Why Flu Season Is the Best Time to Start Medical Billing

Flu season is one of the busiest times of the year for pharmacies offering clinical services. For those looking to prevent the seasonal flu, getting a flu shot at the pharmacy is many people's go-to. It's quick and convenient, and saves the patient a trip into a clinic. Pharmacies have been offering flu shots for patients for years.

It is the ideal time to get started with medical billing because it hands you a high volume of simple, repetitive claims to build your billing workflow on. It's one core service that allows you to start small and build your practice. You can credential once, practice clean claims across thousands of low-risk vaccine encounters, and start collecting reimbursements for administration during your busiest season.

In this blog, we'll cover:

• Why start medical billing with vaccines?
• Why is flu season a good time to start medical billing?
• Beyond flu: expanding the clinical menu
• Where to start with medical billing set up

Why start medical billing with vaccines?

If each time you gave a flu shot you could make more money for doing the same amount of work, what would you say? Billing for vaccines is widely available to pharmacists in most states, and whether or not it's flu season, that's often where most pharmacies start.

Medical billing can seem intimidating if you're just starting out, but it's worth the investment. If you're only billing vaccines through the pharmacy benefit, you're typically only getting reimbursed for the vaccine itself. Billing through the medical benefit covers the actual administration of the shot. This means you're only getting reimbursed partially for the exact same service and patient experience with pharmacy benefit.

This difference can be significant, especially at the volumes pharmacies typically see during flu season. The CDC estimates that retail pharmacies in the US administered approximately 36.4 million adult flu vaccines last season across roughly 62,000 locations. This averages to about 590 shots per pharmacy per season, although this volume can vary meaningfully depending on the number of providers in the pharmacy, location, core season demand, and more.

It's easier to add a new billing workflow into a process you're already familiar and comfortable with than it is standing up an entirely new service and a new billing workflow. It's a chance to get comfortable with the billing element with a service you already know inside out, before expanding it across other newer services.

Why is flu season a good time to start medical billing?

Starting with flu season means starting medical billing with a small set of CPT codes and straightforward billing submissions that look the same each time. It's a chance to practice submitting clean claims and get used to the system before moving onto more complicated services. Using a simple workflow allows you to learn and adjust throughout the season, and eventually optimize the workflow to what works best for your team.

With flu season carrying the highest volume of vaccine appointments, there's also an immediate opportunity to capture return on investment for standing up medical billing. Depending on the vaccine being administered, pharmacies can see a per-dose advantage ranging from around $10 to $40 per administration.

Consider this example of flu vaccines in a Michigan pharmacy. For each dose administered, the $9.99 reimbursement value would have been left on the table. If this Michigan pharmacy is administering the average number of doses per season, that's $5900 for adult flu shots alone, before considering child flu vaccinations, pregnant women flu vaccinations or Covid-19 vaccinations.

Pharmacies have the opportunity to start generating this additional revenue and fine-tune their billing workflow, closing out the season with a foundation for adding additional clinical services.

Beyond flu: expanding the clinical menu

Once you've built confidence with medical billing, it's a good time to start adding on other clinical services. Medication therapy management, test-and-treat for ailments like strep throat are common clinical services available for pharmacists to offer to patients in many states, and make great additions to a growing clinical services practice.

Pharmacists' scope of practice as well as what's eligible for medical billing by pharmacists varies by state.

The best place to start understanding what's billable in your state is by looking to your state Medicaid agency's provider to understand the reimbursement pathways, your state board of pharmacy to confirm your legal scope, and if you serve Medicare patients, the CMS billing guidance and lastly your state pharmacy association for resources and state-specific guidance.

Once you've decided on which additional clinical services you want to offer at your pharmacy, you may need to credential and contract further and follow many of the same steps as in your initial flu season setup.

Where to start with medical billing set up

Getting paid for services brings in areas like provider enrollment, payer rules, and documentation standards that are outside of the pharmacy's usual clinical services workflow. If you're brand new to medical billing, it's hard to know how and where to get started.

Regardless of the state you're practicing in, you can get started by:

1. Confirm your scope before you start to build anything. What you can bill for is decided by what your state licenses you to do, so start with understanding what you can bill for in your pharmacy.
2. Prepare your payer identifiers. Two things need to exist before a claim can go anywhere: an individual NPI (National Provider Identifier) for any pharmacist that will be providing billable services, and, where applicable, enrollment with Medicare and/or your state Medicaid program. This is administrative work and it's the step most commonly skipped or rushed, which can lead to bounced claims down the road.
3. Credential with payers. Each payer has its own credentialing process, and their timelines run weeks to months. Enrollment with Medicare/Medicaid doesn't automatically mean commercial payers will reimburse you.
4. Map your services to codes. CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes are how clinical work becomes a claim. Pharmacy clinical services like point-of-care testing, vaccine administration, and medication therapy management each have their own code sets. Some services are billable only under specific payer or state programs. Pay attention to this, this is where "we're licensed to do this" and "we can bill for this" can quietly diverge.
5. Build your encounter documentation habit before your first patient. Each claim that is submitted needs documentation to back it up, so clinical documentation is a non-negotiable. Payers want to know what was assessed, decided and communicated to the patient.
6. Decide how you'll submit your claims. CMS-1500 forms are the standard claim forms healthcare providers use to bill for the services they provide. They can be sent directly to the insurance companies and/or government agencies like Medicare and Medicaid, or go through a third party clearinghouse for a fee. The clearinghouse cleans the claims and routes them to payers, helping catch any errors.

These steps don't have to happen one at a time. You can work on scoping, enrollment and credentialing at the same time, helping you get to the setup finish line sooner.

Medical billing made easy, with MedMe

One of the last decisions you'll need to make while you're getting set up with medical billing is whether you're going to do all billing in-house with your existing team, procure a service that helps with medical billing, or outsource the billing work completely. This depends on how much control you want over the process and how much you're willing to invest up front.

MedMe's Medical Billing Suite is an extension of the end-to-end EHR platform that helps simplify medical billing for those who want to keep the work in house, but work with a collaborative partner to reduce the lift from the in-house team. MedMe's white glove service provides end-to-end support, from credentialing and contracting, to patient insurance verification, coding and claim generation, denials management and reconciliation, and everything in between, visualized in a custom dashboard. Our mission is to improve access to patient care through community pharmacies, so we work hard behind-the-scenes to automate administrative work and bring the expertise that compliments your team's focus and expertise on patient care.