1. Lessons Learned: Billing Insurance at Local Public Health Units in North Dakota
Molly Sander, MPH
Immunization Program Manager
North Dakota Department of Health
Introductory Slide

2. North Dakota Population: 646,844 5.6% American Indian.
33% of ND children are VFC-eligible.
Rural State:
9.3 people per square mile (U.S. = 79.6).
Lack of access to health care in rural areas.
North Dakota Overview

3. North Dakota Local Public Health Units
28 autonomous local public health units (LPHUs).
One clinic in each of the 53 counties in ND.
Mixture of single city/county, single county, or multi-county districts.
Administered 50,735 doses to children 18 and younger in 2010 (excluding H1N1).
31,464 doses (62%) to insured children.
North Dakota Local Public Health Units
Total doses administered in 2010: 341,254 (excluding H1N1). LPHUs gave 14.9%.

4. Vaccine Supply Policy
As of January 1, 2008, North Dakota became a VFC-Only Vaccine Supply Policy State.
VFC-Only: supplies vaccines for administration to Vaccines For Children eligible children.
Medicaid-eligible, American Indian/Alaskan Native, uninsured, or underinsured.
Previously, North Dakota was a Universal State: supplied vaccines for all children, including the insured.
In order for LPHUs to continue to immunize insured clients, a billing mechanism had to be developed.
Vaccine Supply Policy History
In 2010, LPHUs were responsible for administering 14.9% of doses administered to children 18 and younger in ND (excluding H1N1). In 2010, LPHUs were responsible for administering 13.7% of doses administered to insured children 18 and younger in ND (excluding H1N1).

5. NDIIS Billing System
A billing system was added to the North Dakota Immunization Information System (NDIIS).
Only accessible to LPHUs.
24 of 28 LPHUs originally used the NDIIS billing system.
Four chose not to bill insurance.
The NDIIS was developed and is currently maintained by Blue Cross Blue Shield of North Dakota (BCBSND).
North Dakota Immunization Information System (NDIIS) Billing System.
Of the three LPHUs that chose not to bill, three only offer VFC vaccines and one does not immunize children.

6. NDIIS Billing System
When LPHUs enter a dose for an insured patient into the NDIIS, an insurance claim for vaccine cost and administration fee is generated and sent to BCBSND weekly.
If a BCBS client, BCBS reimburses LPHU (weekly).
78.4% of insured clients at LPHUs are BCBSND.
If non-BCBS client or if there is a BCBS member liable portion, the claim is transferred to the University of North Dakota (UND) for billing to other insurance or to the patient, if needed.
NDIIS Billing System.
LPHUs bill for all insured children and BCBSND insured adults.
LPHUs also bill Medicaid and Medicare Part B (have always done this).

7. North Dakota’s Billing System
BCBSND reimburses LPHU weekly for BCBS clients
LPHU administers vaccine, enters billing info into NDIIS
Billing info is electronically transmitted to BCBSND weekly
BCBSND sends BCBS member-liables and non-BCBS insurance claims to UND
UND Reimburses the LPHU monthly (after $2 administration fee is withheld)
UND Bills non-BCBS insurance and patients for member-liables
Flow Chart of ND Billing System

8. NDIIS Billing System
LPHUs are reimbursed for vaccines and administration fees prior to UND being reimbursed by client or insurance.
UND reimburses LPHUs monthly.
UND keeps $2.00 of each administration fee billed for expenses and unpaid claims.
Includes administration fees for BCBSND vaccines and commercial claims.
NDIIS Billing System

9. NDIIS Billing Screen Screen shot of the NDIIS Billing System.
CPT codes for vaccines and administration fees are coded in the background, so LPHUs don’t have to worry about knowing codes.

10. NDIIS Billing Screen NDIIS Billing Screen.
Once billing information is added once for a patient, it is automatically populated the next time the patient comes to the clinic. LPHUs only have to enter data, if billing information has changed.
When the health units order private vaccine, they can log the lot number and cost per dose into the NDIIS, so they don’t need to enter that information each time a dose is administered.

11. NDIIS Billing Screen
System allows for primary and secondary insurance.

12. 2009 LPHU Billing Results
The LPHUs billed insurance for $1,814, in vaccines and administration fees.
Reimbursement received for $1,686, (92.9%).
$1,477, BCBSND (91.3%).
LPHUs received reimbursement for $1,617, (89.7%).
$69,052 withheld for UND services ($2 per administration fee).
2009 LPHU Billing Data
Reimbursement received is either through insurance or member liable payment

13. 2010 LPHU Billing Results
The LPHUs billed insurance for $1,964, in vaccines and administration fees.
Reimbursement received for $1,810, (92.2%).
$1,605, BCBSND (81.7%).
LPHUs received reimbursement for $1,753, (89.3%).
$56,966 withheld for UND services ($2 per administration fee).
2010 LPHU Billing Data

