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1 Addressing Challenges in Adult Vaccine Financing Thursday, June 8, :00 PM ET In Case of Technical Difficulties If you hear an echo: Make sure you are only logged in once on your computer Select one form of audio only (either computer speakers or telephone connection) If the audio is choppy: Press pause in the top left corner of your screen Wait 10 seconds and then click the play button Dial at any time for live assistance 1

2 Welcome and Introductions Agenda Agenda William Schaffner, MD NFID Medical Director and Professor of Preventive Medicine and Infectious Diseases, Vanderbilt University School of Medicine Addressing Challenges in Adult Vaccine Financing Angela K. Shen, ScD, MPH CAPT, US Public Health Service Senior Science Policy Advisor, National Vaccine Program Office Office of the Assistant Secretary for Health US Department of Health and Human Services C. Michael Soppet, MD Primary Care General Internist Internal Medicine Associates of Dothan Questions and Answers This webinar is supported by an unrestricted educational grant from Merck & Co., Inc. NFID policies restrict funders from controlling program content. General Information Please note that today s webinar is being recorded All phone lines will be placed on mute throughout the program To hear audio: Computer: Follow directions Phone: ; Access Code After the presentations, there will be a Question and Answer period Use the Chat box on the lower left side of your screen to type your question At the end of the webinar, participants will be directed to an online evaluation Following the webinar, all registered participants will receive an with a link to the presentation slides 2

3 CME Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM To receive credit, you must complete the online evaluation and pass the posttest with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test until June 8, 2018 Disclosures Marla Dalton (NFID staff, content reviewer) owns stock, stock options, or bonds from Merck & Co., Inc. William Schaffner (NFID medical director, presenter) served as an advisor or consultant for Dynavax, GSK, Merck & Co., Inc., Novavax, Inc., Pfizer Inc., Sanofi Pasteur, and Seqirus All other activity planners/reviewers and staff for this activity have no relevant financial relationships to disclose 3

4 Learning Objectives At the conclusion of this webinar, participants will be able to: Identify challenges facing providers of adult vaccinations Discuss strategies to address financing barriers Identify practical resources for healthcare professionals About NFID Founded in 1973, NFID is a non-profit 501(c)(3) organization dedicated to educating the public and healthcare professionals about causes, prevention, and treatment of infectious diseases across the lifespan Reaches consumers, health professionals, and media through: Coalition-building activities Public and professional educational program Scientific meetings, research, and training Longstanding partnerships to facilitate rapid program initiation and increase programming impact Flexible and nimble organization 4

5 Addressing Challenges in Adult Vaccine Financing Angela K. Shen, ScD, MPH CAPT, US Public Health Service Senior Science Policy Advisor US Department of Health and Human Services Objectives I. Provide an overview of vaccine financing in the United States II. Review some challenges facing providers of adult immunization III. Share some efforts to address barriers and available resources 5

6 Public & Private Sector I. OVERVIEW OF VACCINE FINANCING IN THE UNITED STATES Vaccine Financing in the United States Vaccines for Children (VFC, ~45% of children) Entitlement for children up to age 19 served by: Medicaid Without health insurance American Indians and Alaska Natives Underinsured children can receive VFC vaccines in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) 6

7 Vaccine Financing in the United States Federal Government provides the vaccine and providers are paid an administration fee, based on a fee schedule. For children on Medicaid, the State Medicaid program pays the administration fee. The state sets the rate, based on the fee schedule. Section 317 Discretionary funding that has been stagnant Has objective to improve adult IZ Medicare Vaccine Financing in the United States Federal health insurance for those age 65 years and older, disability, permanent kidney failure Coverage under: Part B (named by statute) influenza, pneumococcal, hepatitis B for high risk Part D All other vaccines (e.g., Zoster, Tdap/Td) 7

8 Vaccine Financing in the United States Medicaid (non-vfc) No cost-sharing for adults in expansion population State Medicaid program reimburses providers for both vaccine and administration fee Reimbursement rate for administration fee is set by states (no fee schedule) State receives Federal match for both the vaccine and administration fee at the state s regular match rate (between 50-70% based on state per capita income) Vaccine Financing in the United States Private sector (~50% of children) Price of vaccine negotiated with purchaser (distributor/manufacturers) Payment negotiated with various payors Providers responsible for administering vaccine then seeking payment (compare with pharmaceuticals where patient fills the prescription) 8

9 II. CHALLENGES FACING ADULT PROVIDERS First Dollar Coverage Applies to the patient perspective First Dollar Coverage means: ACIP-recommended vaccines at no costsharing to the patient (no copays, coinsurance, deductibles) What does financing mean for the provider? 9

