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Unregistered
March 13, 2009, 11:20 AM
Okay guys, I got my fistula installed just three days ago and it's buzzing just fine.
This is where the bottom dropped out - I work for a bank who has Carefirst/Blue Choice as their insurance company. I was informed yesterday that they will NOT under any circumstances pay for home hemo dialysis. They will only pay for "in-clinic" dialysis.

Does anyone know where I can start in pushing for a change here?

Dori Schatell
March 13, 2009, 03:09 PM
Hi Unregistered,

In just the past couple of days, I've learned some interesting things about health insurance companies. One is that under the Federal ERISA law (Employee Retirement Income Security Act) of 1974, individuals are no longer allowed to win damages if they sue health insurance companies--they can only win the amount of the unpaid claim.

What this means in practice is that they have nothing to lose by turning you down. If they say "no" to everything, only a fraction of the folks they decline will take any action to get them to pay--so they win. The first answer from a health plan, then, will nearly always be no.

BUT...what health plans hate more than anything else is hospitalization. They make their money by collecting your premiums and paying out as little as possible. Cancer and ESRD are two of the diagnoses that cost them the most. So, the first point to make to them is that longer/more frequent HD cut the hospitalization rate.

Here is a new study showing significantly fewer hospital days in folks treated with nocturnal HD for 2 years vs. a group who stayed on standard in-center. (Bold is mine):

Clin Nephrol. 2008 Jan;69(1):33-9.
Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis.

Bergman A, Fenton SS, Richardson RM, Chan CT.
Department of Medicine, Division of Nephrology, The Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.

BACKGROUND: Cardiovascular disease remains the leading cause of death among patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) (5 - 6 sessions per week; 6 - 8 hours per session) is a novel form of home-based renal replacement therapy, which has been shown to improve several cardiovascular risk factors. The impact of NHD on hospitalization rate has remained unclear. We hypothesized that augmentation of small and middle molecular clearance by NHD would result in a reduction of dialysis related or cardiovascular specific hospitalizations. METHODS AND RESULTS: In this controlled cohort study, we studied 32 NHD patients (age: 43 +/- 2 [mean +/- SEM]) 1 year before and 2 years after conversion to NHD and 42 CHD patients (mean age: 44 +/- 2) (matched for age, dialysis vintage and controlled for comorbidities) during the same time period. The primary outcome was the change in a composite of dialysis or cardiovascular related admissions rate before and after conversion to NHD. Secondary outcomes included changes in all cause hospitalization rate, visits to emergency, reasons and duration of hospitalization and dialysis-related biochemical parameters. During the study period, dialysis or cardiovascular-related admission rate was stable for the CHD control cohort (from 0.48 +/- 0.14 to 0.40 +/- 0.12 [end of study] admission per patient year, p = NS). In contrast, [b]conversion to NHD is associated with a decrease in our composite endpoint (from 0.50 +/- 0.15 to 0.17 +/- 0.06 admission per patient year, p = 0.04). Cardiovascular disease (37%) was the principal cause for hospitalization in the control population. In comparison, vascular access related admission was the primary cause of admission for the NHD cohort (56%), p = 0.001. Of the biochemical parameters, NHD is associated with a decrease in plasma phosphate (from 1.7 +/- 0.1 to 1.3 +/- 0.1 mM, p = 0.01) and an improved control of anemia (from 114 +/- 2 to 122 +/- 3 g/l, p = 0.02). CONCLUSION: Conversion to NHD is associated with a decrease in dialysis and cardiovascular-related hospital admission. The clinical and mechanistic relevance in uremic patients of improved phosphate and anemia management requires further examination.

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Who have you talked to at the insurance company? You need to get past the "bean counters" -- the folks with no medical backgrounds who just push papers around. Ask for a supervisor, and then a supervisor's supervisor. See what you can get them to put in writing. If you haven't read the fine print of the policy, it's not a bad idea to do that as well--they may not know their own policy.

We are also happy to talk with insurance companies. So, if you can find your way to a real person with a medical background, put them in touch with us.

Unregistered
March 13, 2009, 03:48 PM
Dori:

I seem to have a lot of irons in the first who are looking into this. First, my HR person, second my NxStage representative, third my medical consultant. However, all of them have gotten different stories as to what the situation is. A Davita Program Manager advised that Carefirst will only pay as an "out of network provider". My medical consultant stated that Carefirst won't pay at all. NxStage states they will work on it, but it will take time. I don't know who to believe.

Also something that doesn't make sense. Mid-Atlantic Nephrologists, one of the largest in the state of Maryland just opened up their own home dialysis training facility. What I don't understand is if you have Carefirst as the largest in the state of Maryland as far as insurance, and then the largest nephrologists opening up a home dialysis center, wouldn't you think at least ONE person would be covered under Carefirst?

I am tired and frustrated and do not know where to turn next. My GFR is down to 13%. The only option Carefirst gives me is to quit my job and choose Medicare...

