Managing Your Practice: Answers to your questions about...

October 1, 2006

Reimbursement for the HPV vaccine; Dealing with sales reps; ER coverage

Reimbursement for the HPV vaccine

Q. My patients are asking when my practice will offer the new HPV vaccine. Is it usually covered by insurers? How should I charge and bill for it?

A. Most insurance policies will cover the HPV vaccine-but it may be considered preventive service. So, if a patient does not have coverage for preventive care, it may not be reimbursable. Before you administer the vaccine, check with the managed-care companies with which you have contracts to determine whether they cover the vaccine and if there are any restrictions on reimbursement. Keep in mind that to fully cover your costs, the reimbursement must be enough to compensate for wastage and loss, not just the cost of the vaccine and its administration. Most carriers will not allow you to bill the patient beyond contract allowances, so it's important to include wastage when you compute the necessary reimbursement. If reimbursement from a particular insurer isn't enough to cover your costs, advise covered patients to call the company and request an increase. Ob/gyns shouldn't have to shoulder the burden of insufficient reimbursement.

Dealing with sales reps

Q. Pharmaceutical representatives are calling on our practice at all hours of the day and taking parking spots from patients. How do we establish limits on their visits?

A. Policies regarding visits from pharmaceutical representatives vary among practices, depending upon their philosophy and logistics. Some physicians totally ban representatives. Some allow representatives to call only during specific times and/or on specific days. Some practices prohibit sampling because they feel it promotes the use of branded drugs in cases in which generics can treat a condition at lower cost. And some offices don't have storage space for samples.

Whatever your practice's preference, it should become policy agreed upon and adhered to by all partners and staff, and it should be stated in writing for the pharmaceutical representatives. Those who fail to comply should be asked to curtail their visits.

ER coverage

Q. Our local hospital requires us to cover the emergency room in order to retain privileges. The ER keeps getting busier and most of the patients are uninsured. Besides increasing our liability exposure, attending to the ER takes us away from the patients in our office, inconveniencing them and causing us to lose revenue. How can we mitigate the financial harm that this obligation entails?

A. In some areas of the country, specialists are being paid a fee by hospitals to cover the ER. Meet with the administrators of your hospital and make the case that they either reimburse you for covering the ER, or hire physicians for coverage. Prepare for the meeting by analyzing the financial details-including losses from uninsured care and from cancelled office hours-and demonstrate how unpaid ER coverage threatens your practice's viability. If there is more than one hospital in your region, consider switching your admitting privileges, and/or negotiating with one hospital versus the other for more favorable treatment. Hospitals are motivated not to lose your paying patients, so you should be able to turn this motivation to your advantage.

If the hospital(s) at which you have privileges can't afford to pay you for ER coverage and your privileges depend upon providing that service, then you'll be compelled to continue to take a loss on this obligation and consider it to be-and call it-public service.