How Pharmacies Are Tripling Vaccine Reimbursement Through Smarter Billing Strategies
Webinar Date: May 20, 2025
Presented by: Dr. Angelina Tucker, PharmD, BCGP, CDCES & Rachael Matz, Head of Clinical Solutions, DocStation
Introduction: The Vaccine Billing Challenge
Pharmacies today are balancing on a razor’s edge: high demand, tight reimbursement, labor shortages, and the growing complexity of clinical services. Amid all this, one of the most overlooked revenue streams—vaccine reimbursement—continues to be constrained by outdated billing practices and limited system capabilities.
During our recent DocStation webinar, Rachel Matz, Director of Clinical Solutions, and Dr. Angelina Tucker, pharmacist and network lead at CPSN Texas, opened with a bold truth:
“Billing isn’t just about revenue—it’s about sustainability and being able to offer more services to our communities.” – Dr. Angelina Tucker
Many pharmacies unknowingly leave thousands of dollars on the table each month due to long-held assumptions about vaccine billing—particularly the belief that the pharmacy benefit is the only viable billing path. But this is no longer true. In fact, sticking to that single route can drastically undercut reimbursement by 2 to 3x.
That’s why DocStation is talking about a comprehensive framework designed to help pharmacies find and recover missed vaccine revenue through smarter billing. This isn’t just a guide—it’s a transformation strategy rooted in real data, clinical insight, and scalable technology.
S – Search for Hidden Billing Pathways
The first pillar of the SHOT Method addresses one of the most deeply ingrained myths in pharmacy operations: that vaccines must be billed through the pharmacy benefit (usually Medicare Part D or commercial PBMs).
“There’s this myth that there’s only one way to bill a vaccine. And when that claim gets rejected, most pharmacies just flip it back through the PBM—usually at a fraction of the value.” – Rachel Matz
This behavior is reinforced by dispensing systems that automatically default to Part D or PBM billing. However, many vaccines—especially for Medicare beneficiaries—are also reimbursable through the medical benefit, particularly under Medicare Advantage plans. The catch? Most pharmacies either don’t know how to access this benefit or assume it’s too complicated.
Real-World Financial Impact
These aren’t theoretical numbers—they’re based on actual claim data from DocStation pharmacy partners. The difference lies not in the clinical service provided, but in the billing path chosen.
Dr. Tucker emphasized that this change starts with awareness:
“The biggest shift isn’t just in the software—it’s in your mindset. You have to stop assuming that rejections mean the end of the road.”
By teaching pharmacy staff to identify and act on alternative medical pathways, you dramatically increase claim value—without adding clinical labor.
H – Harness the Medical Benefit Advantage
Discovering alternate billing routes is only the first step. The second pillar focuses on harnessing these opportunities in real time at the point of care.
DocStation does this by integrating payer-specific rules, eligibility logic, and pre-validation into your vaccine workflow. This lets staff immediately see when a vaccine should be billed through the medical benefit rather than the pharmacy benefit.
“One of our goals is to make 95% first-pass claim acceptance the new industry standard,” said Rachel.
What Makes a “Clean Claim”?
To avoid rejections and ensure timely reimbursement, pharmacies should follow a structured clean-claim checklist:
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Real-time eligibility verification
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Correct diagnosis codes (ICD-10) matched to vaccine type
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Provider-level detail (NPI and Tax ID matching payer requirements)
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Date of service accuracy and consent documentation
Dr. Tucker shared that prior to implementing these systems, many pharmacies were missing out on thousands of dollars a month—not due to a lack of effort, but because of invisible process failures. These gaps are often overlooked when eligibility checks are limited to PBM pathways or run too late in the process.
“It’s not that pharmacists aren’t trying. It’s that their systems don’t show them what’s possible.”
O – Optimize Your Submission Process
Even with the right billing pathway identified and a clean claim ready to go, bottlenecks still occur—often during EDI enrollment or due to fragmented workflows across billing, documentation, and staffing.
