Familiarize yourself with the costs and expenses associated with immunizing to help you negotiate and receive the most appropriate payment for immunizing your patients.
View the Managing Costs page for information on controlling your practice’s expenses related to immunizing.
For private sector vaccines, you should not accept carrier refusal to pay separately and adequately for the vaccine product and the administration/counseling. Viable businesses pass on their increased costs to their purchasers to maintain profitability. Insurers understand business principles including the concept of return on investment and expect it in their business. Your practice – and all pediatric practices – are part of the public health infrastructure for the nation’s childhood immunization program. It is imperative that you be incentivized to participate in immunization efforts by appropriate payment for immunization administration. Learn more about payment and coding here.
Vaccine Administration of State-supplied Vaccine
The Vaccines for Children (VFC) Program is a federal program administered by the states, which provide vaccine product at no cost to physician offices to administer to children meeting eligibility criteria. Some states have created universal purchase programs, which purchase all vaccine for all children in the state and distribute it to immunization sites including pediatric practices. Other states have created universal select programs that exclude one or more vaccines. The greatest benefit of the VFC and universal purchase programs is that the vaccine product is provided to practices at no upfront cost, relieving the provider of the financial outlay to purchase the vaccine product.
However, your practice still incurs overhead expenses for vaccines, including storage, maintenance, inventory, administration, and vaccine spoilage and loss. In the private sector, those expenses would be covered through the vaccine product payment. As the vaccine product payment does not exist for VFC vaccine or in a universal purchase state, your practice should be paid for all overhead costs through enhanced payment of the immunization administration fee, or some other arrangement with the payer.
Immunization Administration Expenses
The Centers for Medicare and Medicaid Services (CMS) uses its Medicare Resource-Based Relative Value Scale (RBRVS), which assigns relative value units (RVUs) to services based on the resources utilized. The RVUs of a Current Procedural Terminology (CPT) code take into account the physician work, practice expenses, and medical liability insurance expenses associated with that service. Immunization administration codes are valued on the Medicare physician fee schedule (Resource-Based Relative Value Scale [RBRVS]) as follows, view them here.
Below is a table of costs associated with vaccinating children with private-sector vaccine or public-sector vaccine through the Vaccines for Children (VFC) program, and from where you should look for payment for these costs.
American Academy of Pediatrics