Preserving critical public health services: Creating reimbursement strategies with private and public health plans

Thursday, March 7, 2019


Public health authorities at the state and local levels provide various essential and critical public health services to benefit communities. Often these services are provided without any reimbursement. Many public health authorities find themselves struggling to continue offering valuable services to vulnerable populations in their communities with little to no funding. To overcome these obstacles, public health officials needed to start seeking funding through alternative methods. The Affordable Care Act (ACA) expanded the set of services eligible for reimbursement through third parties. Certain preventive services now have mandated coverage by both public and private health plans. This creates the opportunity for public health officials to expand their sources of funding and in turn, provide better health outcomes for their communities.   


Although the ACA created an opportunity for public health authorities to seek third party reimbursement for public health services, new policies take time to interpret and implement. The H1N1 pandemic in 2009 charged local communities with dispensing and administering the H1N1 vaccine to the general public as quickly as possible. The Massachusetts Department of Public Health (MDPH) quickly acted to ensure that these public providers had access to the H1N1 vaccine, but hoped to find a way to help already over-burdened communities pay for the additional costs associated with administering these vaccines. Through initial funding and assistance from MDPH, UMass Medical School’s Commonwealth Medicine division approached the health plans about establishing a mechanism for public providers to claim and receive reimbursement for immunization services. While health plans expressed concerns of providing services outside the primary care network, they understood the urgency of the pandemic, as well as the long-term benefits of providing their members additional access points to essential preventive services in communities across the state. 


Commonwealth Medicine developed solutions for the billing and reimbursement challenges faced by public health providers. By partnering with state and local authorities in Massachusetts and Maine, Commonwealth Medicine has:

  • Provided a mechanism for cities, towns, and school districts in Massachusetts and Maine to get reimbursed for vaccination services at public health clinics by establishing key contracts required for reimbursement and providing a comprehensive centralized billing solution.
  • Solved a reimbursement issue for the Massachusetts State Public Health Laboratory (MSPHL) by enrolling the lab as a provider for the state’s Medicaid plan (MassHealth), Medicare, and various private health plans. This enables MDPH to bill and receive reimbursement for its Sexually Transmitted Infectious Disease Unit which receives specimen submissions from providers across the state. This unit’s work provides both comprehensive laboratory services for disease surveillance and investigation and ensures critical linkage to care consistent with public health goals in the treatment and prevention of sexually transmitted infections.  
  • Transitioned claiming for state-mandated Childhood Blood Lead Laboratory Screenings. Commonwealth Medicine identified opportunities to streamline the collection of billing data and helped SPHL navigate ever-changing claiming requirements to ensure the laboratory continues to receive funding critical to maintaining its operations. The Childhood Lead Poisoning Prevention Program not only helps diagnose and treat childhood lead poisoning but works to eliminate sources of poisoning.


The success of Commonwealth Medicine’s billing support for public health initiatives across New England can be seen in the numbers:

  • Revenue collected for services provided at local vaccination clinics in Massachusetts and Maine reached $2.2 million in 2018, up from $330,000 in 2010
  • The number of local health departments, school districts and visiting nurse associations taking part in the vaccine reimbursement program also jumped dramatically, from 80 to 189 over the past decade
  • The number of public and private insurers paying for the vaccination clinics has doubled from six to 12
  • Reimbursement to municipalities has expanded from the administration of influenza and pneumococcal vaccinations to include all vaccinations – for children and adults – routinely recommended by the CDC’s Advisory Committee on Immunization Practices.
  • The MSPHL has also seen steady reimbursement growth for sexually transmitted infection and blood lead testing services. Over $1.6M is expected in revenue for FY2019 for laboratory services. 

The Centers for Disease Control (CDC) cited the reimbursement program pioneered by Commonwealth Medicine as one of six “Billing Success Stories.” The CDC also frequently recognizes MDPH for achieving some of the highest immunization rates in the country.