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Answer: There are several reasons why you cannot and should not treat patients as cash patients for flu shots. If the shots are a covered service, you have to bill the insurer for them. Many managed care contracts do not allow a provider to "balance bill" a patient above what the plan will pay for a covered service, and most HMOs and PPOs pay for flu shots. All Medicare HMOs pay for the shots because the managed care version of Medicare must cover at least what the traditional Medicare fee-for-service program does, and it covers flu shots. The Medicare program prohibits participating providers from charging a Medicare beneficiary more than the allowed fee for a service. And, in the case of flu shots, Medicare pays 100 percent of the allowance, just as it does for laboratory services. The Medicare reimbursement is about $11 for the flu shot and its administration.
For patients for whom the shot is a noncovered service, you should recognize that providing this service on a cash basis can be very competitive, especially when grocery stores and drugs stores are providing the shots for $5. So, even if there is a patient subgroup that you could treat as cash patients, providing flu shots on a cash-only basis may not be the moneymaker you anticipated. |
