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A summary of presentations from the weekly Summit partner webinars

May 1, 2025 – The latest Summit Summary

Billing and Coding Payment Work Group Update – Carolyn Bridges, MD, FACP, Director of Adult Immunizations, Immunize.org; Jennifer Tinney, Program Director, The Arizona Partnership for Immunization (TAPI); Mitchell Finkel, Consultant, Avalere Health

Carolyn Bridges, MD, FACP; Jennifer Tinney, and Mitchell Finkel gave an update about the work of the Billing and Coding Payment Work Group.

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Billing and Coding Payment Work Group Update – Carolyn Bridges, MD, FACP; Jennifer Tinney, and Mitchell Finkel
This task group meets monthly and last met in person in August 2024. The group has identified priority areas that impact the ability of providers to implement ACIP vaccine recommendations. The group’s updated tools can be found at www.izsummitpartners.org/naiis-workgroups/billing-coding-payment-taskgroup/.

Discussion Topics from August 2024

  • Declines in provider confidence that payments for vaccines and vaccine administration or dispensing fees will cover costs
  • Pharmacy benefits management organizations (PBMs) increasingly lowering payments to pharmacists for vaccines and dispensing
  • Delays in updates to vaccine payments with new vaccines or new formulations
  • Challenges with LTCF patient and staff vaccination after COVID-19, especially Part A stay patients and uninsured staff
  • Continued challenges with Medicare B versus D vaccines depending on setting
  • Lack of CPT code for vaccine counseling for adults when no vaccine administered

Actions Taken by the Work Group and Partners

  • Updates made to pharmacy and medical billing guidance on website
  • Algorithms and guidance updated, including for the need to work with in-network providers, hepatitis B vaccine now in Part B, and contacting manufacturer assistance programs
  • White papers for billing and payment issues facing:
    • CHCs/FQHCs (updated and published in January 2024)
    • LTCF for staff and residents (in progress)
  • Data collection on main reasons for claims rejection
  • Pilot project to have the working group review reports of vaccine payment issues received on the NAIIS website

Update on Common Reasons for Claims Rejection
The following are the main categories the working group has identified for common reasons for claims rejection.

  • Medicare Part A, B, and D, and who can vaccinate where (e.g., non-traditional billing systems, dental)
    • During COVID, many limitations were suspended and vendors and public health departments got involved, but when the emergency status was lifted, all that stopped, and the systems for ordering and for payments became complicated and confusing.
    • As another example, beginning on January 1, 2025, hepatitis B could be given by a mass immunizer under Medicare Part B. However, health plans have until July 2025 to implement this, so these claims are currently being rejected.
  • Plan-specific snags (e.g., combination vaccines, pre-authorization)
    • Changes to the vaccine schedule through the year (age ranges, prices, etc.) challenge the systems to keep up. For example, plans may reject changes based on specific claim details that do not reflect recent changes.
  • Low margins on privately purchased vaccines (even lower for NPs and pharmacies)
  • New vaccine payment lags (e.g., ACA lags, after code changes)
  • Limited networks (e.g., few PCPs carry vaccines, out-of-network payments)

Although payments for vaccines given within the typically recommended age range are usually reimbursed easily, recent changes or new vaccines may mean delays in payment or requirements for additional documentation (which may be difficult for mass immunizers to manage). Footnotes on the immunization schedules provide scenarios to help guide decisions and coverage, but they rarely make it to the health plan claim and providers, despite their arguments for necessity, rarely get paid for those cases.

Avoiding Common Errors
The Summit has developed a resource that includes Top Questions associated with coding and billing for adult vaccines, which also includes some pediatric vaccine billing, to help providers avoid common errors. The resource includes:

  • An algorithm describing overall vaccine coverage by insurance type
  • Information about CPT coding for vaccine counseling
  • Information about U.S. vaccine insurance coverage policy and reimbursement policy
  • Coding case scenarios

Common Errors
State Medicaid payers often use fee schedules that are updated manually each year. When the vaccine fee schedule is updated only once per year, however, it may be difficult to ensure proper payments, as price increases over the course of a year are common. Therefore, providers may have long periods of time during which they’re being paid at an outdated rate.

