Medicare Compliance & Reimbursement

PIllinois pediatrician sentenced after billing for vaccines she received for free.

Forget about digging through lus: the latest Medicare Physician Fee Schedule and calculating the conversion factor when it comes to determining your Part B reimbursement rate for flu shots. CMS has come out with a handy MLN Matters article elucidating this information. According to MLN Matters article MM7120, released on Oct. 22,the Part B payment allowance for flu immunizations is as follows:

90655 (Influenza virus vaccine, split virus, preservative free, when administered to children 6 to 35 months of age,for intramuscular use): $12.398

90656 (Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older,for intramuscular use): $12.375

90657 (Influenza virus vaccine, split virus, when administered to children 6 to 35 months of age, for intramuscular use): $6.297

90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for dates of service September 1, 2010through December 31, 2010: $11.368.

If your MAC reimburses for either 90660 (FluMist) or 90662 (Fluzone High-Dose), the Part B payment amount effective Sept. 1 for 90660 is $22.316, and for 90662 is $29.213. Carriers differ on whether they will cover these types of influenza immunizations.

(Editor's note: Annual Part B deductible and coinsurance amounts do not apply to these charges, the article notes.To read the article in its entirety,visit www.cms.gov/MLNMattersArticles/downloads/MM7120.pdf.)

When the CDC offers you free vaccines to administer to uninsured patients, don't even think about billing insurers for the products. That's the lesson learned from the recent sentencing of an Illinois pediatrician who accepted free vaccines intended for uninsured or under-insured children. The doctor admitted that she billed insurers for the vaccines (which she received as part of the Vaccines for Children program) as if she had paid for them on her own.The HEAT Task Force, which is part of the government's initiative to combat health care fraud, discovered the wrong doing, and the doctor was subsequently ordered to serve a three-year term of probation, with the first six months taking place under home confinement.

(Editor's note: To read the Department of Justice's press release on the sentencing, visit www.stopmedicarefraud.gov/HEATnews/illinois.html#oct-06-2010.)