Don't Let Insurers Pay Less Than AWP for 90734
Published on Tue Jun 21, 2005
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 [...]
