HomeMy WebLinkAbout2014-11-24 15-017 ORDERCOUNCIL ACTION
Item No. 15-017
Date: November 24, 2014
Item/Subject: ORDER, Authorizing the City Manager to Execute a Memorandum of
Understanding with the University of Massachusetts Medical School.
Responsible Department: Health and Community Services
Commentary: This Order will authorize the City Manager to execute a memorandum of
understanding with the University of Massachusetts Medical School to bill insurance on behalf of
the Public Health and Community Services Department Travel & Infectious Disease Program for
reimbursement of administrative costs associated with public vaccine clinics. The State of Maine
Immunization Program has arranged for the University of Massachusetts Medical School to act
as a third -party vendor for public health entities so that insurance claims can be made.
This agreement would be of no cost to the City of Bangor. As a fee for service, the University of
Massachusetts Medical School would receive 20% of approved and paid claims. The agreement
would be subject to an annual renewal by both parties. This was reviewed and recommended
for approval by the Government Operations Committee on November 17, 2014.
Manager's Comments:
Associated Information: Order
Budget Approval:
Legal Approval:
Introduced for
X Passage
_First Reading
Referral
Department Head
C-2-21 VV - U&'//
City Manager
Page _of_
Finance Director
Solicitor
15-017
NOVEMBER 24, 2014
Assigned to Councilor Civiello
CI`T'Y OF BANGOR
(TITLE.) ORDER, Authorizing the City Manager to Execute a Memorandum of
Understanding with the University of Massachusetts Medical School.
BY THE CITY COUNCIL OF THE CITY OF BANGOR:
BE IT ORDERED, that the City Manager is hereby authorized to enter into a
Memorandum of Understanding with the University of Massachusetts Medical School to act as a
third -party vendor for the Public Health & Community Services Department Travel & Infectious
Disease Program.
IN CITY COUNCIL
NOVEMBER 24, 2014
MOTION MADE AND SECONDED FOR PASSAGE
PASSED
CITY CLERK
15-017
NOVEMBER 24, 2014
Memorandum
To: Government Operations Committee
From: Patty Hamilton, Director of Health & Community Services
Date: November 13, 2014
Re: Flu Clinic Reimbursement
PH&CS, Travel Health & Infectious Disease program has been working with the State Immunization
program to provide flu shots in school settings for several years now. We vaccinate teachers, parents
and siblings at these 'school located clinics'. Research shows that by providing vaccines in school settings
more children are immunized resulting in fewer missed days of work for parents, fewer missed days of
school for children and an overall decrease in circulating flu in the community.
We participate in the Universal Vaccination program meaning we receive 'free' vaccine from the state of
Maine for this purpose and are required to provide vaccines free of charge to children up to age 19.
Receiving free vaccine does not however mean there are no costs associated with providing the service.
To help cover costs such as staff time, supplies and disposal we are allowed to ask for a $10.00
administration fee. Although we have been fairly successful this is not a reliable way to recoup our
expenses.
We have had on-going discussions with State of Maine Immunization program staff about the barrier of
cost to us to continue to offer this service. In response the state began conversations with the University
Of Massachusetts Medical School who has for several years acted as a third party vendor in
Massachusetts for entities like ours to recoup vaccine expenses.
Signing this MOU would allow us to go through this vendor and have them act as a clearing house for
insurance claims for vaccine administration from public clinics. This would allow us a more stable
revenue stream and over time would enable us to more accurately budget for this program. This
agreement would be no cost to the City of Bangor. The University of Massachusetts Medical School
would receive 20% of approved claims. The legal department has reviewed the MOU and recommended
a yearly MOU vs. an automatic renewal and the University has agreed and made this change.
15-017
NOVEMBER 24, 2014
Agreement By and Between
XXX (Public Clinic)
and the University of Massachusetts Medical School
This Agreement is entered into as of September 1, , by and between
(hereinafter referred to as the "Public Clinic"), located at
and the University of Massachusetts Medical School, located at 529 Main Street, Charlestown, MA
(hereinafter referred to as "UMMS").
