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A summary of presentations from the weekly Summit partner webinars

August 17, 2023 – The latest Summit Summary

L.J Tan (Immunize.org) – Update on August 2 meeting hosted by Summit in Washington, D.C.
Billing and Coding Approaches/Tips to “Get More Vaccines in Arms” – Jennifer Tinney (TAPI)
Department of Veterans Affairs: Progress with Veterans Health Administration reporting immunizations to the IZ Gateway – Pamela Belperio (Department of Veterans Affairs)
Billing and Coding Task Group Update – Carolyn Bridges (Immunize.org)
Announcements

L.J Tan (Immunize.org) – Update on August 2 meeting hosted by Summit in Washington, D.C.

Address upcoming fall season with three respiratory pathogens: RSV, COVID-19, and influenza
Helping providers find a way to implement all three vaccines for patients’ maximum protection
Three subgroups working to create three educational products that will launch after Labor Day
- One page document specific to the fall 2023 season to help providers decide the best option to begin giving the three vaccines; for example, co-administration, one at a time, or referring to another provider who can administer the vaccines
- One page document with talking points to provide clinicians with the necessary information so they are confident talking to patients about the three vaccines
  - Deliver clear, concise, and competent recommendation for the vaccines
- Personalized vaccination action plan
  - One year calendar to map out vaccination aligned with well care visits
  - Once patient has received recommendations for vaccines, patient and provider can sit down together and fill out the plan
- Meeting summary will be released soon
- Email any questions to L.J Tan at Tan@immunize.org

Billing and Coding Approaches/Tips to “Get More Vaccines in Arms” – Jennifer Tinney (TAPI)

Jennifer Tinney, Program Director, The Arizona Partnership for Immunization (TAPI), a statewide immunization coalition, gave a presentation on billing and coding approaches as well as tips to “Get More Vaccines in Arms.”

(VIEW SLIDES)

Arizona

Seven to eight million people; 50% live in two urban counties
International border of Mexico and boarders five states
One of the largest reservations in the nation
Many snowbirds (winter visitors) that impact local providers and community health centers
Crossover of people into the state to get vaccines or healthcare

More people (kids and adults) getting county health department vaccines (2008)

No state funding for vaccines
County health departments required to provide immunizations for school at no cost
- Costing county health departments $1.79 million/year
- VFC vaccine cannot be given to privately insured children
No services for adults

Financing for vaccines in Arizona –high level discussions

Brought together stakeholders in the community
- State and county public health
- Primary care and pediatric offices
- Health plans
- Manufacturers
Addressed decreasing immunization rates and how to increase the number of kids going to county health departments
Addressed overload of health departments with wait lists
Developed a set of recommendations that the county health departments should begin billing for immunizations for kids that have now expanded to adults
Work on increasing reimbursement rates to at least 130% above retail cost of the vaccine to help private providers continue to carry and manage vaccines in their offices
Train vaccine providers on vaccine business and practices, as well as flexible buying

TAPI has a program that does billing on behalf of the public health department immunization clinics

Looks at reimbursement and cost
Advocate for changes in health plans that impact private providers
- By making billing and reimbursement smoother for primary care providers, less kids will needto be seen in county health departments
Contracting and claims processing
Monitor payment system
Bill for vaccine, administration fee, STI treatment, family planning, behavioral health for many of the county health departments

In 2018, TAPI did an environmental scan on what’s happening in the adult vaccine delivery system.

Unable to put in standing orders because technology requests to HR’s take too long
Problems with adult payments
- Low reimbursement
- More complex with adults due to shared clinical decision making and who could bill
- Challenges with which providers were contracted to give vaccines and prescriptions at the pharmacy had lower payments (paid dispensing fee instead of administration fee)

Outbreaks impacting payments

Gains in the coverage started with the hepatitis A outbreak before COVID-19
Since COVID-19, things have gotten better
Immense gains as a result of the outbreaks
- More understanding of the importance of immunizations in both primary care and in safety net clinics
- Changes in networks, policy, and payments
Monkeypox reinforced need for keeping COVID-19 policies
However in March, only 37% of stakeholders surveyed felt vaccine payments adequately cover the purchase, insurance, and staff costs of vaccines

