As practices start offering vaccinations for COVID-19 to their patients, we are getting a lot of questions about whether the patient can be billed for the administration. The answer is an emphatic No.
The Office of the Inspector General has received complaints from patients about charges by providers when getting their COVID-19 vaccines. So, on April 15, 2021, the Principal Deputy Inspector General Christi A. Grimm issued a message regarding provider compliance with the COVID-19 Vaccination Program. All participating organizations and providers must administer the COVID-19 vaccine with no out-of-pocket cost to the patient. Providers that have charged impermissible fees must refund them and ensure that individuals are not charged fees for the COVID-19 vaccine or vaccine administration in the future.
Practices also may not deny anyone vaccination based on the vaccine recipient’s coverage status or network status; may not charge an office visit or other fee if COVID-19 vaccination is the sole medical service provided; and may not require additional medical services to receive COVID-19 vaccination.
So, what about patients who have no insurance, or their insurance plan doesn’t cover vaccinations? What if the claim is applied to the deductible or the patient has a co-insurance?
There are solutions so the practice gets paid the full amount.
First Solution: The COVID-19 Uninsured Program Portal
The CARES Act Provider Relief Fund included allocations for coverage of COVID-19-related services to uninsured patients. The program is overseen by the Health Resources & Services Administration (HRSA; see https://coviduninsuredclaim.linkhealth.com/), administered by United Health Group, and covers the same services as Medicare. However, it is not a United Health or Medicare program and you do not need to be credentialed with either of these payers.
Those practices that have not taken advantage of this program will need to start. Vaccine administrations are covered the same as Medicare ($40 per dose as of March 15, 2021). Prior to that date, reimbursement is $16.94 for the first dose, and $28.39 for the single or second dose. Timely filing requirements are the same as Medicare—1 year from the date of service. Providers must agree to:
- Verify each patient has no other healthcare coverage
- Accept the program payment as payment in full
- Confirm the patient was told they will not be billed
- Accept the terms and conditions. Claims may be subject to post-reimbursement review
Payments are received via Optum Pay Direct Deposit to the same bank account on file for United Health Group. All claims submitted are final. No corrected claims, late charges, or appeals are accepted. United Health Group has Smart Edits in place to assist in clean claim submission.
To obtain a temporary member ID to bill the program, this information is required:
- First and last name
- Date of birth
- Social Security Number (SSN) and state of residence; if not available, enter state identification/driver’s license
- Date of service
- Address, middle initial, and patient account number are optional.
If you do not have an SSN and state of residence or state identification/driver’s license for the patient, you will need to attest that you attempted to capture this information before submitting a claim and the patient did not have this information at the time of service. Temporary member IDs are only valid for 30 days.
Providers will be required to attest that they checked for healthcare coverage eligibility and confirmed that the patient is uninsured.
Second Solution: The COVID-19 Coverage Assistance Fund Portal
On May 3, 2021, the U.S. Department of Health and Human Services announced a new program to cover the costs of administering the COVID-19 vaccines to patients who do have insurance, yet it either does not cover vaccinations or applies cost-sharing to the patient. This population is referred to as the “underinsured”.
The COVID-19 Coverage Assistance Fund (CAF; see https://www.hrsa.gov/covid19-coverage-assistance) is also funded by the Provider Relief Fund Program and overseen by the HRSA. It is specifically for COVID-19 vaccine administration fees.
This program is administered by the SSI Group. There is no credentialing or contracting involved. Providers can enroll with the HRSA and must attest to the following:
- They have submitted a claim to the patient’s primary health insurance plan and there is a remaining balance from that health insurance plan that either does not include COVID-19 vaccination as a covered benefit or covers COVID-19 vaccine administration, but with cost sharing.
- They have verified that no other third-party payer will reimburse them for COVID-19 vaccine administration fees for that patient encounter, or other patient charges related to that COVID-19 vaccination, including copays for vaccine administration, deductibles for vaccine administration, and co-insurance.
- They will accept defined program reimbursement as payment in full.
- They agree not to balance bill the patient.
- They agree to program terms and conditions and may be subject to post-reimbursement audit review.
This program may be a little easier than the uninsured program, as the practice does not have to obtain a temporary member ID for each patient. There are no appeals process for these claims. However, if there is an error, you can correct the claim and resubmit.
Claims can be submitted going back to December 14, 2020 when the first vaccine received an Emergency Use Authorization. Reimbursement is at the national Medicare rates listed above, and for any patient cost-sharing related to vaccination (ie, copays, deductibles, and co-insurance). Practices should receive an electronic remittance advice (ERA) with ACH payment in 5 business days on clean claims.
Bottomline, this is not a cash service. Stay compliant and take advantage of the programs available to you.