Adding up the Benefits of Billing for Influenza Vaccinations Administered in School-located Clinics Holly Groom1,2, Suchita Lorick1, Kelly Martin3, Robert Moore4, Julie O’Neill4, Rosa Duran4, Bo-Hyun Cho1, Garrett Asay1, Mark Messonnier1 1Oregon Immunization Program, 2National Center for Immunization and Respiratory Diseases, 3Marion County Health Dept., 4Yamhill County Health Dept. March, 2011

Disclosure Information The authors have no financial or other conflicts of interest to disclose The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy

Background Oregon Immunization Program (OIP) provided no-cost influenza vaccine to local health depts. from 2006-2010 for school-located clinics 2010-2011 season marked first year where LHDs accountable for cost of vaccine

Objective Implement a pilot project to bill for influenza vaccine administered in school-settings Track staff time to implement clinics and process billing Evaluate costs as a model for other local health departments

Setting Oregon has established Billables program Process LHDs order vaccine from OIP LHDs enter eligibility code in IIS (3-month timeframe) OIP runs reports to identify VFC eligibles OIP bills for non-VFC doses administered

Provider Services Team – Health Educator Territories Clatsop Columbia Umatilla Tillamook Hood Wallowa Washington Multnomah River Gilliam Morrow Clackamas Sherman Wasco- Yamhill Union Polk Marion Baker Jefferson Lincoln Wheeler Linn Grant Benton Crook Lane Deschutes Malheur Yamhill- ,mostly rural 94% white 14% hispanic ~99,000 people; 25% 0-18 yrs Median income: 55K 13% below FPL Marion- urban rural mix (Salem) 92% white 23% Hispanic ~318K; 27% 0-18 yrs Med. Income: 47K 16% below FPL OR 90% white 11% hispanic Med income: 50K 14% below FPL Harney Coos Douglas Lake Curry Josephine Jackson Klamath

Setting- Marion County Previously held school clinics, but no billing experience in schools 2 schools selected with ~70% eligible for free/reduced lunch K-5- 350 enrolled K-8- 564 enrolled LAIV only; administered by RN/LPN during school hours- parents not req’d Marion has had school clinics since 2006

Marion fee consent form INSURANCE INFORMATION: I will pay cash today Amount:__________ Please bill my health insurance I cannot afford to pay Available in Sp and Eng. Wording is important

7 paid staff-Marion Total paid time: 147.4 hrs Clinic day 39 hours Communications 50.7 hours Consent process 24 hours Training 7 hours Billing 26.7 hours Total paid time: 147.4 hrs Clinic day includes an additional 16 hrs of volunteer time (6 people)

Billing outcomes- Marion # Claims (for 191 persons) Reimb. rate per dose (Total) Expected reimb. Actual reimbursed Outstanding State Medicaid 159 $15 $2,385 Uninsured (VFC) 5 $75 Private- fully paid 33 $30 $990 Private – partial pay; billing client 9 $270 $180 ($90) Private- claim denied; 317 code 12 $360 (360) Total 218 $4,080 $3,635 ($450)

Billing outcomes- Marion # Claims (for 191 persons) Reimb. rate per dose (Total) Expected reimb. Actual reimbursed Outstanding State Medicaid 159 $15 $2,385 Uninsured (VFC) 5 $75 Private- fully paid 33 $30 $990 Private – partial pay; billing client 9 $270 $180 ($90) Private- claim denied; 317 code 12 $360 (360) Total 218 $4,080 $3,635 ($450)

Billing outcomes- Marion # Claims (for 191 persons) Reimb. rate per dose (Total) Expected reimb. Actual reimbursed Outstanding State Medicaid 159 $15 $2,385 Uninsured (VFC) 5 $75 Private- fully paid 33 $30 $990 Private – partial pay; billing client 9 $270 $180 ($90) Private- claim denied; 317 code 12 $360 (360) Total 218 $4,080 $3,635 ($450)

Billing outcomes- Marion # Claims (for 191 persons) Reimb. rate per dose (Total) Expected reimb. Actual reimbursed Outstanding State Medicaid 159 $15 $2,385 Uninsured (VFC) 5 $75 Private- fully paid 33 $30 $990 Private – partial pay; billing client 9 $270 $180 ($90) Private- claim denied; 317 code 12 $130 $360 (360) Total 218 $4,080 $3,635 ($450)