Gaps create missed opportunities (2023) – combination of factors

Patient factors
- Vaccine fatigue – people tired of talking about vaccines
- “Belligerent” now a word used when talking about people with hesitancy
- Few options for uninsured (317 funding in AZ exhausted in 3 months)
- Until the Inflation Reduction Act, there was noo out-of-pocket costs fix for patients insured Medicare Part D
  - No out-of-pocket costs in the pharmacy
  - Some out-of-pocket costs for other insured
- Payment system
  - Complexities of Part D billing in a medical office; referrals are decreasing
    - Complexity and payment structures impact strong provider recommendation and access to vaccines
    - Shrinking plan networks
  - Many immunizers limited to flu, pneumococcal, and COVID-19 vaccines ; can’t give everything a patient needs
  - Seeing more plan denials for complex patients after COVID-19
    - Patients being sent to county health departments for vaccines the primary care can’t cover because can’t show “medically necessary”
  - Don’t have records and relationships with many OBGYN’s as many are not contracted as primary care providers so they are not able to bill for vaccines
  - Tricare denying COVID-19 claims based on the dose number given and not documented, for example dose when given at a drive-in clinic
- Office factors
  - Vaccine conversation fatigue
  - Loss of primary care providers during COVID-19
  - High turnover rate – 30% of staff vacancy

What it takes to give a vaccine in an office

Payment for administration fee is $15–25
Payments from the health plans don’t always cover the vaccine purchase price, which includes the management and initial outlay for the vaccines
Offices have to weigh out good patient care
Patients taking more time for complex medical issues so there’s not enough time for the staff to do everything involved, like multiple codes and clinical presentations

Public health – getting vaccines in arms

Patients are not turned away
No deductibles or co-pays are collected
Safety net counties are reimbursed about 10% above the cost of the vaccine plus the administration fee, so they can handle complex billing
Partners work together to advocate and make changes for those sustainable payment solutions
Outreach by public health
Partners are able to work together – public health reserve core structure to support more clinics
Unrestricted public health funds to purchase vaccines

Billing for county health departments and non-traditional partners

Partners: county immunization clinics, school districts, fire departments, national guard, lab (testing to vaccine), hospital systems, medical volunteers
$20 in COVID-19 claims processed, close to one million claims

Moving in the right direction

Part D first dollar coverage stretches public health funding for uninsured patients
Pharmacy administration payment went to an admin fee instead of the lower dispensing fee
Gains with Medicaid payment on vaccine
Admin fee and new counseling codes (talk to a patient but don’t give a vaccine; https://www.izsummitpartners.org/content/uploads/2020/11/naiis-cpt-code-scenarios.pdf)
- More patients requiring 2–3 vaccine or counseling sessions with their healthcare provider before getting the vaccine
- Having these codes paid will be a change for the offices – higher revenue for offices that can provide adult routine vaccines
- Keeps offices in business and bring in staff
- Records in registry shows where patient got dosed

Vaccine billing resources

Resources and provider and patient education
Shared clinical decision making – what vaccines should look like outside the age range
Adult Current Procedural Terminology: Coding Case Scenecios
COVID-19 Insurance Information for Patients and Staff
whyimmunize.org

QUESTIONS

Q: You talked about pharmacists being able to now charge an administration fee instead of a dispensing fee, is that specific to Arizona or how or are multiple states now able to do that?

Jennifer Tinney: CMS made a statement years ago that they could, and state Medicaid programs adopted that at different times. Ours took quite a while to put that in place. It wasn’t until COVID. I think some pharmacies are still facing the same thing and it depends on our contract with those private health plans whether it is a drug benefit or a health benefit. At least having our Medicaid patients to be able to be sent to the pharmacies knowing the pharmacy was going to have it in stock and that they were paid appropriately with an admin fee. At the time it was something like a $3 fee for dispensing, so it was low given everything you do with vaccines.

Q: I wanted to ask you about the account billing for counseling provision that you said could be very important and it is becoming important. On your end is that just for standalone counseling for children or does that also apply for adults?

