HOW YOU CAN PREVENT VACCINE BILLING ERRORS
Optimize Vaccine Billing for a Profitable November
Flu and COVID-19 vaccines galore will likely fill your November schedule, which is fantastic for your pharmacy as long as you’re billing correctly. You want to ensure you follow every step of the vaccine billing process to get full reimbursement from your PBM. We’ve worked with countless independent pharmacy owners who didn’t realize they were billing their PBM incorrectly or how it even happened.
remove the DUR code. Even if you’re unsure whether your PBM requires the code, it’s good to get into the habit of including this code and staying on top of DUR codes.
Any error can lead to missing money.
Review all your costs and PMS entries if you feel like you’re not being adequately reimbursed. Check your claim and determine how much you were paid for ingredient costs and administration fees. Then compare them with the prices you actually billed. Any discrepancies? Various errors could have led to a mixup: errors in the drug file, issues in how your PMS sends billing data to your PBM, and so on. We recently worked with an owner who experienced a similar situation with COVID-19 vaccine reimbursement. He was reimbursed an ingredient cost of $70 and an admin fee of $20, so he received a total reimbursement of $90. The problem was that the vaccine cost $140! He should have been paid an ingredient cost of $140 in addition to the $20 admin fee. If you experience an issue like this, call your PMS company and have them check the back end of the claim to look for any errors.
Never forget these 2 factors.
When billing your PBM for vaccine reimbursement, you always need to remember two parts: ingredient cost and administration fee . The ingredient cost is the price of the vaccine itself. Meanwhile, the administration fee is how much you get paid to give a patient their shot. You need to know how to properly input these fees into your PMS system to bill for the vaccine accurately.
While you may think you know exactly how and where to input these fees, you’re likely placing these numbers in the wrong spot if you’re having issues getting
paid. Double-check with your PMS company about exactly where you need to input these numbers to bill your PBM and get reimbursed.
Check with your PMS company.
Always enter the DUR code.
When checking on their end, a PMS company can see what went wrong and what got lost in translation. There are countless opportunities for billing to get warped as it travels through the PMS system. With the company’s help, you can discover what led to the
If it seems you are getting paid for the ingredient cost but not the administration fee, you may have
forgotten to include the required DUR code that will actually allow you to get paid your administration fee. You should be submitting the code MA 3N PH for most vaccine claims. Every once in a while, you will encounter a claim where you need to
lowball reimbursement and how to ensure it doesn’t happen again.
Sometimes it can take multiple PMS and PBM calls to get it right. It is worth the effort.
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