Stay up to date on Medicare pricing, and payer policies and guidelines.
Medicare: Flu Vaccine Pricing
Medicare payment allowances for 2017-18 influenza vaccine, which took effect Aug. 1, are listed in MLN Matters No. MM10224. New on the list is CPT 90682 — Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use.
Note that Novitas Solutions, the Medicare payer for Texas, was to have initiated a mass adjustment process by Nov. 1 to reprocess any claims for the current flu season that were paid using pre-Aug. 1 vaccine payment allowances. Make sure your payments were adjusted, if applicable. If not, notify TMA using the TMA Hassle Factor Log.
BCBSTX: HPV and Shingles Vaccines Policy Shift
Blue Cross and Blue Shield of Texas (BCBSTX) says it is tightening up how it pays for vaccines for human papillomavirus (HPV) and shingles resulting from the herpes zoster, and will recover payments made in error.
The payer will cover vaccines that adhere to guidelines recommended by the U.S. Food and Drug Administration (FDA) and Advisory Committee on Immunization Practices (ACIP). It will consider vaccines administered outside the FDA and ACIP recommendations as experimental, investigational or unproven, and will periodically review such claims for payment. It will recover payments for these vaccines when administered outside the FDA and ACIP recommendations, according to its contracts.
- To prevent shingles and its complications, BCBSTX considers the vaccine Zostavax medically necessary for anyone age 50 or older in recognition of FDA guidance. (ACIP recommends Zostavax at age 60 or older.)
- To prevent HPV and its complications and associated diseases, including cancers, BCBSTX covers Gardasil, Gardasil 9, and Cervarix. Administration of these vaccines is recommended for males and females 9-26 years old, optimally at age 11 or 12. For patients 9-14 years old, ACIP recommends two doses, with the second dose at six to 12 months after the first. For patients 15-26 years old, ACIP recommends a three-dose regimen, with the second dose at one or two months after the first, and the third dose six months after the first
Review BCBSTX’s Preventative Services Policy CPCP006 for details on its complete, approved immunization schedule.
Humana: Flu and Pneumonia Vaccine Guides
Flu and pneumonia vaccinations are key to patient health, Humana notes, and thus have become important quality metrics for programs such as the Healthcare Effectiveness Data and Information Set, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS surveys of patients’ health care experiences). Humana has published two guides in the What’s New section of its provider website:
TMA Can Help
Visit www.texmed.org/Immunizations for news and information. Also, TMA’s Be Wise — ImmunizeSM program has downloadable patient education materials and other resources for physicians, including grants to host a vaccination event in your community.
Be Wise — Immunize is a service mark of the Texas Medical Association
Published Nov. 28, 2017
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