Pediatric Coding Alert

 Experts offer 3 strategies for upping your Menactra reimbursement

Advanced planning, patient billing and AAP documentation will help you combat low reimbursement for the new meningococcal conjugate vaccine.

Expect About $85-102 From Most Insurers

Insurers vary widely on their payment for Menactra using 90734 (Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 [tetravalent], for intramuscular use) and V03.89 (Other specified vaccinations against single bacterial diseases; other specified vaccination). Menactra is now available from Sanofi Pasteur (previously Aventis Pasteur). Wholesale acquisition cost (AWC) is $82.50, and average wholesale price (AWP) is $102.50.
 
Here's what you can expect from three insurance companies:
 
United: "In most markets, United has not yet set a fee for Menactra (90734)," says Jeff Winokur, vice president managed care with Kelson Physician Partners in Hartford, Ct. Until United does set a fee, which is expected to be about $92 on July 1, Kelson practices are not accepting the "default" United payment, which is 50 percent of the 90734 charge.
 
Aetna: The corporate recommendation for all regions is to pay 90734 at $87. Aetna regions in his markets are offering this fee, Winokur says.
 
Blue Cross: Blue Cross plans differ on Menactra reimbursement. For example, after notifying Carefirst (BC in Maryland and Virginia) that Kelson practices would not accept its original fee, which was below $82.50, the insurer revised its fee to about $87.
 
Empire Blue (New York) will be honoring the AWP of $102.50, effective May 1, says Richard Lander, MD, FAAP, pediatrician at Essex-Morris Pediatric Group in Livingston, N.J.
 
Winokur also reports that Blue Cross of Florida has adopted the AWP fee of $102.50 for both HMO and PPO enrollees.

Fight 90734 Underpayments With 4 Tips

Aetna, Cigna, United and most Blue plans have set fees less than the AWP. "The AAP has issued a statement that vaccines need to be reimbursed 18-28 percent above cost for pediatricians to break even (this excludes the administration fees)," says Jill Stoller, MD, FAAP, pediatrician at Chestnut Ridge Pediatric Associates on Woodcliff Lake, N.J.
 
Best practice: "We are having patients pay unless the companies pay at least 100 percent of the AWP ($102.50),"  Stoller says. Patients sign an advance beneficiary notice (ABN) and pay out-of-pocket for the vaccine.
 
Winokur has adopted a similar policy: "While we are seeking reimbursement at least 15 percent above our cost, we are in no circumstances accepting reimbursement for 90734 at less than cost." He recommends that practices avoid losing money with these steps:
 
1. Survey and identify 90734 reimbursement from all payers.
 
2. Notify contracted plans that if the insurer pays less than cost, you will treat Menactra as a noncovered benefit and have the patient (parent) sign a waiver and bill the patient. "The patient can then send the bill/receipt to the insurance plan, or the insurer can direct the practice where to send the patient to receive the vaccine." Winokur says.
 
3. Make sure you participate in a vaccine purchasing program that offers a discount on the cost for Menactra. 
 
4. Include the AAP's letter encouraging Menactra coverage and reimbursement. AAP members can get a copy of "mening_conjugate_vaccine_11.pdf" by going to www.aap.org/moc. Look for the Menactra coverage letter under the "Private Sector Advocacy" link on the main page.

Opt for Alternatives if Noncovered Negotiations Fail

You can only balance-bill the patient as long as the insurance plan considers Menactra a noncovered service. If an insurer considers the service a contracted service, you must accept its reimbursement and cannot bill the patient.
 
When a payer makes Menactra a contracted service, you have two financially sound options:
 
1. Furnish a prescription for Menactra to the patient and have the parent purchase the vaccine from the pharmacy,  Stoller says. When the patient presents to your office with the vaccine, code and charge the administration (90465-90466, Immunization administration under 8 years of age ... when the physician counsels the patient/family ...; or 90471-90472, Immunization administration ... with ICD-9 code V03.89, Other specified vaccinations against single bacterial diseases; other specified vaccination).
 
2. Refer the patient to the health department for the vaccine.