  • Potential solutions being considered by the working group:
    • Work with Medicaid to develop a separate fee schedule or advocate for real-time updates
    • Appeal claims on an individual level
    • Create resources to help providers have access to current state Medicaid reimbursement rates to compare it to their costs
  • Pharmacy billing considerations:
    • The working group has developed a “cheat sheet” to summarize which benefit a given vaccine might be processed under, along with specific notes a provider should consider including when submitting a claim.
  • Billing algorithm:
    • This resource provides guidance, based on a patient’s insurance status, about where and how to build the claim or send the patient. For example, a private provider with a patient who is uninsured may send that patient to the local public health department or a manufacturer patient assistance program; for a patient who is insured, the coverage and billing may differ. (This resource has been updated to reflect recent changes in the vaccine environment.)

Vaccine Payment Challenges Reports: Pilot Project
This pilot project has been developed to collect anecdotal reports and determine action steps for the working group. The challenges that prompted this project include substantial delays in payment and issues with payment amounts with the move from QIV to TIV, introductions of RSV vaccine and associated payment delays, addition of new brands to the field and the associated delays. The reporting form can be found on the main Summit page. [In addition to the challenges already presented (i.e., delays in payments and annual fee schedule challenges), there may be delays if the payer only wants to cover one vaccine out of several.]

Vaccine Coding and Billing Task Group
All attendees of the NAIIS in-person meeting are welcome to attend the next task group meeting, which will be a breakout session on May 14. Topics of discussion — in addition to what is happening to Medicaid — include a review of the activities/learning of the year and prioritization of activities for 2025–2026. Group priorities for the coming year are (1) Expanding understanding of systems, organization, and processes that impact timeliness of payments, and (2) Developing templates for providers to respond to payment issues.

QUESTIONS & ANSWERS

Q: What is the best advice for providers in terms of delays? How much time do you have after getting a claims rejection to resubmit? How much time do you have after administering a vaccine? If you know there’s going to be a delay in payment, can you wait to then submit that claim?
Jennifer Tinney (TAPI): Very often, when there’s a new vaccine and we try to bill it right away, it gets rejected, meaning it doesn’t even go into the system. It gets rejected by the clearinghouse or the front end of the health plan. And then we hold those claims, and we must keep checking back to see if the codes have been loaded for that one.
 As a coalition, we reach out to the health plans; for instance, when RSV and the monoclonal and the vaccine came out, that was a tight, fast turnaround. It was approved by ACIP, and then everybody was talking about it: “Go get the vaccine right now, especially if you’re pregnant in the last trimester; and get the monoclonal [for your infants].” And we had no idea what to tell providers, because we didn’t know if everybody was going to cover it and how quickly they were going to cover it. So we polled all the health plans, and our big ones, the majority of them answered pretty quickly and said, “Yes, we intend to cover it. We’re probably going to cover it right away. We’re still trying to figure out how to do that.” So we then knew that they were committed to covering it right away and we submitted the claims.
 We submitted October through March before all of them had the codes in the system, so we have to go back about each month and remember: “Let’s resubmit this batch and see if the codes are there and whether [the plan] is ready to take it.” And it took until March before we had the codes for the majority of our bigger health plans, and then payments start to trickle in after that. So, payments started coming in the end of March, April and May [for immunization claims submitted October through March]. One of our large health departments had about $1.5M outstanding in vaccine purchase, waiting for those payments to come in, and of course, they are trying to tell the Board of Supervisors — who were a little concerned that we had this sort of outstanding debt — that this is normal.
 But that’s sort of the way it happens once the codes are in. Now we hit timely filing, but if we can prove that we submitted them and were rejected, we’re still within the timely filing which could be 3 to 6 months depending on the health plan. So we try to stay on top of it and continue to do it monthly.
Mitchell Finkel (Avalere Health): To submit claims, as soon as you administer it [the vaccine] and keep your claim field free, you have 90 days, for most payers, after the date of service to submit a claim. If there is a rejection, generally it is another 30 to 90 days, depending on the payer, to resolve that claim. So, most lag-related issues should be able to be resolved within the allowable window of a POA claim and or a resolution process. Generally, if you have up to 180 days, and it’s rejected on month one of when a new vaccine came out, then by that 180 day mark, that plan should have already put in a new coverage policy in place, because that’s about a half a year. So hopefully, there shouldn’t be providers that lose money on a product, in which case there are other appeal mechanisms that providers could be using to resolve those claims as well.
Carolyn Bridges (Immunize.org/NAIIS) [follow-up]: We have had examples where it’s been a year, and those seem to be more managed. Medicaid plans seem to be the ones where there have been some examples of maybe longer delays. Is that what you’re seeing, as well?
Jennifer Tinney (TAPI): Most of our managed Medicaid have a private side and a Medicaid side. And typically if there’s a holdout, it’s on both sides — it’s just within their system. So I don’t necessarily think that we see a difference in one versus the other. But we’ve been managing Medicaid for a long time. We have established plans that are there. So they have the routine down and it’s usually — when I say “plan-specific,” I mean it’ll roll out everywhere except [that] one plan that you think is going to get it immediately, but instead you’re a year in with them before they can fix it. For that plan, first, they have to become aware of it. One of the things that we do is file for reconsideration if it’s been denied, and then you can file for an appeal after that. We [usually] skip that, and we ask to open a project with our provider representative at the plan, because we want to spend some time with them talking through and showing what we think the glitch is and why it’s not following through.
 We try to come in from a public health perspective: “This is why the recommendation is in place. This is why it’s important. This is why you need to cover it,” because we know if we can fix it at that level, then it’s going to fix it for all the other providers who are having the same problem. Now [some provider may say,] “Okay, I’m not giving this vaccine anymore because they don’t pay it.” We just have to get it fixed and straightened out. And those kind of projects can take another year to 18 months. So it’s a process.
Mitchell Finkel (Avalere Health): I always think about a provider with limited resources — [or] even on the payer side — there are only five or six people in that office, or [maybe] many medical reviewers but only so many people in control of that policy. Unfortunately, everybody has time limitations, and it’s working through the process while having the best intentions in place.