10 Managing the Business of Vaccination: providers THE NATIONAL VACCINE PROGRAM OFFICE Actually More Complex 10

11 CDC Vaccine Price List National Vaccine Advisory Committee (NVAC) National Adult Immunization Plan (NAIP) National Adult and Influenza Immunization Summit (NAIIS) III. EFFORTS TO ADDRESS CHALLENGES 11

12 Implementing NVAC Recommendations: Building on NVAC Work NVAC Pediatric Financing Working Group (March 2009) Assuring Vaccination of Children and Adolescents Without Financial Barriers NVAC Adult Working Group (February 2012) A Pathway to Leadership for Adult Immunization THE NATIONAL VACCINE PROGRAM OFFICE The Pediatric Experience Payor education: AAP business case Provider education: Coding, reimbursement, strategies lower cost (e.g., VPG), improve practice efficiency THE NATIONAL VACCINE PROGRAM OFFICE 12

13 Focus on Providers Patients: May be unaware of recommended ACIP vaccines (not know they are fully covered under the ACA) Providers: May be learning the business of vaccination (not know coverage for payment and how to code) Payors: Payment for vaccine (product) and administration (services) THE NATIONAL VACCINE PROGRAM OFFICE Questions to NVAC What are the data gaps to understanding financing barriers to providers for providing vaccination services? What are the types of studies needed to better understand vaccine and vaccination costs associated with providing adult vaccines? THE NATIONAL VACCINE PROGRAM OFFICE 13

14 One Answer The total cost of administering vaccines, including administration, storage, purchase, and other incidental costs; reimbursement received for administered vaccines; opportunity costs of purchasing and storing vaccines; and the average net profit and loss associated with vaccine administration among various provider types and provider settings. THE (FIRST EVER) NATIONAL ADULT IMMUNIZATION PLAN 14

15 Four Overarching Goals Strengthen the adult immunization infrastructure Improve access to adult vaccines Increase community demand for adult immunizations Foster innovation in adult vaccine development and vaccination related technologies THE NATIONAL VACCINE PROGRAM OFFICE National Adult and Influenza Immunization Summit (NAIIS) Our charge: Determine what we can do as the NAIIS and as individual organizations to improve adult and influenza vaccination rates: Identifying data gaps and filling them Identifying barriers and addressing them Working Groups Provider and Access Influenza Quality Measures Maternal, Adult composite, ESRD 15

16 Reminder Coverage with no cost-sharing Actual dollar payments often vary by insurer and individual insurance plans Each claim submission requires appropriate Current Procedural Terminology (CPT ) and ICD-10- CM codes even if the insurer considers immunization a routine service Coding and Billing Website 16

17 Manufacturers Provide Hotlines Many manufacturers provide hotlines to assist coders; these may also offer guidance for claims preparation, appeals, and specific payers vaccine coverage and reimbursement policies Contact your vaccine representative to learn more about their reimbursement support services Resources Websites Subscribe to Updates

18 Additional Information National Adult Immunization and Influenza Summit NVAC Meetings In-person or via live webcast html Download the National Vaccine Plan and the National Adult Immunization Plan: THE NATIONAL VACCINE PROGRAM OFFICE Addressing Challenges in Adult Vaccine Financing C. Michael Soppet, MD Primary Care General Internist Faculty, American College of Physicians I Raise the Rates Initiative State Chair, I Raise the Rates Initiative in Alabama Member, American College of Physicians Immunization Technical Advisory Committee 18

19 Best Practices in Adult Immunization Billing, Coding, and Inventory Control The Immunizing Event along a Process Continuum Phase I Phase II Inventory Control (Steps 1-4) Vaccine Administration and Documentation (Steps 5-7) Claims and Revenue Collections (Steps 8-10) Auditing and Report Generation (Steps 11-12) Phase III Phase IV 19

20 The Process of Office Immunization Step One: order vaccine Step Two: receive and reconcile vaccine quantity against order Step Three: store the vaccine safely and securely Step Four: distribute vaccine to the intermediate user (vaccinator) Step Five: identify and administer vaccine to end user (patient)-pre-visit planning Step Six: document vaccinating event in the medical record and State Registry Step Seven: enter a charge in the practice management system Step Eight: bill for both the administration fee and the vaccine charge Step Nine: generate an insurance claim and collect copayment (Part D only) Step Ten: reconcile all charges with collections Step Eleven: reconcile inventory begin day - vaccine doses given = vaccine doses end of day) Step Twelve: produce cash flow (Income and Expense) statement How You Are Paid 1. Two fees for each shot, one for the vaccine and one for the administration 2. Must code correctly for each in order to be paid for any 20