DocStation simplifies this with a centralized and accelerated EDI onboarding process, reducing what traditionally takes 30–45 days to under 10 days in many cases. But this is only part of the optimization effort.
Workflow Best Practices:
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Enroll all Medicare Advantage plans during EDI setup, not just a subset
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Integrate vaccine billing with dispensing workflows to avoid dual entry
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Forecast staffing needs by historical vaccine volume (flu, COVID, shingles seasons)
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Train all staff to recognize and respond to reimbursement opportunities
“We can’t rely on one billing guru anymore. Every pharmacist needs to be fluent in spotting revenue opportunities.” – Dr. Tucker
In short, operational success is not about individual heroics. It’s about standardized systems and staff empowerment.
T – Track and Maximize Reimbursement
Claim submission is not the finish line—it’s the starting point of the revenue cycle. This final SHOT pillar focuses on ensuring payment follows submission, through proactive tracking and follow-up.
DocStation’s platform includes a robust dashboard that:
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Flags underpaid or denied claims
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Tracks appeal deadlines and resubmission windows
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Automates follow-ups and generates alerts for pending action
“A lot of pharmacies lose 15–20% of vaccine revenue just by not tracking what happens after the claim goes out.” – Rachel Matz
Data-Driven Optimization
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Identify which payers routinely underpay
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Track reimbursement timelines and aging reports
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Use analytics to guide vaccine inventory decisions
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Optimize documentation to reduce recurring errors
“When you make data your compass, your billing strategy becomes a revenue engine.” – Dr. Tucker
Implementation Roadmap: From Setup to Sustainability
Rolling out the SHOT Method isn’t disruptive—it’s guided and step-by-step. DocStation’s implementation roadmap is designed to meet pharmacies where they are and build from there.
Roadmap Milestones:
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System Assessment – What’s missing? What’s possible?
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EDI Plan Setup – Registering with medical payers and Advantage plans
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Workflow Redesign – Mapping your current state vs. optimized state
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Staff Onboarding – Training for billing, documentation, and eligibility
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First Claim Submission – Guided live support for your first successful claims
Supported transitions from platforms like Mobile Mediclaim, PrimeRx, XFin and more are included.
“We walk with you through each stage to ensure momentum and measurable wins.” – Rachel Matz
Real-World Results & ROI
One independent pharmacy in the DocStation network increased monthly vaccine revenue from $3,500 to over $10,000 in less than six months by following all four SHOT pillars.
Others have reported:
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3x claim reimbursement without increasing patient volume
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95%+ first-pass approval rates
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Decreased reliance on outside billing vendors
Final Thoughts: Making Every Shot Count
This method is not just about billing. It’s about redefining how pharmacies view clinical services as a sustainable, revenue-generating part of care delivery.
It transforms overlooked processes into high-efficiency revenue engines—empowering pharmacists to practice at the top of their license, improve margins, and serve their communities better.
“This isn’t just billing—it’s business transformation.” – Dr. Angelina Tucker
Q&A: Real-World Scenarios & Expert Responses
Q: Who are you credentialing through?
A: Credentialing varies by payer and region. DocStation helps you navigate centralized credentialing networks and payer-specific requirements.
Q: Does DocStation support bulk or batch claim submissions?
A: Yes. DocStation enables batch claim functionality, ideal for high-volume clinics and peak vaccination seasons.
Q: Do all payers reimburse for the counseling code?
A: Reimbursement depends on the payer. DocStation’s eligibility engine helps identify when and where to use counseling codes.
Q: How do you handle rejected claims from Medicare Advantage?
A: Don’t stop at the PBM rejection. Use DocStation’s real-time eligibility tool to identify Advantage medical benefits and resubmit appropriately.
Q: How can I find out if my current system is missing billing opportunities?
A: Use DocStation’s assessment tool to uncover gaps in eligibility, credentialing, and medical claim routing.
Q: Where can I go for more help?
A: Schedule a 1-on-1 consultation with DocStation’s Clinical Solutions team for a personalized billing performance roadmap.
