Wiki FQHCs billing non-preventative vaccines?

[meghanduggan]

I am at an independent FQHC and I am coming up against a wall because my supervisor is insisting that we bill these to Medicare. Medicare will RTP them because the shingles vaccine is the only thing that occurred that day. When I research this, the only vaccines medicare covers are flu, pnumo, hep b. I also found that any other vaccines are a part of the encounter rate and not separately billable. When I ask other FQHCs what they are doing I get different answers. Some adjust off as a non-billable encounter. others have a prescription program they are a part of and can bill these. Others just drop them to the patient after getting an abn on every visit. I am really not sure what the clear answer is on these. Could use some advice. I have been pushing back on these for over 2 years now. Bonus points if you are a Maine FQHC.

 

[Pam Warren]

Since the shingles vaccine is only covered by Medicare if recipients have a Part D (prescription plan), it's non-covered regardless of how you bill it. And Medicare is notorious for not providing clear guidance on how to handle getting paid for non-covered services. Whether or not you have a qualifying visit is irrelevant, since at adjudication, this will fall back to the provider, and also because vaccines can be billed without the visit. You do however have to bill Medicare for the vaccine so that they can process/issue an EOB, and calculate whether the carve out rule applies, so that's why an ABN is important--you need to get paid and Medicare won't be the one to do it!

If patients have Part D, they can pick up the Shingrix at the pharmacy and have you administer it....although the pharmacy does that as well.