21 How You Are Paid 1. Once a year, update your vaccine fees 2. Reconcile this against all your insurance fee schedules 3. Document the Vaccine Administration 4. Generate an Insurance Claim (collect a co-pay only for Medicare Part D) 5. Receive payment within three weeks; if no payment, follow-up calls 6. Audit the payment against the cost Vaccine Pneumovax- 23 CPT code $89.95 Prevnar $ Influenza Quadrivalent $19.03 Average Reimbursement Administration Administration 1st dose (Commercial) CPT code Average Reimburse ment $21.86 Influenza High Dose $42.72 Zostavax $ Hepatitis A $63.88 Hepatitis B $61.48 Menactra $ Bexsero $ Gardasil $ Tdap $47.00 Yellow Fever $ Typhim $99.21 Administration 2nd dose (Commercial) $11.29 Flu (Medicare) G0008 $25.72 Pneumococc al (Medicare) Hep B (Medicare) G0009 $25.72 G0010 $

22 Medicare Vaccine Worksheet 2016 version Medicare Vaccine Payment only Profit or loss Margin Administration Fee (Profit or Loss Margin) (or G000-) (or G000-) Vaccine Vaccine Vaccine Total Time Cost Vaccine Profit/ ROI Materials Nursing State Admin fee Total Administration Administration Purchase Billing admin Cost of Money Part B/D loss Vaccine cost Cost IIS Billing Cost fee fee Cost* Cost cost (B+C+D) Payment margin Cost cost** Cost (J-M) payment profit PPS 23 (90732) $80 $8.0 $0.65 $ not added $89.95 $ % $0.52 $ 8.00 $ 5.00 $ 2.31 $15.83 $23.09 $7.26 $8.56 = $ $7.26 $80 ROAI for Pneumococcal Polysaccharide Vaccine = 10% Maximum You Should be Paying for Vaccine Purchase ) Influenza Trivalent $9.80? 2) Influenza Quadrivalent $17.00 $ ) Influenza High Dose $37.00 $ ) Pneumococcal Polysaccharide 23 $75.00 $ ) Pneumococcal Conjugate 13 $ $ ) HPV-9 $ $ ) Zostavax $ $ ) Hepatitis B $41.00 $ ) Tdap $32.00 $ ) Tetanus Toxoid $29.00 $ ) Neisseria Meningitides A, C, Y, W $99.00 $ ) Trumemba (Neisseria group B) $98.00 $

23 How to Find Medicare Payment Information 23

24 Payment for Vaccine Component-Medicare Documenting the Vaccine Administration The Role of Quality Control in Documentation 24

25 PDSA Daily Worksheet for Vaccines Completed PDSA Daily Run Sheet 25

26 Generate an Insurance Claim Form 1500 Box 21. Diagnosis code A. Should reflect the ICD 10 code describing the reason for the office visit. In this case the patient s asthmatic condition Box B. Should reflect the location where the service is provided. In this example 11 indicates the service was provided at an office Box D. Procedures, Services, or Supplies. NCCI edits require a modifier 25 to recognize the office visit as a distinct service from the vaccine administration The SK modifier can be used to indicate that the patient is considered high risk Box F. Charges. Should reflect the HCP s usual and customary charges The reporting of the vaccines National drug code (NDC) may be required by some payers including Medicaid and TriCARE. 26

27 Filling Out The Form Generate Reports Why generate reports? What reports to generate? How often to generate these reports? 27

28 Using Daily Run Sheet for Reporting 1) Formalizes pre-visit immunization planning 2) Documents the ask rate at 100% 3) Documents the Refusal Rate easily 4) Can augment this with a signature required refusal form 5) Filled out contemporaneously by the nurse will double check documentation 6) Can be used to verify that the dose was given and check at end of day against vaccines documented as administered and charged in the Electronic Record 7) Keeping it allows for running count of progress (% of patients vaccinated) PDSA Daily Worksheet for Vaccines 28

29 Doses Administered Tally Sheet (Daily) Inventory Control Report 29

30 Stock Inventory Example Audit the Payment Against the Cost 30

31 Audit the Payment Against the Cost Measure the Rates of Immunization 31

32 Questions & Answers CME Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM To receive credit, you must complete the online evaluation and pass the posttest with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test until June 8,

33 Join Us For Upcoming NFID Webinars Updates from June 2017 ACIP Meeting Thursday, July 13, 2017 at 12:00 PM ET Registration: Subscribe to NFID updates: 33