Setting- Yamhill County Previously held school clinics, and some billing experience in SBHC 3 schools selected with ~50% eligible for free/reduced lunch 1 HS- 320 enrolled 2 K-8- 704 enrolled LAIV and TIV; administered by MRC and student nurses (volunteers) during school hours; parents not req’d Held clinics since 2007

Yamhill fee consent form CHECK ALL THE BOXES WHICH APPLY TO YOU  I AGREE TO PAY THE FULL FEE (Stop here. Sign & date bottom of the form)  I HAVE MEDICAID OR OREGON HEALTH PLAN (complete section #1)  I HAVE PRIVATE INSURANCE OR MEDICARE (Please complete both parts of section #2 if appropriate)  I agree to pay fees not covered by insurance  I wish to apply for a reduction in the fees not covered by insurance (complete section 3 also)  I WISH TO APPLY FOR A REDUCED FEE and I DO NOT HAVE MEDICAID/OREGON HEALTH PLAN. (Your fee will be adjusted according to Federal Poverty level guidelines. Please fill out Income Information form)

5.5 paid staff-Yamhill Total paid time: 129.1 hrs Clinic day 11.75 hours Communications 63.75 hours Consent process 27.5 hours Training 6.6 hours Billing 19.5 hours Total paid time: 129.1 hrs Clinic day includes an additional 191 hrs of volunteer time (58 people)

Billing outcomes- Yamhill # Claims Reimb. rate Expected reimb. Actual reimbursed Outstanding State Medicaid 41 $15.19 $622.79 Uninsured (VFC ) 36 $0-15* $470 $435 (35) Private- fully paid $0 Private LAIV– partial pay; 43 $30 $1,290 $745 ($546) now billing for admin fee Private TIV– partial pay; 6 $35 $210 $91 (119) now billing for admin fee Private- claim denied; 317 4 $140 (140) Total 130** $2,733 $1,893 (840) *Sliding scale option used by 7 clients. Payment range $0-$10 ** 35 outstanding claims not included: 9 Medicaid; 26 private insurers

Why claims are denied Provider is out of network/pre-approval not obtained Submitted incorrect or incomplete beneficiary information Client deductible not met

Billing Challenges Difficult for LHDs to establish contracts with private insurers Different reimbursement rates based on eligibility of client; often need to bill clients the balance How to handle students who have access to free vaccine elsewhere? Impossible to anticipate what a client’s plan will reimburse—forces f/u billing for balance due KP will provide free vaccine at clinic but not reimburse. Do you offer vaccine to avoid MO or refer them to their clinic? Don’t want to use VFC vaccine

Staffing costs- Clinic labor Staff time- clinic labor Staff cost- clinic labor Marion 120 hr 42 min (38 min staff time per vaccinee) $3,928 Yamhill 109 hr 36 min. ( 40 min staff time per vaccinee) $5,000 Staffing costs include hourly plus benefits

Staffing costs- Billing labor Staff Billing time Staff cost (billing time) Total reimbursed Net benefit to billing Net benefit to billing/hr spent billing Marion 26 hr 42 min (8.4 minutes staff time per vaccinee) $730 $2,976 $2,246 $86 Yamhill 19 hr 30 min (7.1 min staff time per vaccinee $800 $1,079 $279 (only 130/165 claims processed) $15 To capture costs associated with the billing process, and reduce total reimbursement by staff costs to determine the net benefit to billing in school setting. Total reimbursed= insurance reimbursement amount- amount billed by the imm program for non-VFC vaccine

Summary Considerable time required to fully implement clinics (range 130-147 hours) Billing amounts to ~15-18% of total staff hours (range 7.1-8.4 mins per vaccinee); offers opportunity to recoup costs associated with staff time Reimbursement rates vary widely between and even within private insurers

Considerations Self-reported time on biweekly web-based survey; subject to recall bias and differences in how staff track time Other costs associated that are not included; other benefits from vaccinating these students are not considered Only conducted in 2 counties; different geographic areas may have different outcomes

Conclusions With an established billing process in place, OR is uniquely prepared to introduce billing in all vaccination settings Implementing school clinics is resource intensive; billing can offset some staff costs IF possible, establish contracts and agreements (roster billing) with insurers to minimize processing time and maximize reimbursement Need for standards around allowable billing practices; consult with experienced counties

Acknowledgements Mimi Luther, Vaccine Manager, OIP Collette Young, OIP

Holly Groom heg4@cdc.gov 971.673.0562 Questions? Holly Groom heg4@cdc.gov 971.673.0562