Continued Underpayment of Rotateq Vaccine by Tricare South/PGBA

We recently received an excess of $7,000.00 in refund requests from PGBA on behalf of Tricare South.  The refund requests listed hundreds of patients, and some services dated as far back as January 2008.  Although the refund requests did not list CPT codes, it was determined that the refund requests referred to Rotateq, CPT code 90680.  PGBA retroactively deemed the NDC in use as obsolete.  The refund request was reconsidered and eventually reversed; however, we continue to struggle with PGBA for correct payment of the Rotateq vaccine.

We have been receiving payments of only half the expected rate from Tricare/PGBA for the Rotateq vaccine for the majority of 2011 and into 2012.  We have spoken with representatives at PGBA countless times and have received conflicting information from almost every representative we have spoken with.  We have attempted to bill the vaccine using several different methods, as advised by the representatives, including billing the vaccine using package qualifier "F2," billing the NDC as 2 milliliters, billing the NDC as 2 units, billing the strength value as "P" to indicate we are administering a package, etc.  PGBA is aware of the issue and has made no effort to resolve it internally. 

After researching the issue, we discovered the following as posted by the California Medical Association:

[California Medical Association] worked with TriWest to correct error resulting in underpayment of RotaTeq vaccine In July 2010, the CMA began receiving reports from physicians about a sudden decrease in payments for the RotaTeq vaccine (CPT 90680). Physicians reported that beginning with May 1 dates of service they saw their rates drop from $70/dose to $35/dose, which didn’t cover the cost of the vaccine. CMA reached out to our contacts at TriWest and asked them to investigate. As a result of CMA’s efforts, TriWest identified a clerical error causing underpayments not only for RotaTeq, but several other vaccines that did not have a set CHAMPUS Maximum Allowable Charge rate. The vaccines had been entered into the TriWest system as two-unit vaccines rather than 2 ml vaccines, thus reducing the payment by 50 percent. TriWest corrected the error and, at CMA’s request, automatically reprocessed all affected claims.

We filed a complaint with the Texas Department of Insurance requesting similar action.  As stated by the CMA, a clerical error with TriWest resulted in 50% payment.  I believe that, upon researching the issue with Tricare South/PGBA, a similar error will be found and could easily be resolved, relieving the issue for pediatric practices across Texas and the rest of the Tricare South region.

We requested assistance in reaching a resolution to the 50% underpayment of Rotateq vaccine (CPT code 90680) with Tricare/PGBA.

I have found two other blogs on this issue with PedSource, however, the authors mentioned they had yet to receive correct payment.  Are there any other pediatric practices in the Tricare South region who have discovered a resolution resutling in correct payment?  I was advised the correct allowable was $70.63, and upon submission of a corrected claim by paper appending the NDC with the letter "P" to indicate package, we are receiving the correct amount, but it is very time consuming to monitor each Rotateq administered to each Tricare patient. 

Any tips on resolving this issue would be much appreciated!