14. 2009 LPHU Billing Costs Large LPHU in ND Small LPHU in ND
Total Cost: $227,050
$149,140 in privately purchased vaccines.
$23,965 for personnel to manage vaccine inventories.
$10,913 for NDIIS data entry.
$31,418 for billing management.
$11,614 for UND.
Total Reimbursement: $274,478.83
Revenue: $47,428.83
Small LPHU in ND
Total Cost: $56,160
$22,437 in privately purchased vaccines.
$2,870 for personnel to manage vaccine inventories.
$26,450 for NDIIS data entry.
$3,175 for personnel for billing management.
$1,228 for UND.
Total Reimbursement: $28,764.54
Revenue: ($27,395.46)
Billing Costs for 2 North Dakota LPHUs in 2009
The assessment of costs was not standardized.
The large LPHU made money and the small LPHU lost money. A better cost analysis needs to be conducted in the future to understand actual costs and revenue.
The LPHUs also receive federal immunization dollars through contracts. In 2009, the state of North Dakota appropriated $1.2 million to cover losses for LPHUs related to administering immunizations.

15. Member Liables BCBSND: Other Insurance:
In 2009 and 2010, only 1% of claims had a member liable amount.
Other Insurance:
For 2009, 76.4% of commercial insurance was not covered.
For 2010, 61.9% of commercial insurance was not covered.
UND bills patients for member-liable portion.
No one has refused to pay and been sent to collections.
Member Liables: claims for which a patient must pay a portion.

16. PAR Agreements
All LPHUs that are billing insurance signed a Participating (PAR) agreement with BCBSND.
Requires that LPHUs bill for all clients with that insurance.
Without a PAR agreement, some insurance companies consider LPHUs “out of network” and do not reimburse for the cost of vaccine or the administration fee.
Does not make the child VFC-eligible.
PAR Agreements

17. PAR Agreements The need for PAR agreements varies by LPHU.
The LPHUs billed 116 different insurance companies in July 2009 – June 2010.
Insurance companies vary in different areas of the state.
Individual LPHUs must determine the need for PAR agreements with insurance companies.
PAR Agreements
% out of network determined by UND reports. Out of network units for non-BCBSND companies divided by the number of units billed for non-BCBSND companies.
Negative of PAR agreements: must bill insurance

18. Third Party Billing
In 2010, UND was paid $56,966 for processing 28,483 services.
In 2010, UND billed $215,241 in member liable, private pay and other commercial payers.
It collected and paid LPHUs $147,961 and retained $56,966, or approximately 38.5% of revenue received from commercial and BCBSND member liable claims (3.1% of total revenue), to cover the cost of the billing/collection service.
Third Party Billing
28,483 claims: although a significant portion of the claims were first dollar claims paid by BCBSND which means there was no work performed on the claim by UND
Of the 5 health units using their own system, 4 are using Ahlers, 1 is using SAGE
2 other LPHUs: KIPHS and Champs

19. Third Party Billing
The ND Department of Health and LPHUs are exploring other options for third party billing.
As of January 1, 2011, 5 LPHUs have started using their own internal billing system.
2 others will be using internal systems in the near future.

20. LPHU Billing Lessons Learned
Insurance is complicated.
Various coverage for immunizations.
PAR Agreements.
LPHUs considered “out of network” for some plans.
Required to bill insurance if PAR.
A negative for mass clinics, school clinics, and emergency response.
Require legal review.
LPHU Billing Lessons Learned

21. LPHU Billing Lessons Learned
Difficult to determine underinsured children.
Parents don’t know coverage for vaccinations.
Recommend using private vaccine if unknown and exchanging VFC dose later if insurance doesn’t cover vaccine – complicated and time consuming.
Cash flow issues at smaller LPHUs.
Third Party Billing: may be more expensive than purchasing an internal billing system in the long run, depending on the number of doses billed.
LPHU Billing Lessons Learned

22. LPHU Billing Lessons Learned
Time Consuming.
LPHU staffing required for billing.
Hired a full-time coordinator for the LPHU billing program at the NDDoH.
The NDDoH, LPHUs, BCBSND, UND, and other stakeholders continue to meet monthly to discuss billing issues.
For the first two years, weekly meetings were required.

23. Advantages of LPHU Billing
The LPHUs are able to continue to serve insured clients.
Further cost analysis is needed to determine costs and revenue from immunization billing.
Federal 317 vaccine that was previously used for insured children is now used for special projects and uninsured and underinsured adults.
Advantages of LPHU Billing.

24. Acknowledgements Laura Olson, North Dakota Department of Health
Blue Cross Blue Shield of North Dakota
Brandi Melicher, University of North Dakota
North Dakota Local Public Health Units
William Riley and Associates
Acknowledgements

25. Molly Sander, MPH Immunization Program Manager
North Dakota Department of Health
Contact Information