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Billing and Reimbursement Outcomes for School-Located Vaccination for Influenza in Two U.S. Areas
Authors: Benjamin Allaire (RTI), Simon Neuwahl (RTI), Tara Vogt (CDC), and Amanda Honeycutt (RTI)
Background
School-Located Vaccination for Influenza (SLV-I) can be an efficient way to administer annual influenza vaccine to school-aged children. Public health departments (HDs) lead most SLV-I programs, which can be costly to conduct. To improve the sustainability of SLV-I, HDs may need to implement billing students’ health plans for vaccination services. This study provides important information about SLV-I billing approaches and outcomes.
Methods
We solicited participation of HDs that bill for SLV-I services. For a sample of schools in each participating HD’s service area, data were collected on (1) the number of claims submitted to third parties and the outcomes (reimbursed >$0.00, denied) by payer type (Medicaid, private), (2) the average amount billed and reimbursed by payer type, (3) the amount paid out-of-pocket by parents/guardians/students. Data were collected for claims and payments for influenza vaccine doses administered in participating schools’ first SLV-I clinic of the season. Key staff in each HD were also interviewed to learn about their billing process.
Results
Two HDs from different states participated in the study. The first (HD1) chose to conduct all billing activities internally. The second (HD2) collected insurance information from students, but contracted with a commercial biller for claims submission. HD1 and HD2 provided data on 1,069 and 405 claims, respectively, of which 17 and 12 claims were denied without any reimbursement. HD1 had an almost even split of claims between Medicaid and private insurance (51% vs. 49%). In contrast, 85% of HD2 claims were submitted to private health insurers and 15% to Medicaid. Medicaid reimbursed 85% and 96% of the billed amount in HD1 and HD2, respectively while private insurers reimbursed 82% and 92% of HD1’s and HD2’s billed amount, respectively. Out of pocket payments comprised 6% and 7% of total reimbursement for HD1 and HD2, respectively.
Medicaid reimbursed $26.40 per claim for HD1 and $13.80 per claim for HD2, reflecting differences in state Medicaid caps on vaccine administration reimbursement. Private insurance reimbursed $34.60 and $26.10 per claim, respectively, for HD1 and HD2. Vaccine for Medicaid-covered students was provided by the federal Vaccines for Children program; therefore, vaccine fees were not included in Medicaid claims. Overall, HD1 was reimbursed $30.40 per claim and HD2 was reimbursed $24.20 per claim. Including all doses administered, even to students for which no claim was generated and no reimbursement was received (139 doses in HD1 and 0 doses in HD2), we estimate reimbursement at $26.30 and $23.70 per dose administered for HD1 and HD2, respectively.
Conclusion
Our results suggest that HD billing for vaccines administered in SLV-I clinics is feasible. Recent studies have estimated SLV-I costs per dose administered, including vaccine, at between $13 and $26. Our analysis revealed reimbursement per dose administered at similar levels. This finding suggests that billing may allow HDs to cover most costs incurred during SLV-I clinic operations and potentially help SLV-I sustainability.