MythBusters! Billing for COVID-19 Vaccine Administration in the Pharmacy

As the COVID-19 vaccine rollout is expanding to the broader population, articles about billing for vaccine administration are everywhere, even at the national level.

It’s great that this conversation is getting national attention. Like everyone else in the pharmacy community, we are huge advocates for making it as easy as possible for pharmacists to get reimbursed for all the clinical services they provide, including COVID-19 vaccines.

But with this recent uptick in news coverage has come some myths, specifically around medical billing. The bottom line is this: when it comes to medical billing, you can easily get reimbursed for all of your COVID-19 vaccine administration claims.

MYTH #1 You risk not getting paid if you bill through the medical benefit

FACT: With the right partner, you can easily get reimbursed through the medical benefit

There’s no question that medical billing is complex, which is likely how this myth is continuing to pick up steam. And the truth is that if you are trying to bill the medical benefit without any help from a medical intermediary, you will have problems: there would be no real-time response from the payer to let you know if the claim will be paid, you would need to translate the claim from NCPDP to ANSI X12, find out how to submit a claim to each unique payer, and the list goes on and on.

That’s why you need a medical billing expert like OmniSYS to handle this complexity for you. Pharmacies who use OmniSYS can get 99% of their medical claims reimbursed, and not just for COVID-19 vaccine administration but for everything else covered under the medical benefit like DME, specialty drugs and point-of-care testing.

MYTH #2 Bill the pharmacy benefit first

FACT: Bill the medical benefit first!

The pharmacy benefit is designed to reimburse based on a product, while the medical benefit is designed to reimburse for a service. When you are billing for the administration of a COVID-19 vaccine, you are a provider and that is a service. The advantage to billing through the medical benefit is that you can capture the full reimbursement amount without any of the fees that come from billing the pharmacy benefit.

MYTH #3 You need to sign up with multiple medical intermediaries to get reimbursed

FACT: The right medical intermediary can help you get reimbursed through all plans.

The myth that’s circulating here is that you need to sign up with multiple medical intermediaries, or worse yet, that you need to start the enrollment process payers with you are not currently contracted with in order to get reimbursed.

Remember, it doesn’t matter whether or not you have a medical contract with the payer for COVID-19 vaccine claims – payers are required to reimburse you. The challenge is how to submit claims to payers with whom you are not contracted. The answer is OmniSYS’s open network billing solution for COVID-19 vaccine administration – we will process claims through any payer on your behalf. You can learn more here.

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