UMMS makes available to Public Clinics services related to collecting reimbursement that may be
available for the vaccines that Public Clinics administer to patients. The available reimbursement
sources may be: commercial health insurers and Medicare Part B.
Public Clinic provides and administers vaccines ("Vaccine Administration") for which certain payers
have agreed to provide payment ("Payer(s)").
Payers include Insurers and Medicare as those terms are defined below:
A. Certain commercial health insurers ("Insurers") that have agreed to provide payment to Maine
public clinics for Vaccine Administration and to use UMMS as a clearinghouse to facilitate such
payment.
B. The federal Medicare Part B Program ("Medicare"). Public clinics that participate in the Medicare
Part B Program are eligible to receive payment from the Medicare Part B Program for Vaccine
Administration, in accordance with Medicare Part B Program requirements.
UMMS has agreed to act as a clearinghouse for claims for Vaccine Administration from Public
Clinics.
The parties hereto agree as follows:
Section I. Pavers
The responsibilities of the parties set forth in this Agreement will apply to the claims for Vaccine
Administration by the Public Clinic with respect to only those Payers checked below ("Claims"):
A. F-1 Insurers: Commercial health insurers that have agreed to provide payment to Maine Public
Clinics and to use UMMS as a clearinghouse to facilitate such payment. Certain Insurers may
require different or additional terms and conditions than those set forth in this Agreement. If
that is the case, such terms and conditions will be set forth in either a written amendment to
this Agreement signed by Public Clinic and UMMS or a separate agreement signed by Public
Clinic and UMMS.
B. El Medicare: Public Clinics that participate in the Medicare Part B Program are eligible to
receive payment from the Medicare Part B Program for Vaccine Administration, in
accordance with Medicare Part B Program requirements.
Pagel of 8
15-017
NOVEMBER 24, 2014
Section II. UMMS Services
A. UMMS: General Responsibilities
The following services will be provided to Public Clinic by UMMS with respect to Claims for all
Pavers checked in Section I, above.
UMMS will:
1. Provide training material to Public Clinic regarding all data requirements necessary to prepare
and submit Claims, including the Health Screen and Permission Form (attached hereto as Exhibit
#1). The Health Screen and Permission Forms are updated annually, and UMMS will provide
Public Clinic with current forms in a timely manner.
2. Collect the Health Screen and Permission Form and other data for Claims for Vaccine
Administration by Public Clinic.
3. Verify eligibility of individuals receiving Vaccine Administration in the plan identified Health
Screen and Permission Form in section 10 titled Health Insurance.
4. Prepare and submit Claims for payment of Vaccine Administration for individuals UMMS has
determined to be eligible in a particular plan sponsored by a Payer, pursuant to Section I, above.
5. Attempt to resubmit and reprocess any rejected or denied Claims at the discretion of UMMS
only.
6. In the event that third -party liability coverage is identified, UMMS will attempt to submit the
Claim to the appropriate payer or return the Claim to Public Clinic, as appropriate.
7. Reconcile Claims and provide a report to Public Clinic that includes a summary of paid and
denied Claims.
8. UMMS will not be responsible for unreimbursed/denied Claims.
B. UMMS: Payer -Specific Responsibilities
1. Insurers: UMMS will provide the following services for Claims to "Insurers" if that box is
checked in Section I.A. above:
a. Submit Claims for Vaccine Administration defined in Exhibit #2 attached hereto, entitled
Vaccine Administration for Insurers, to Insurers for complete Health Screen and Permission
Forms received by UMMS for services provided by Public Clinic for individuals UMMS has
determined to be eligible for coverage by Insurer. When additional Insurers agree to provide
payment for Vaccine Administration, UMMS will provide Public Clinic notification of such
agreement, including which Vaccine Administration services the additional Insurer will cover.
b. Receive payment from Insurers on behalf of Public Clinic for Claims approved for payment by
the Insurers ("Insurer Approved Claim(s)").