Q: Can you provide a clarification of the one-year grace period after an ACIP recommendation and, when payers start to pay, when does that one year clock start?
Jennifer Tinney (TAPI): It’s my understanding that you have one year from the date that the ACIP recommendation was signed in by the CDC, to offer it in the next calendar year.
Mitchell Finkel (Avalere Health): One year in the beginning of a plan. So if an ACIP recommendation was voted on in June, and the CDC director signs off on it in June, then plans will be required to cover it a year and a half later. So for June 2025, it will be January 2027, if that plan has a plan year of January 1.
Jennifer Tinney (TAPI): Generally we only see those kinds of delays with the employer-funded plans, which we have a lot of in Arizona (now, we’re at about 60-something percent of employer-based plans). Many times, because if they’re going back to renegotiate prices, they don’t renegotiate the fee schedules or cover anything new until they’ve worked with that employer on what their next plan piece is going to be. For the most part, the plans will adopt them ‘right away-ish.’ I think it used to be that it was from the date of the MMWR publication, which was always 2 to 3 months after the ACIP vote, which gave us 2 to 3 months to get the plans ready, get the providers ready. And now, because it’s based on as soon as they’re signed on by the CDC, it’s sort of “ready, set, go” and we need a little bit more time to move those systems in place.
Mitchell Finkel (Avalere Health): A general rule I’ve always thought of is that the majority of plans will cover a given product within 3 to 4 months of an ACIP vote. Unfortunately, when you’re a provider, knowing a majority [of plans are doing that] is not helpful when you could be in that minority [of plans not yet covering] and having members in the minority.
Jennifer Tinney (TAPI): That’s something I’d like to clarify, too. Because we, as a system, [may] say, “Oh, the majority cover it. So that’s good.” But if you’re a practice and the main employer is a company that has one insurance payer, everybody who walks through your door that’s insured is going to be insured through that one payer. So, if that payer is taking longer, or there’s an issue, then that’s where you see practices differ like night and day. Yesterday they had vaccines and tomorrow they don’t. It could be because that’s their main payer, and they just can’t get through it. Rather than looking at it as “Oh, well, but the majority paid it; so one doesn’t…” It’s not one in that practice, it’s the only one.

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Announcements
  • Registration is open for the Adult and Influenza Immunization Summit: Looking Back, Moving Forward, May 13–15, 2025. This summit will be held at the Crowne Plaza Atlanta Perimeter at Ravinia.
    • Registration is open at https://www.izsummitpartners.org/2025-naiis-registration-form/.
    • Registration requires a case-sensitive password from NAIIS. Registrants for the meeting must be members of the Summit; a membership form is available at the Summit website.
    • The registration site has been updated with an agenda and the poster sessions.
      • Poster awards will be presented at the Summit’s award luncheon on Wednesday, May 14.

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