Pharmacy immunizations: How to manage a successful claims process

September 15, 2013

With the flu season right around the corner, pharmacies should engage payers as early in the year as possible to ensure adequate time to finalize contracting, fully test their billing capabilities, and stock inventory before the official start of the vaccine season.

From aspirin to milk to makeup, people can get just about anything at their local drug store. Now healthcare joins the list, as more pharmacies offer expanded medical services, including screenings and immunizations.

In light of this past winter’s influenza epidemic, which proved to be the nation’s worst in the past 10 years, immunizations give retailers a significant opportunity to provide enhanced services to their patients.

And the flu shot is just one type of immunization. Pharmacies now offer other vaccinations that previously were available only at doctors’ offices, such as those for hepatitis A, HPV, and TDAP. In fact, Emdeon, as a major processor of vaccination/immunization eligibility and claims transactions, saw a more than 500% increase in these transactions between the 2011 and 2012 seasons.

Early communications

Some potential challenges do accompany these enhanced service opportunities. Pharmacies face a significant learning curve when contracting with health plans for these services: Immunizations are not regarded as a pharmacy benefit, with which pharmacy retailers are more accustomed, but are regarded as a medical benefit. Without strong payer relationships, pharmacy retailers risk disrupting customer service and losing out on revenue if they can’t adequately process vaccination claims.

With the flu season right around the corner, pharmacies should engage payers as early in the year as possible to ensure adequate time to finalize contracting, fully test their billing capabilities, and stock inventory  before the official start of the vaccine season. Since the timing is often late summer or early fall, this also provides pharmacies with time to communicate their offerings to patients through targeted marketing efforts well in advance.

Preparation

Pharmacies that begin billing for immunizations often encounter workflow challenges because employees who deal with the public don’t understand medical benefit rules or how to accurately process these transactions, including eligibility requests. Patients who are eligible to receive immunizations, therefore, may be erroneously charged for the service or turned away outright, which can injure the pharmacy-patient relationship.

To avoid such problems, pharmacies can thoroughly train their staffs on how to decipher medical cards, submit eligibility requests, and accurately process claims. They should also implement a workflow that may allow easy access in the store to health plans’ online portals.

Pharmacies shouldn’t hesitate to reach out to health plans and clearinghouses for assistance along the way. Certain clearinghouses provide comprehensive guides that educate pharmacies on how to fulfill a medical claim, to ensure that they collect pertinent information, including legal name, tax identification number, group and individual National Provider Identifiers (NPIs), and transaction destination data such as service location and billing address. Failure to include the right data could result in a suspended or denied claim.

Retail pharmacies should test all transaction types, creating mock eligibility requests or claim submissions, which will allow them to work the kinks out of their processes well before the first patient asks for a vaccination.

Growth opportunity

Immunizations can represent a tremendous growth area for pharmacies: It’s estimated that less than half of all Americans receive a flu shot in any given year. Meanwhile, just 19.7% of adults who received a vaccination did so in a pharmacy in 2012, according to CDC records. And history suggests that the number of vaccinations tends to spike in the year following a flu epidemic (such as the one that occurred this past winter).

Pharmacies should remember, however, that product and service expansions can lead to unexpected challenges for both the pharmacy and the payer. With help from clearinghouses, pharmacies are able to solidify their payer relationships and enhance the member experience by ensuring that the entire immunization process, from vaccine delivery to health plan billing, is a seamless one.

And immunizations are just the tip of the iceberg for pharmacies. Strong health-plan relationships give pharmacies a foot in the door to contract for other clinical services. In the quest for more coordinated, consumer-friendly care, payers and pharmacies could collaborate to engage in activities such as disease management and wellness counseling for health plan members.

Not only do these offerings provide cost-savings opportunities for payers; they help to increase foot traffic for the retailer, driving greater revenue from both front-of-store sales and the potential to offer more clinical services in the future.

Mike Carmody is the director of DME/MedRx pharmacy services at Emdeon, where he is responsible for pharmacy solution product development and workflow efficiencies.