A recent report by NBC news focused on the physical, mental, and economic toll that many independent pharmacists have experienced as a direct result of their efforts to administer COVID-19 vaccinations. In most cases, pharmacists told reporters that while the exhausting days and mounds of paperwork have certainly been an impediment, the far more serious concern came when they tried to get reimbursed for the vaccines. In fact, the report noted, the lack of reimbursement has become so severe, that many pharmacies have been forced to reconsider whether they would be able to continue to serve as vaccinators.
"It's a shot in the arm for sure to know that you're helping people," Chris Antypas of Asti's South Hills Pharmacy in Pittsburgh said in the report. Antypas says he has worked 80-to100 hours per week, running vaccination clinics in addition to his normal pharmacy duties. "But we're certainly sacrificing our business, and it's already difficult to be profitable. It's just a drain on you."
According to the Centers for Disease Control (CDC), the federal government is providing the vaccine free of charge to all people living in the United States, regardless of their immigration or health insurance status. Patients are not to be charged a copay, administrative fee, or assessed for the cost of the vaccine.
Instead, providers are to "seek appropriate reimbursement from the recipient's plan or program," or "seek reimbursement for uninsured vaccine recipients from the Health Resources and Services Administration (HRSA)."
Unfortunately, the reimbursement process has not been as smooth as federal regulators envisioned it would be. This has led to frustration and the type of financial difficulties highlighted in the NBC report. As a result, certain resources have been developed to help facilitate the claims process and minimize the risk of a claim being rejected. These resources include:
• The National Community Pharmacists Association has released a short (20 minute) video presentation, "Troubleshooting COVID-19 Vaccine Billing Issues," in which NCPA Senior Director of Professional Affairs Lisa Schwartz offers helpful guidance for submitting vaccination-related claims. Among the "tips" covered in Schwartz's presentation:
• Pharmacists should use the NDC listed on the vaccine vial, which is preferred by most payers, although some will accept the NDC listed on the carton.
• The pharmacist should be listed as the "ordering professional."
• Day's supply should be "1."
• The quantity should reflect the volume of the vaccine administered – either 0.3mL or 0.5mL, depending on the vaccine.
• Use "MA" (medication administered) as the professional service code.
• The basis of cost determination should be "15," which represents "free product or no associated cost." (This should be used for payer systems that cannot process a $0.00 claim • submission.)
• Use submission clarification codes as follows:
• Initial dose of two-dose vaccine: SCC 2 "override."
• Second dose or single dose: SCC 6 "starter dose."
The presentation also addresses common questions associated with seeking reimbursement from Medicaid, commercial plans, and the HRSA uninsured program.
• NCPA has also prepared a 3-page "Vaccine Billing and Reimbursement" guide, which expands on many of the topics raised in the video. The guide offers an overview of processes to follow in seeking reimbursement under Medicare, Medicaid, commercial plans, the federal HRSA Uninsured program, and for underinsured patients.
• HRSA Underinsured Patient Reimbursement Information. The Health Resources and Services Administration (HRSA) has established a COVID-19 Coverage Assistance Fund to cover vaccine costs for patients whose health insurance does not cover vaccine administration fees. HRSA has released a fact sheet that pharmacists can use to understand the process to follow in seeking reimbursement for vaccines administered to under-insured patients. Pharmacists can also find assistance in HRSA's detailed "Health Care Claim Submission Companion Guide."
• HRSA Uninsured Patient Reimbursement Information. HRSA also provides guidance for pharmacies seeking reimbursement for vaccinations administered to uninsured patients. That fact sheet can be accessed via the HRSA website.
As vaccines become increasingly available, pharmacists will continue to be integral to the nationwide effort to vaccinate as many Americans as possible. This is exactly why eliminating obstacles to reimbursements is so important.
The NBC report cited American Pharmacist Association Vice President Anne Burns, who noted that there is a lack of information regarding how widespread pharmacy reimbursement issues have become. She mentioned that insurers had "overly complicate" the system with various billing codes that cause reimbursements to be rejected more often. "There's been variability in reimbursement and more rejected claims," Burns said, "but at the end of the day, the important thing is that pharmacies get paid for delivering the vaccine and there's not a significant lag time in getting there."
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