What to Look for in Payer Contracts

April 5, 2021, 4:25am · 6 min read

A good vaccine contract can help to streamline coverage, improve your reimbursement rates, and avoid claim denials. A bad one will come back to haunt your practice again and again. Because contracts are often long and complex, knowing where to focus when reviewing and managing them will save you headaches and profits. Here are some of the most important areas to spend time on when you’re negotiating and maintaining contracts:

  • Reimbursement Rate: Each payer offers different rates for reimbursement, typically based on flat fee or a percentage of the average wholesale price of vaccines. When negotiating and maintaining your contracts, be sure to take note of how your office will get reimbursed and what the rate should be.
  • Fee Schedules: Fee schedules can change multiple times a year, leaving you undercharging without realizing it. Consider appointing a specific staff member to manage your fee schedules so changes are caught prior to billing.
  • Coding Requirements: Some payers have very specific coding requirements when it comes to payment for vaccines. In order to cut down on denials and reimbursement management, make sure you understand if specific payers are satisfied with CPT codes alone, if they need additional NDC codes, or if they require additional information for reimbursement.

These elements are just a few contract intricacies, but keeping a handle on your reimbursement rate, fee schedules, and the individual coding requirements of each payer can go a long way in helping your office to make the most of your submitted claims.

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Stop Losing Money on Your Vaccine Program

From ordering and inventory management to billing and coding, we’ve put together a guide outlining the common ways offices lose money on vaccines—and tips on how to avoid them.

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Published: April 5, 2021, 4:25am