbursed is a major obstacle to vaccine immunization rates.  Pharmacies and physicians have opposite problems.  Pharmacies can process in real time vaccines covered by Medicare Part D and pharmacy benefit plans.  Their systems cannot process medical claims.   Physician have the capability of submitting claims covered by the medical benefits,  but their medical management systems cannot process real time Medicare Part D or pharmacy benefit claims

Setting: tbd

Population:  Medicare D, B and lives covered by commercial pharmacy benefit  and health plans

Project Description:  In 2007 we launched a web application that provided physicians  and nontraditional pharmacy providers with the ability to submit real time claims for Medicare Part D.  In November 2010 we launched an application that provides pharmacies and immunization clinics the ability to check patient eligibility  and submit vaccine claims covered by Medicare Part B and for a growing list of commercial plans.   

Results/Lessons Learned:  All parties:  physicians, pharmacies, pharmacy benefit plans,  health plans, and manufacturers  required an orientation on the differences between vaccines covered by Medicare B and D and how they are reimbursed.  Plans understood the underlying benefit but they lacked an understanding of differences between pharmacy and medical reimbursement systems.   Once oriented, the uptake was significant.  We currently have over 19,000 physicians enrolled in our application and are contracted with the majority of the Medicare Part D sponsors.  For Medicare Part D, vaccine availability issues has been the biggest factor in utilization rates for our enrolled providers.  The momentum with our Part B and commercial application is very encouraging.  Even medical providers are interested in using the application.  They want to know the eligibility and reimbursement before providing a vaccine.  This is of particular value for high cost vaccines.