CMS Updates Vaccine, Medication Payment Files Retroactive to July 2009

Onus Is on Physicians to Recoup Money Owed Them

September 27, 2010 03:35 pm Sheri Porter

The AAFP has learned that CMS is making it the responsibility of individual physicians to ensure that billing adjustments arising from new pricing for vaccines and other medications are made.

Earlier this year, CMS released new pricing files for vaccines and medications covered under Medicare Part B; those changes were effective on July 1, 2010, and were retroactive to July 2009. However, it appears that CMS is requiring physicians to point out any necessary billing adjustments to their Medicare carriers to ensure proper payment.

In comment number 6805.2 of its written instructions to Medicare contractors(www.cms.gov), CMS specifically states, "Contractors shall not search and adjust claims that have already been processed unless brought to their attention."

CMS did not respond to AAFP News Now's questions regarding whether this is standard procedure when prices are adjusted.

Cynthia Hughes, C.P.C., an AAFP coding and compliance specialist, recommends that physicians review their billing records to compare how much Medicare paid them for vaccines and other medications during the time period in question to the rates in CMS' revised pricing files(www.cms.gov).

"Unfortunately, CMS replaced the old average sales price, or ASP, files with the updated version, so there's not an easier way for physicians to compare the old and new rates for vaccines and medications they provided in the practices," said Hughes.

Vaccines that may be affected by the new pricing include

  • pneumococcal polysaccharide,
  • seasonal influenza,
  • hepatitis B,
  • a tetanus booster when indicated due to injury, and
  • rabies, although this is rare.

Physicians who discover they are owed money should contact their Medicare contractors for instructions on how to get those claims reprocessed, said Hughes. She cautioned against refiling claims without prior contractor instructions, however, because the claims could be rejected as "duplicate" claims.

Solo FP Willard Snyder Jr., M.D., of Brunswick, Ga., said he won't necessarily be sifting through his billing records to figure out if CMS owes him money for past-purchased vaccine. In particular, he points to the pneumococcal polysaccharide vaccine as an area that may not be worth his time.

Although the average pricing code for the pneumococcal polysaccharide vaccine was updated by CMS from $37.61 to $43.25, that's still less than the $43.81 Snyder paid per dose for the 10 doses he purchased. "Even though I'm losing less than a dollar on each vaccine I purchase now, the government shouldn't expect me to take a loss," said Snyder.

According to Snyder, his only recourse is to stop providing the pneumococcal vaccine for his patients, a decision grounded on principle and one that he is strongly considering. "That's my line in the sand; I'm not going to continue to lose money," he said.

But Snyder is concerned about his patients. About 25 percent of Snyder's patient population is of Medicare age, and he worries that if he is forced to send them to the health department for the pneumococcal vaccine, they won't get vaccinated at all. "I'm afraid they won't want to make the extra trip, or they'll go shopping and just forget about that stop at the health department," said Snyder.

The real risk is that patients who don't receive the vaccine will fall ill and end up in the hospital, he added.

Snyder did note that although the price difference for the pneumococcal vaccine may not be worth his time and effort to recoup, the increase in price for the influenza vaccine could make the treasure hunt worthwhile, particularly because he purchased more than 100 doses during the period indicated.


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