Jennifer Tinney: In our state with Medicaid, with both adults and children, it came into play with COVID. It was COVID-specific for a while. Now I my understanding is that there are new CMS codes that have been approved for counseling and I have not followed up to see if that language does include adults. Someone else might be more of an expert, but for our state Medicaid does include adults as of now.

Link to resources on using the new CMS codes for time billing, which can be used to cover counseling for adults:

www.izsummitpartners.org/content/uploads/2020/11/naiis-cpt-code-scenarios.pdf

Department of Veterans Affairs: Progress with Veterans Health Administration reporting immunizations to the IZ Gateway – Pamela Belperio (Department of Veterans Affairs)

Pamela S. Belperio, PharmD, BCPS, AAHIVP, National Public Health Clinical Pharmacy Specialist, Deputy Director Health Solutions (12POP2), Population Health, Department of Veterans Affairs, gave an update on the VA’s progress with immunization exchange using the CDC IZ Gateway.

(VIEW SLIDES)

Veterans Health Administration Immunization reporting

Prior to 2022, VA had no enterprise-wide, electronic way to report and query immunization data from state and jurisdictional immunization information systems (IIS)
This data gap became heightened during COVID-19 pandemic and it became clear that the VA needed an integrated way to get immunization information out to the community providers where many veterans were getting COVID-19 vaccination
Providers needed to do proper outreach to veterans to make sure getting vaccinated
Pressure and requests from federal agencies from state and local jurisdictions to share immunization data
Many states have laws that mandate reporting of certain immunizations, not able to meet the requirement due to lack of an enterprise-wide electronic way to get the information to state registries

Goal

Quickly deploy a VA-wide solution across all the states and VA medical centers with the CDC’s bidirectional immunization data exchange using IZ gateway that provided a centralized automated infrastructure to quickly ramp up the electronic communication and immunization data exchange

VHA Gateway Immunization Information Exchange

This provided a national automated solution to have electronic communication with all of the 62 VA jurisdictions
- Took over a year to get agreements signed
- Meet privacy and legal requirements
CDC controls IZ Gateway, allows for one single, seamless connection to the IZ Gateway so any state or jurisdiction that’s also connected will be able to have bidirectional immunization exchange
- In every state and jurisdiction, when an immunization is documented, it gets pushed into a central hub and the information is sent through the IZ Gateway which is routed to the appropriate state or jurisdictional IIS based on where that VA is located
- Able to get the information back and route to the appropriate VA medical center where the patient has an upcoming primary care appointment
Both VHA HER Systems are integrating with the IZ Gateway
- VistA – Legacy EHR
- VA is transitioning to an Oracle/Cerner Millennium electronic health record
  - Currently five sites

VHA IZ Gateway Immunization Project Status

How does the immunization exchange with the VHA occur?
- There has to be a signed IZ Gateway multi-jurisdictional provider agreement (PGA) and CDC data use agreement
- CDC works with state to make sure they are able to connect with IZ gateway
- Testing scheduled
- Initiate automated reporting
- Testing sessions
  - Test about 1,150 patients in every state
  - Test cases are run live for evaluation
  - Date to go live
- Working on querying phase
  - Acquiring data from ISS so that that information is available within the VA’s medical record
  - More comprehensive picture of what immunizations the veterans have received in the community so as to not double up and can forecast for future immunizations
- Status of states and jurisdictions
  - Live with automated query and reporting – 37
  - Live reporting (query scheduled) – 4
  - Awaiting testing and go-live – 6
  - Awaiting agreements – 7

Immunizations reported by VA via IZ Gateway per month in 2022 and 2023

Live in May 2022
Have reported over 2.8 million vaccinations to the state registry
Live with query in June 2023, we have alreadyidentified a million vaccinations that veterans received in the community that we weren’t aware of
Most commonly reported immunizations are COVID-19 and flu in the months of October, November, and December
- Big influenza campaign in October lead to 471,000 flu vaccinations reported to the states
In the other months most common immunizations were either COVID-19, zoster, pneumococcal, and Tdap.

