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Billed for a pneumonia vaccination

NEWS FLASH! Medicare now covers two pneumonia vaccinations for those 65 and older. (See sidebar.) Here's what you need to know about billing. 

One month after turning 65, Ron visited his doctor for his “Welcome to Medicare” preventive visit. During that visit, the physician recommended that Ron get a pneumonia vaccination. He agreed and the nurse gave him the shot. A month later, Ron got a bill for $35 from the physician’s office for the vaccination. The billing clerk at the physician’s office told him that his Medicare Advantage plan would not pay for the vaccination. 

Ron decided to find out the reason his plan would not cover the vaccination. He talked to two different customer service representatives and got two different explanations.

  • The plan denied coverage because Ron got the vaccination in the doctor’s office and not a pharmacy.
  • Ron has to pay the physician and then submit a claim with his Medicare Advantage plan for reimbursement.

After some research, Ron realized that neither of these explanations was correct.  A pneumonia vaccination is a free preventive service for Medicare beneficiaries.  Ron followed the procedure for appealing a claim in the Medicare Advantage plan’s Evidence of Coverage. Ron learned that the person who initially reviewed his claim was new to the position and did not check the plan’s coverage manual. He should not have been charged a copayment for the vaccination. As for the two wrong answers he received, the plan representative handling the appeal said, “The answer was in the manual. They just didn’t look for it.”

Here’s what you need to know about a pneumonia vaccination.

  • A physician's order is not necessary for billing the vaccines.  
  • Beneficiaries can either receive the vaccination in the doctor’s office or a pharmacy.
  • Original Medicare beneficiaries should confirm that the physician accepts Medicare assignment. If not, the physician may charge a copayment for the visit but cannot charge for the vaccination. The Part B deductible does not apply.
  • Beneficiaries with Medicare Advantage should check with their plans about coverage of the vaccination. There is no copayment for the vaccination. 

Last updated: 12-30-2015