1. 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

2. 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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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)

10. 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)

11. 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)

12. 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)

13. 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)

14. 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 enrolled
LAIV and TIV; administered by MRC and student nurses (volunteers) during school hours; parents not req’d
Held clinics since 2007

15. 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)

16. 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)

17. 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

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

19. 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

20. 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

21. 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

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

23. 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

24. 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

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

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