Page 2 of 8
15-017
NOVEMBER 24, 2014
c. Make payment to Public Clinic in an amount equal to the amount received by UMMS for
Insurer Approved Claims less a fee of 20% per Insurer Approved Claim paid to UMMS by
Insurers.
2. Medicare: UMMS will provide the following services for Claims to "Medicare" if that box is
checked in Section I.C, above:
a. Assist Providers with the acquisition of a National Provider Identifier ("NPP') if the Provider
does not have an active NPI.
b. Assist the Provider with the completion of the CMS 855B Medicare Enrollment Application for
Clinics, Group Practices, and Certain Other Suppliers.
c. Review the Medicare Enrollment Application to ensure that all sections have been properly
completed and executed.
d. Submit Claims for payment of Vaccine Administration of Influenza and Pneumococcal
vaccines for individuals UMMS has determined to be eligible for Medicare.
e. Accept payment for Medicare claims that have been approved for payment by Medicare
("Medicare Approved Claims") according to the method checked below:
0 UMMS will offset the amounts to UMMS for Medicare Approved Claims under the
agreement by offsetting the amounts UMMS owes to Public Clinic for Insurer Approved
Claims pursuant to Section II.B.1.c, above. UMMS reserves the right to withhold payment
for Insurer Approved Claims until UMMS has been compensated for 20% of the Medicare
Approved Claims;
OR
UMMS will submit an invoice to the Public Clinic for 20% of the Medicare Approved
Claims per the 835 and paper remittance advices.
Section III. Responsibilities of Public Clinic
A. Public Clinic: General Responsibilities:
Public Clinic is responsible for the following activities with respect to Claims for Vaccine
Administration for all Pavers checked in Section I, above ("Claims").
Public Clinic will:
1. Within thirty (30) calendar days after Vaccine Administration, submit the Health Screen and
Permission Forms to UMMS for each Patient and each Member in electronic or paper form.
Health Screen and Permission Forms must be completed in entirety to ensure approval of Claims
by Payers.
2. Obtain copies of patient insurance cards, whenever possible, and attach them to the Health
Screen and Permission Form when submitted to UMMS.
Page 3 of 8
15-017
NOVEMBER 24, 2014
3. Submit a copy of the invoice for all privately purchased vaccines related to the Claims.
4. Sort and batch the Health Screen and Permission Forms and related documents by Insurer, if
possible.
5. Maintain originals of the Health Screen and Permission Form and copies of related documents
submitted to UMMS.
6. Submit copies of completed Health Screen and Permission Forms to UMMS via
• Paper sent by certified U.S. Postal Service mail or some other delivery service/system by
which shipments may be tracked:
To: University of Massachusetts Medical School
Center for Health Care Financing
529 Main Street, 3rd Floor
Charlestown, MA 02129
ATTN: Holly Oldham
B. Public Clinic: Payer -Specific Responsibilities
1. Insurers: If the box for "Insurers" is checked in Section I.A, above, Public Clinic will:
a. Enroll and maintain enrollment in the Maine Department of Public Health (MDPH) Vaccine
Program.
b. Enter all vaccination information into the Maine Immunization Information System (MIIS) as
required by MDPH.