VHA Gateway project go-live timeline

Focusing on reporting out—getting the community and state and jurisdictional immunization registries with all veteran immunization information
Several states have not signed the agreement so working with VA central office leadership to reach out to governors of those states to emphasize the importance of the bidirectional reporting for the community providers and for comprehensive veteran care

QUESTIONS

Q: Do any of the territories have IISs and will the VA be able to connect with them, as well?

Pamela S. Belperio: We are pursuing any tariff state or jurisdictional territory that has an IIS and medical center, clinic, or federal health center where it would be useful to make sure those providers get the information for our veterans as well as providers get that information.

Q: Are immunizations obtained outside the VA centers automatically loaded into the IZ Gateway platform? How often is this information obtained from outside immunization locations loaded into the IZ Gateway?

Pamela S. Belperio: Whenever a veteran goes to a community provider or another provider in the state, whether it’s a local pharmacy or a health organization, and if those providers are reporting those immunizations to the state immunization registry, patient hasn’t opted out or it’s automatic. It’s a little bit different between the states. Any information that is in the state immunization registry, if that state is connected to the IZ Gateway when we query, we get that information back when we report it at the time that the vaccination is administered within the VA healthcare center or the clinic. Right at the time that the provider documents that encounter it gets sent in real time essentially to the IZ Gateway and is received by the IIS so the reporting out of vaccinations from the VA and to the community through the IZ Gateway is in real time. The way we have our query set up is that the night before patients who have an appointment scheduled at one of our VA medical centers we send out those queries to the state registry so that we can get that information back so that it’s there at the time that the provider is face-to-face, virtual, or on the telephone with the patient for the first appointment.

Q: is there a way to tell the total number of eligible veterans for certain vaccines and who among that population has not yet received those vaccines?

Pamela S. Belperio: Internally in the VA we do have that information. We have internal dashboards that have all of the veterans that are seen at a particular VA medical center, and we track the immunization rates for most vaccinations so we can look at a patient panel and identify which veterans have received an immunization either within the VA or from outside. Outside information comes in through the IZ Gateway or through somebody manually entering the information. We can identify which veterans have not yet gotten their required pneumococcal vaccine based on their the ACIP recommendations so that we can outreach to those patients. The IZ Gateway is just a router and many of the IISs also do forecasting so that that information is available to the outside community providers. But now that we’re providing our VA information to those forecasters, they’ll be much more complete so that outside community providers will have that information more readily available. Inside the VA system nationally we can track to see who is due for a vaccination. There are some facilities that will send out letters to those veterans saying they are past due for a vaccination or that a vaccination is coming up and to make an appointment. There’s a pretty tight follow up on specific immunizations. This will make a more comprehensive picture of who really needs that outreach.

Q: Is historical immunization data something that the VA is also able to share with the registries in addition to new vaccines that are being given?

Pamela S. Belperio: The answer is yes, that is the next phase. As we’re completing the connections with the states that are already connected through the IZ Gateway starting this winter or spring of the of the next year, we are going back to provide all of the historical VA administered vaccinations. We will probably work with each IIS separately and do a batch loading of all the historical information jurisdiction by jurisdiction. We have that plan in place. Our technical development plan is ready for that and we hope to have that live in hopefully winter or spring of 2024.

Billing and Coding Task Group Update – Carolyn Bridges (Immunize.org)

Carolyn Bridges, MD,FACP, Director for Adult Immunization, Immunize.org, gave an update on the Billing and Coding Task Group.

May 2023 NAIIS in person meeting priorities

Working on updating various tools on billing and coding
Billing and coding guide and resources were some of the most downloaded or accessed web pages on the Summit website
Three resources on top billing questions underway
- Changes with inflation reduction act
- CPT coding
- Common problem billing scenarios – how to avoid problems with billing

Announcements

Beginning in September we resume our weekly schedule.
If you are registered for the Summit not getting the emails from Mailchimp, please add “NAIIS” at info@izsummitpartners.org to your contact list.
If you have any agenda items that you are interested in sharing with the Summit, please let us know and we can add you to an upcoming call as a speaker or panelist. Contact information: info@izsummitpartners.org.