Come One, Come All for the Covid-19 Vaccine 1/18/21

By now many of you have mobilized operations to begin the initial phases of vaccinating for Covid-19, but it doesn’t stop there. Operations are continually evolving invoking new challenges daily (if not hourly). Billing for the Covid-19 vaccines has also presented some unique obstacles to overcome. The Coronavirus Aid, Relief and Economic Security (CARES) Act outlines several of these requirements. 

Billed Claim

When the vaccines are provided free of charge, the vaccine product code should NOT be included on the claim. Only the administration codes should be reflected on the claims. Note, this is a different process than we typically see when we bill other drugs provided free of charge.

CPT/HCPCS

CMS has provided tables that call out each code, payment allowance and its effective date for the vaccines. There are a few reasons why these are unique and have created challenges around accurate charge capture and reconciliation. 

• Each administration CPT is unique to the product administered

• The vaccine administration CPT are also unique to the dose administered

Cost Sharing per Payer

Medicare Part B:

• Covid-19 vaccine and its administration has been added to the preventive vaccines that are covered under Medicare Part B without deductible or coinsurance. 

Medicare Advantage Beneficiaries:

• Covid-19 vaccine and its administration for Medicare Advantage Beneficiaries will be covered through the original fee-for-service Medicare program for 2020 and 2021. 

Private Health Plans

• Non-grandfathered group or individual health plans must offer coverage to the Covid-19 vaccine and administration without cost sharing.

• No cost sharing also applies for both in-network and out-of-network plans. 

Medicaid, CHIP, and Basic Health Program:

• State Medicaid programs have seen a temporary increase in the Federal Medical Assistance Percentage (FMAP) to provide the Covid-19 vaccine and administration to its beneficiaries without cost sharing. There are some exceptions based on individual states’ statutes and offerings. 

Uninsured

• The Health Resources and Service Administration (HRSA) may cover the Covid-19 vaccine and administration.

• To receive HRSA funds, organizations must confirm the patient is uninsured. You must accept payment in full, and agree to not balance the bill patient. Also, you understand that payment is subject to post-reimbursement audit review. 

Shout Outs!

1. Chargemaster and IT teams should ensure that only the vaccine administration codes are billed on the claim. The vaccine product code should not be billed out, even with a token charge while the vaccine is provided free of charge. Since the vaccine administration codes are unique to the product, these claims should not be held up in claims processor edits. 

2. Chargemaster and IT teams to validate the correct combination of vaccine manufacturers to administration codes are set up properly. It may be advantageous to have a validation process in place to monitor for miss-matches as patients begin receiving their second dose.

3. Billing and Claims teams should ensure claims for Medicare Advantage Plans are set up to bill directly to original Medicare FFS. This may also require the claim to split from other services provided during that visit that should still be billed to the Medicare Advantage Plan.

4. Billing and Claims teams to ensure out of network plans are set up to not balance bill the patient. 

5. Billing and Claims teams to also establish a process to validate patients are not eligible for any federal benefits and bill the HRSA program for any patients with limited benefits.