2. Medicare: If the box for "Medicare" is checked in Section I.C, above, Public Clinic will:
a. Submit a complete CMS 855B application to the appropriate Medicare billing intermediary as
directed by UMMS.
b. Submit all other documents as required by Centers for Medicare & Medicaid Services (CMS)
to obtain and maintain the Medicare Provider number.
c. Pay Medicare any enrollment or revalidation fees as required by CMS
d. Ensure that the individual responsible for authorizing the CMS 855B application supplies
his/her Social Security Number.
e. Ensure that the individual responsible for authorizing the CMS 855B application signs and
dates the application.
f. Provide UMMS with authorization to transmit electronic Claims in 837 files and to access all
835 remittance advices from the Medicare intermediary upon enrollment. If Medicare is not
Page 4 of
15-017
NOVEMBER 24, 2014
able to conduct electronic transactions, Public Clinic will authorize UMMS to roster bill and to
receive remittance advices.
g. Maintain an active Medicare Provider number for the dates of service applicable to each Health
Screen and Permission Form submitted to UMMS.
h. Pay UMMS 20% of Medicare Approved Claims for invoices properly submitted to UMMS per
Section II.B.3.e.
Section IV. Public Clinic Representation and Warranty
Public Clinic hereby agrees, represents and warrants that it shall accept as final payment in full for
Vaccine Administration the amount paid to UMMS by the Payers less a fee of 20% per Payer
Approved Claim by all Payers, and that Payers, if applicable, shall have no further liability for that
Claim. Public Clinic further represents that it shall not charge, collect a deposit from, seek
compensation, remuneration or reimbursement from eligible patients, or have any recourse against
anyone other than the Payers for Vaccine Administration. The provisions of this Agreement shall
survive termination of this Agreement and shall be construed to be for the benefit of the eligible
patient.
Section V. Confidentiality
UMMS acknowledges that, in the performance of services under this Agreement it shall comply with
all applicable federal and state law relating to confidentiality and the security of data, including the
Privacy, Security, Breach Notification and Enforcement Rules at 45 CFR Part 160 and Part 164,
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
the Health Information Technology Economic and Clinic Health Act (HITECH) provisions in Title
XIII of the American Recovery and Reinvestment Act of 2009, and M.G.L. Chapter 93H.
Section VI. Recordkeepin2
UMMS shall maintain all records required by law and shall additionally maintain all records, books,
files and other data in sufficient detail as to properly substantiate claims made for Payer reimbursement
on behalf of the Public Clinic.
Section VII. Taxpayer Identification Number and Form W-9 Certification
Public Clinic will sign and submit to UMMS a University of Massachusetts substitute W-9 Form
provided by UMMS.
Section VIII. Term of Agreement
This Agreement commences on September 1, 2014 and ends on June 30, 2015.
Page 5 of 8
15-017
NOVEMBER 24, 2014
Section IX. Integration
This Agreement constitutes the entire agreement of the parties with respect to the subject matter
hereof, including all attachments hereto, and supersedes all prior agreements, representations,
negotiations, and undertakings not set forth or incorporated herein.
Section X. Contact Information
Inquiries relating to this agreement should be directed to the following individuals:
For UMMS:
University of Massachusetts Medical School
Center for Health Care Financing
529 Main Street, 3`a Floor
Charlestown, MA 02129
Mary Fontaine
(800) 890-2986
Vaccine.Reimbursement@umassmed.edu
For Public Clinic:
Provider Name:
Address:
Address Line 2:
City/State/Zip:_
Phone Number:
E-mail:
IN WITNESS THEREOF, the parties hereto execute this Agreement as of the date first written above:
Public Clinic:
Signature
Print Name:
Print Title:
UMMS:
Signature:
Marc A. Thibodeau
Executive Director, Center for Health Care Financing
Commonwealth Medicine, UMMS
Page 6 of 8
15-017
NOVEMBER 24, 2014
Exhibit #1
INFLUENZA, 'VACCINE .HEALTA SCREEN & PERT►IISSION FORM .1 NPL I
`FullName: Date of Birth; Age:'; Gender: SchoolName:
Street Address: Tawi-Xity: Zip Code: Daytime Phore:
.Grade:: Teacher: SchoolAdministrative Unit (District)
'.,Please muxs &e foDm+�g.queitions about &e penon named above. C-o=na&, may be wrillm on the'back ;of this Sohn.
