Wiki Vfc question - help!!

[LADY_SETSUNA_CJ]

Once again I come to the forums for an answer to a question I seem to run into on a regular basis, as I am a Medicaid (AHCCCS) biller at a pediatrics office.

Scenario:
A patient comes in with a primary insurance of lets say BCBS with a secondary insurance of AHCCCS. The parent states on the consent form they have 'insurance that covers immunizations therefore do NOT qualify for VFC' so we provide the patient with stock immz at regular price (non VFC immz). Then we receive a primary EOB applying the immz to deductible. We of course bill to secondary and receive a denial stating 'procedure code is inconsistent with the modifier used or a required modifier (SL) is missing'. Of course the later being the issue.

Question:
If we did not use VFC immunizations, technically the SL modifier would be inappropriate considering the SL modifier is specifically for 'state supplied immunizations'. Of course AHCCCS will not pay unless this modifier is applied to the claim. Do we append the SL modifier for a lesser payment or.... write off the claim???

I have asked this question a zillion times to reps, peers, etc and noone can give me a straight answer. But I can't be the only person who has run into this issue. We did find a passage on the CDC website once stating that if we billed a primary insurance and they did not pay we could 'replace' our stock immz with VFC immz and bill out the VFC price with the SL modifier but when speaking to our AHCCCS rep she informed us that we could not do this but couldn't provide us with an answer or solution to our problem.

Any input would be greatly appreciated. Thanks.

 

[cingram]

ok you confused me and I did vfc a lot. vfc is allowed for people on ahcccs, patients with no insurance and patients with a high deductible. if ahcccs is 2ndary they will not pay on the admin. When you put the sl on the vaccine they are including the admin fee in there as well. no matter what the admin will have to be a writeoff for ahcccs. what I did when ahcccs was secondary was this and this is for using vfc. I put the vaccines and the admin in the system but put a 0 charge on the vaccines and make sure they did not go on the claim since they were supplied by the state and put that with the sl just so I knew what was done. (company policy) then I would bill out the admins only. Again this is for VFC vaccines where ahcccs is 2ndary. Also remember if they have ahcccs as a secondary they can revieve VFC. The company I worked for I had to know this very very well. I billed for 3 peds offices.

Sorry I forgot to put in there that is was AHCCCS that told us that when they are secondary and vfc is used to bill the admins only.
In this situation since you did not give VFC you would have to write the rest off. AHCCCS WILL NOT pay for it. I have faught this many times and they will only pay for VFC no matter what

 

[LADY_SETSUNA_CJ]

I'm aware of how to bill VFC. It's basically the immunization code billed out as the 'admin' price with a SL modifier and no administrative codes. That much I am clear on. The issue isn't how to bill the VFC... let me try to re explain it. We occasionally have patients that have a commercial carrier as primary and AHCCCS as secondary. We bill out stock immunizations at clinic price, not VFC stock, because the offices 'assumes' the primary insurance will pay for the immunizations (we post verify insurance eligibility) and the parents aren't always aware of what their insurance will pay so they sign 'covers immz NOT VFC eligible' on the waiver.

After billing the the primary insurance they come back and apply the immunizations to ded/coins/noncovered we in turn bill AHCCCS as secondary. They of course do not pay because there is no SL modifier, which is because there was no VFC givin, but actual clinic stock at clinic price.

My delima is how do we get paid by AHCCCS if we did not use VFC??? Personally I feel appending a SL modifier is incorrect being as VFC was not used for the immunizations. Am I wrong??? I know a patient is VFC eligible simply by having AHCCCS be it secondary or primary but in these perticular cases VFC was not given in place of our clinics stock.

Hope this makes better since.

 

[cingram]

oh in that case AHCCCS WILL NOT pay if VFC was not given. This would have to be a write off. That is why the offices I billed for gave VFC when AHCCCS was secondary. I think you end up getting paid more this way too.

 

[LADY_SETSUNA_CJ]

Thank you for your input. I have brought it up to my office manager and we are going to implement a new policy stating if a patient has an AHCCCS policy as secondary they receive VFC regardless of primary coverage. This way the above problem should no longer be an issue.

In the process of searching for this information I also found out we cannot send VFC (non AHCCCS) patients to collections for nonpayment of VFC charges on the CDC website. Which makes perfect sense when you think about it.

 

[cingram]

yes. VFC is very tricky and it took me a while to understand it. also doing it this way it doesnt make it look so bad since you wont be writting off a lot of money.