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Offering Vaccines Could Cost Pharmacies — Unless They Have Help

For months now, Americans have been eagerly waiting for the COVID-19 vaccine to be available at their community pharmacy. For many, that time has finally come. However, pharmacists are beginning to encounter a problem they should have never had to face.

In a recent article on, writer Phil McCausland discussed the plight of many pharmacies currently providing the COVID-19 vaccine. In particular, McCausland highlighted a growing problem in the pharmacy industry as more people turn to drugstores for vaccines:

These small businesses are often not getting paid for the work and costs associated. The reason lies within a decades-old system of medical billing and insurance long left unaddressed by state governments and federal agencies.

Pharmacies are having trouble billing insurance companies for vaccine administration because that service falls under the medical benefit. Many insurance providers simply won’t allow pharmacies to file for reimbursement outside of the pharmacy benefit.

What Is Vaccine Distribution Costing Pharmacies?

In his article, McCausland spoke with Gigi Gronvall, senior associate at the John Hopkins Center for Health Security. “It’s kind of a no-brainer to keep giving [pharmacies] more responsibility,” she said, “especially when we have such a fragmented public health system and such an overburdened medical system right now.” But what is that responsibility costing the pharmacies?

Pharmacists are frequently asked to do the right thing without certainty of fair compensation for their work. They provide a public service and answer a public need, but they often find it difficult to make a living doing so. Here are the costs they have to consider when administering vaccines:

  • Time for pharmacy staff to administer vaccines to patients
  • Training for vaccine administration
  • Storage for vaccines (special freezers, in some cases)

In April 2020, the Department of Health and Human Services granted authorization to all pharmacists nationwide to order and administer COVID-19 vaccines. But federal legislation that gives provider status to all pharmacies still has not been passed. In short, this means that while pharmacists across the country can administer vaccines, not all of them can be reimbursed for it.

The Provider Status Issue

As of October 2020, pharmacists have provider status in 37 out of 50 states. In these states, pharmacists are eligible to bill the medical benefit for clinical care services, including administering the COVID-19 vaccine. That leaves 13 states where pharmacists have no reimbursement path for providing much-needed clinical care for their communities. But even the pharmacists in states with provider status aren’t having an easy time getting paid like providers.

Because of the complexities of the medical billing process, many pharmacists face delays in their reimbursements, if not outright rejections. But there are solutions available that can help pharmacists navigate the world of medical billing and get paid for their clinical care services.

Is a Medical Billing Solution the Answer?

Billing the medical benefit isn’t the same as billing the pharmacy benefit. The process is more complicated. There are different billing codes to keep track of. Many claims require proper documentation to get paid for services performed. Plus, the wait time between claim submission and claim approval or denial is longer — often up to 14 days.

How complicated is medical billing, really? An entire profession was created to cater to it. Physician’s offices and hospitals often have specialized billing and coding departments to handle their claims. Most pharmacies don’t.

Medical billing solutions like FDS MEDBILL were created to simplify the medical billing process and offer vaccine help for pharmacies. Pharmacists have more important things to do than learn the ins and outs of billing the medical benefit of their patients’ insurance plans. Plus, medical billing solutions often aren’t as expensive as pharmacists expect.

How to Get Started with Medical Billing for Vaccines

You need more than just a medical billing solution to start billing the medical benefit. Remember when we said it was a complicated process? Here we go.

It’s best to start with Medicare Part B, as it likely covers many of your patients. The first thing you need to do is complete a CMS 855B application and enroll as a mass immunizer. You should expect to wait up to eight weeks for approval. Once approved, you get a Provider Transaction Access Number (PTAN), which is necessary for billing vaccine administration under the medical benefit. You can apply by visiting the Medicare PECOS website.

Working with commercial payers is a bit different, and it also involves a bit more work. To bill claims to commercial insurance providers, a pharmacy has to be contracted with each individual payer. This can be difficult for smaller retail and independent pharmacies, which is one of many reasons why some become members of a PSAO that will negotiate and enter into contracts on their behalf.

Offering vaccines in your pharmacy is important. And while some immunizations — like the flu shot — can be covered by the pharmacy benefit, pharmacies often need to bill the medical benefit to be reimbursed for administering vaccines. Navigating the world of medical billing can be difficult, but help is out there. Don’t try to do this on your own. Vaccine help for pharmacies is out there, but you have to know where to look and what to look for.


Amplicare is now part of EnlivenHealth®


FDSRX is now part of EnlivenHealth®