Home Forums Discussions General Discussion Pneumovax reimbursements

We have reached a point in our office where we can no longer afford to give Pneumovax with the price hikes, as the current cost is not being completely covered under the insurance reimbursements. Of course, we cannot charge the patient the difference.

Does anyone have this same kind of problem? If so, how are you handling it?

Find a local pharmacy who wants business and refer all to them - have not done in years as it is not worth hassle and they love to do them.

How did you determine that it is not worth administering the vaccinations? From what I read in Illinois, (WPS Medicare) you still come out on top when billing for the vaccination and administration.

I gave up all vaccines many years ago as it was too much of a hassle and the cost was more than the reimbursement. I have only recently started giving tetanus again. Everything else goes to the pharmacies.

You may make a little on a vaccination - assuming you never get one denied, they never decide that since you did on the day of a visit that they will bundle the admin charge and only pay you for the visit or the admin fee (have not had with pneumovax, but have had insurance companies decide to pay me 28 dollars for EKG and disallow the Level 4 office visit). The problem is that we can spend a lot of time trying to see if we can make a few dollars doing something or just concentrate on visits and medical management. I have seen tetanus shots denied left and right by Medicare even when given for an open wound so I just figured that if you make 10 bucks on one, but get one disallowed out of 10 then you are not ahead.

We just looked at this. Clearly, the cost of pneumovax now exceeds medicare reimbursement. That is excluding the syringe and someone to give it. We pay more for the vaccine than medicare pays us. And there is curiosity out there as to why we don't vaccinate????

That is EXACTLY the situation that we have in the office. Are we doing something wrong? How is it a pharmacy can get paid for it, but the MD cannot? I do not see that the pharmacies will eat up these costs, as it is not just breaking even.
Any thoughts?

I just bought a vial of Pneumovax 23.
Here are the stats:

Cost/dose: 53.16
Medicare listed payment for our geographic area:
Vaccine 90732: 57.19
Administration G0009: 24.69

Have you all looked at your current numbers?

Some years ago, my supply company was charging way too much, and yes, the cost exceeded the reimbursement, so I changed suppliers.

I imagine that this has alot to do with differences in regional reimbursement rates. Although it is a federal program, reimbursements vary by region/carrier and so does the coverage of different codes. One discovers this when they relocate.