-)MS NO
1) Does this:personhave`asevere .(life-1hieaterang)allergb toeggs?
2) Hasihispersonevei•hada'severe-reactiontoaninfhienzai•�i intlYpast?
Kyou ansuW*d 'jos U any quer — l-3,'plue see yna he&Wum provider fai jfttivucbi4fimi
4} "Has this.personreceivedanyotl�rvaccinatiominthe past4weeks;bri5'notfeelingwell?
If yes, Type' of vaccine ]date
5) Does thispersonhave long=tetmhealthproblems; aUergies, asthma.orwheezingprioblems, or.onloxjg
termaspirintreatcnent?.' '
&) Does this,personhave aweakenedimrmure system;orcome inclose contactvnthsome(mewho has a,
to
10)'Is this person inmredby MaineCare (Medreaid)?
MaineCare ID 0
10) HealthInsurance: Name of Company.
ID Number: Croup m miber:
,Subscriber Name Subscnber.DateofBirth
11) Doctor's Name: CPhor:e Nuriiber:
PERMISSION TO VACCINATE
>Iwas gi' acopyof'th%`Infbitenz;VaccineInformationStatemerds,Ihave read themorhadthem
explained tome and I understand the benefits and risks of the I46nza vaccine .
..I give-perrti ssion for a record of this.vaccinationto be entered into Abe ImmPact.P;egistry.
( give, permission'for.information to be used to bill IdaineCaie or private insurance for thd'cost of pmyuiuig the vaccine
> .I give my consent for thi,. persontioeceive the most appmpriate vaccine, as deterininedbythe healthcare clinic �,
A Ifmychild refiises,to receive the injectionanddoesnot have.anyofthe corditiaais #4-7lis ted above; you have my
permission to, give the nasal flu mist.
I give permkFionfor the f luvaccim tbbe gk"to tbepersonnmrredabove bysigmbchelow.
Sigtra aeofpareirtorguai�dnv►ifpersuntbbevaecioraiedisarrifmoiorSig ti"bfadi tobevacchudiA
Printed Name, of Parent or'Guaidian:
FOR OFFICE USE ONLY:
Bate Dose,
Vacdne
Lot Nimi]ber
:Dose
Sigrt ium wid U_ of
.:Body
Route
VIS date
Adrlmuftaed
1rl8nrlfattlQ�
VOlIQM1e
'Vatd7r�(R'
Site'
v IM single dme
O M Britt csei
O 7cemesd
'Mkie CDC -W10114
Page 7 of 8
Vaccine Administration for Insurers
Administration
15-017
NOVEMBER 24, 2014
• Administration of influenza virus (includes percutaneous, intradermal, subcutaneous, or
intramuscular injections) for individuals ages 6 months and older enrolled in any Insurer's
health plan, including Medicare Advantage.
• Administration of influenza virus by intranasal for individuals ages 6 months and older enrolled
in any Insurer's traditional health plan only.
Provision of Privately Purchased Influenza and Pneumococcal Vaccine (Payment is not available
for State -provided free flu vaccine.)
• Influenza virus vaccine, trivalent or quadrivalent, split virus, preservative -free, for intramuscular
use, administered to individuals ages 19 and older enrolled in any Insurer's health plan,
including Medicare Advantage.
• Influenza virus vaccine, quadrivalent, live, for intranasal use, administered to individuals ages 19
and older enrolled in any Insurer's traditional health plan onlv.
• Influenza virus vaccine, trivalent or quadrivalent, split virus, intramuscular use, administered to
individuals ages 19 and older enrolled in any Insurer's health plan, including Medicare
Advantage.
0 Influenza virus vaccine, split virus, preservative -free, for intradermal use, administered to
individuals ages 19 and older enrolled in any Insurer's traditional health plan only.
• Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased
antigen content for intramuscular use administered to individuals of any age enrolled in any
Insurer's health plan, including Medicare Advantage.
Page 8 of 8