Submitted on Mon, 2015-06-01
By SMART Health Claims

From 2000 to 2012, vaccines were added to the schedule and the cost of immunizing one child from birth through age 18 increased nearly 500%.

Vaccination costs are climbing. According to the CDC, in 1990, it cost $70 to vaccinate one child in the public sector from birth to age 18 for diphtheria, tetanus, pertussis, measles, mumps, rubella and polio. From 2000 to 2012, ten different vaccines were added to the schedule and the cost of immunizing one child from birth through age 18 went from $370 in 2000 to $1712 in 2012, an increase of nearly 500%. 

Additionally, data from a survey by the National Association of County and City Health Officials found that 19% of US local health departments made cuts to immunization services in 2011.


The CDC Public Health Law Program recently released Health Department Billing for Immunization Services: A Menu of Suggested Provisions, in light of the widening gap between declining funding and rising vaccination costs. The document – one that we regard as an essential handbook for local health departments - provides information about billing-related legal issues, as well as approaches to consider when addressing them.

As local health departments navigate an environment of dwindling funding, many are seeking a way to build a seamless billing program to generate sustainable revenue and continue to serve their communities. To do this effectively, it is necessary to understand the laws that surround the billing process.

Billing for Vaccines: 7 Legal Areas to Consider

The document outlines the following potential legal matters to consider when billing for immunization services:

  1. General Authority to Bill: Health departments considering billing for immunization services must determine whether the department has the legal authority to bill patients or third parties and whether there are any restrictions on that legal authority.
     
  2. Revenue Streams: Because a health department’s motivation to bill for services is to generate income, laws governing whether they are allowed to keep the revenue they generate can affect their ability to cover the expenses of setting up a third-party billing system and improve the delivery of health services they provide.
     
  3. Credentialing:  Health departments must credential its medical staff through an evaluation process before it can begin to bill and receive reimbursement from public or private insurance payers for health services. Credentialing is increasingly difficult when different insurance companies require different information and use varying procedures to gather information from a provider.
     
  4. Contracting: Contracting with third-party payers for services at an agreed-upon rate is one of the most difficult challenges in building a successful reimbursement system. Establishing specific contracting state laws makes it easier and more attractive for insurers to contract with public health clinics.
     
  5. Scope of Practice and Billing Codes: Claims submitted to third-party payers from health departments are typically required to contain accurate completion of information about the patient, including diagnostic and procedure codes.
     
  6. Public Health Clinics as In-Network Providers and Any Willing Provider Laws and Public Health: Willing provider laws require that insurers, managed care organizations and other health plans give all physician (and sometimes other providers) membership on their preferred provider list if those physicians are willing to meet the membership terms and conditions and if they offer the same type of medical service that the insurers or managed care organizations offer their subscribers.One way to facilitate billing by public health clinics is to require insurance companies to treat such clinics as in-network providers. 
     
  7. Essential Community Providers: The Affordable Care Act (ACA) mandates that any qualified health provider (QHP) who operates within the Health Insurance Marketplace must have a sufficient number of, and appropriate geographic distribution of essential community providers to ensure reasonable and timely access to low-income, medically underserved individuals in the QHP’s service area.

 

Billing for Vaccines: 2 Key Takeaways for Local Health Departments

  1. Consider the cost benefits and burdens:  An assessment of total costs, staff investment, and potential reimbursement can help drive the development of a billing program. To make vaccination reimbursement worth the expense of billing, storing, and management, it might be necessary to bill for administration, vaccine cost, and other services related to vaccine delivery such as counseling. Billing for other public health services will help bring in additional reimbursements. 
     
  2. Share this information with your LHD legal counsel: When planning or implementing billing programs or seeking legislative support for new initiatives, this menu of provisions serves as a valuable resource for any legal counsel of a local health department.It is important to keep in mind that any legal provisions must be considered within the policy and legal frameworks of the jurisdiction.

 

While this document is incredibly helpful for local health departments, it is only a resource and does not constitute legal advice and does not represent the views of the Centers for Disease Control and Prevention or the Department of Health and Human Services and should be used in conjunction with advice from legal counsel. Laws will continually change and evolve in this area and the more familiar LHDs are with the laws relevant to their individual areas, the more equipped they will be to implement effective billing practices and avoid cutting vaccination services.
 

Our SMART Health Claims team of public health billing experts are up-to-date on changes and evolutions of laws within each state and will help you understand federal, state and local. Schedule a meeting today for actual legal advice, so you can generate sustainable revenue that will fund vital vaccination services to your community. 
 

 


Upp Technology is a nationally recognized leader in revenue cycle management solutions for public heath, community health, and specialty healthcare providers. Our core mission is to help public health agencies develop new sources of revenue so they can provide essential health services that protect the health and welfare of their communities.
 
Our SMART Health Claims solutions combine a depth of public health expertise with cutting-edge technology to create innovative billing solutions that maximize reimbursements from Medicaid, Medicare, and private insurance and developing new, sustainable revenue streams. Through our billing consultants and innovative cloud solutions we have partnered with more than 300 Federal, State and County level public health organizations nationwide.