Home Forums Discussions General Discussion ZOSTAVAX

OK, time to rant again.

I just met with my Merk rep and was told that physicians can no longer bill Medicare for the administration of the Zostavax. Medicare will pay Krogers or Walgreen's or other non-physician entities to administer it under Medicare Part D, but not physicians. I have been prescribing a bunch of this as I believe it is a tremendous benefit, but no more. I had no expectations of making a killing off of administering it and was quite content just being able to cover my administration costs but I'll be damned if I'll grease someone else's pocket when I am legally prevented from getting the same opportunity to bill for a service. Once again our government has regulated health care to prevent healthy care.

Leslie, who is trying hard not to have an angina attack.

Medicare only pays $17.60 for Zostavax administration.
Are they going to stop paying this?

Yes, that is what I was told today by the Merk people. They will pay the pharmacies under the Medicare part D benefits but not doctors.

Leslie

Well, I guess, we have no choice but to refer patients to the pharmacy then.

Isn't that just the CCHITT now??? When the gov't insurance won't pay a real licensed professional provider to admin an injection but they will pay some large corporate chain pharmacy to do so. I'm so glad the my gov't isn't in the pocket of huge corporate interests, aren't you????
Good Night and Good Luck,
Paul

I think the better thing to do is to continue to advise people to get it but to tell the Medicare patients their insurance will not allow me to give it to them so they will have to look around and find out where they can get it. And that they should complain to their representatives in Congress.

Leslie

I think we should recruit the American Bar Association to help us (perhaps they would be more sympathetic than the AMA).

So if a patient gets an untoward reaction from the vaccine, or a complication from their injection technique, who can they sue? The pharmacy chain? Are the pharmacists carrying malpractice coverage for performing medical procedures?

My billing gal tells me the change in Zostavax administration coding is that Medicare wants us to bill 99211 instead of the previous injection code. For some reason, they retain the old G-codes for influenza and pneumovax. I suspect this is right (because she always is), but I haven't confirmed it myself yet.

I hope you are right, Dave. I got this info from the Merk Rep. I'll give it a whirl and see. But would that also mean that you could not see the patient for another encounter that day and bill both? I love this board.

Leslie

So, what is the difference in the Medicare re-imbursement for 99211 versus the administration fee?

In my opinion, since Medicare payment will be diagnosis driven, and there is no Dx for shingles/herpes zoster vaccination (other than a miscellaneous viral one), the injection would be denied with whatever procedure code you use. At this point, MCare only pays for flu/pneumo/hep vaccines. We would have the pt pick up the vaccine thru whatever source (pharmacy, etc), and bundle it in with the next office visit. We also refer pts to local health dept and let them deal with it. Hopefully that would accumulate some stats there so it could ultimately be covered.

The 99211 charge is reimbursed (by Medicare) at about 4 dollars more than the administration fee was reimbursed.

Leslie

V04.89 vaccination, viral disese, NEC
99211 (separate appt. of course)
We purchase the vaccine, bill Medicare, Medicare denies, bill goes to the patient who pays us. (Sometimes pt has a secondary that kicks in and reimburses the patient, at least partially)

I know this goes without saying, but you are having the pt sign an ABN, right?