Keys to a successful 2013 flu season: Planning starts now

Spring is one of my favorite times of the year. It signals the end of many things and the start of others. Winter becomes spring. Flowers bloom. March Madness wraps up and The Masters’ tee off. Flu season transforms into flu season. Skiing and snowboarding melt into surfing and kayaking.

Wait, what? Flu season transforms into flu season?

Yes, it is true. The golden times of yesteryear when flu season ended in March and started again in September are no longer. Those circa 2008 days have gone the way of paper billing claims. In today’s world, April is the time to begin preparations for the wave of patients who will start visiting pharmacies as early as August to be immunized. On the heels of a severe flu season, past trends suggest the demand for flu shots this year will be tremendous. Since the H1N1 epidemic of 2009, we have seen a proliferation of pharmacies begin electronically billing vaccination claims to commercial payers as a medical benefit. Today it’s not uncommon to see a pharmacy touting “Most Insurances Accepted,” thereby attracting additional customers with convenience and the lack of copay fees. Commercial payers are now accustomed to contracting with pharmacies and have gone as far as educating their members that the pharmacy is a convenient location to receive vaccinations.

According to the CDC, less than half of children and adults in the U.S. received a vaccine by mid-November of 2012. Also, less than 20% of adults immunized received their vaccine at the pharmacy. These statistics demonstrate just how much opportunity there is for continued growth for our industry in the delivery of vaccines.

The key to having a successful flu season in 2013 begins with outreach to national and regional commercial payers now to kickoff the contracting process. By contracting with commercial payers, the claims billing solution enables your pharmacy to submit medical claims for vaccinations electronically to major commercial medical insurance payers in NCPDP format using the existing pharmacy management system. With this specialized processing solution, claims are subjected in real-time to eligibility and plan formulary based edits. Claims are then forwarded to the appropriate payers for adjudication and payments are delivered directly to the pharmacy. Connecting with the payers that offer coverage in your locality now, will allow plenty of time for implementation prior to the upcoming flu season. And when meeting with the commercial payer, it is helpful to compile your store inclusion list, billing tax identification numbers, billing national provider identifier numbers and pay-to-addresses in advance. This will allow for a clean enrollment, which is paramount to a successful vaccination program.

Once contracted, there are a number of resources you can utilize to guide you through the process including billing agents and dedicated customer service representatives with the commercial payer. Be sure to request a list of these key contacts for your staff as you begin implementation. By completing this work during April and May, you can greatly increase the likelihood of success in time for football season!


Mike Carmody
Director of DME/MedRx pharmacy services at Emdeon
Mike Carmody is the director of DME/MedRx pharmacy services at Emdeon. He is responsible for pharmacy solution product development and workflow efficiencies. Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers and patients in the U.S. healthcare system.

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