Dori Schatell
March 13, 2009, 04:56 PM
Heh heh heh. Not too funny, but CareFirst (great name, eh?) also wins if you quit your job--then they don't have to cover you. Don't do it! What exactly is a "medical consultant"? Again, the key here is to make it to someone at "CareFirst" who knows their policy and is a medical professional. It's also best, if possible, to coordinate things through ONE entity--not NxStage + HR + a "medical consultant." You're bound to get multiple opinions, as everyone is talking to someone else at "CareFirst." Someone has to take the lead.

bobeleanor
March 13, 2009, 05:31 PM
Hi Folks

Hi Unregistered

Are you saying your insurance company will not pay for any home dialysis by any provider? Do you have any choices on centers, or are you forced to deal with Davita? Have you filed a complaint with your state health dept. State AG , reps in state cap. your reps in DC. Youtube, can you send something to the news media.

Get and put everything in writing and get a phone voice recorder. I think Maryland is a state that lets a person record without letting other party know about.it

Sadly the medical world has become one in which the healthcare consumer must bring a lawyer or find ways or recording or getting everything on paper

Okay guys, I got my fistula installed just three days ago and it's buzzing just fine.
This is where the bottom dropped out - I work for a bank who has Carefirst/Blue Choice as their insurance company. I was informed yesterday that they will NOT under any circumstances pay for home hemo dialysis. They will only pay for "in-clinic" dialysis.

Does anyone know where I can start in pushing for a change here?

Best Luck
Bob O'Brien

Beth Witten MSW ACSW
March 13, 2009, 11:09 PM
Interestingly, CareFirst has written information for patients about options for treatment for kidney failure including home hemodialysis:
The educational materials by this company provides information on PD and HHD. One section of the information on the HD information states:

At home, hemodialysis is done with the help of a partner, often a family member or friend. If you choose to do home hemodialysis, you and your partner will receive special training.
http://carefirst.staywellsolutionsonline.com/Search/85,P01474

A CareFirst Provider Manual states on page 24:

Hemodialysis

Authorization from Care Management (page 3) is required for inpatient, outpatient or home hemodialysis services, unless the services are performed in a contracted freestanding facility. If hemodialysis services are rendered in a contracted, freestanding facility, the attending physician is responsible for a written prescription or order.
http://www.carefirst.com/providers/attachments/BlueChoiceProviderManual.pdf

On page 3 that is referred to above, it provides a phone number for Care Management - 866-PRE-AUTH(773-2884).

The insurance company may want medical justification to document that home hemodialysis is appropriate for you and may provide case-by-case approval for coverage for home hemodialysis.

You might want to call the number above and ask these questions:
-- Why does the company's educational materials for patients describe home hemodialysis as an option for treatment if it is not routinely covered?
-- Will the company cover hemodialysis 3 times a week (or every other day) in the home if the charge for home hemodialysis is no more than for in-facility hemodialysis done the same number of times a week?
-- Does the company require prior authorization 3 home hemodialysis treatments a week, home hemodialysis done every other day, home hemodialysis treatments 5 or more times a week?
-- If prior authorization is required before coverage is provided for home hemodialysis, what kind of data does the company need to make a determination - medical benefits, cost benefits, other?
-- Does the coverage decision make any difference which dialysis facility is providing home dialysis training and support services ?

If anyone else has other questions to ask, feel free to add them.

Dori Schatell
March 13, 2009, 11:26 PM
Go Beth! It never occurred to me that the company would have their policy in a document you could find online. Awesome sleuthing skills, as usual. :-D

I suspect that the folks helping you haven't seen this document, either, so it's definitely something to share with the crew. I also suspect that the issue really is how MANY treatments per week--more so than whether they are done in the center or at home.

Unregistered, you haven't mentioned which "flavor" of home HD you might be interested in, but Medicare--and health plans--will pay for 3 treatments routinely, 3.5 (every other day) usually without too much hassle, and with a letter of medical justification from a doctor, will most often pay for at least a 4th treatment each week, which can be enough to make short daily HD possible--or nocturnal more than 3.5 nights/week.

It can be a big learning curve to start with nocturnal (even if that's your ultimate goal), but once you get the training, the various types are not all that different. You may want to sign up for our Webinar with Dr. John Agar next Weds. evening to learn more background about HD. Here's the link: http://www.instantpresenter.com/PIID=E156DA82 .

Wendy Ramsay
March 14, 2009, 11:18 AM
I thought I was reading my own story when I read yours. Currently I am holding my breath praying my insurance company will pay for home dialysis. I did the training (which they pay for) and began at home last week. Inititally, they mailed me a statement of coverage letter saying frequent daily and nocturnal dialysis (quotidian) done at home is investigational and not covered. I called the insurance company several times and talked to a different person each time. None seemed to know anything about it at all. They couldn't make any sense as to why they would pay for the training and not the dialysis. Davita never heard of such a thing since they have many patients on Home dialysis and their insurance companies pay without problem. They also have patients with the same insurance on home dialysis. Mistakenly, someone at Davita thought the statement of coverage letter was a denial and we were to begin an appeal. Another call by me to the insurance company connected me with a woman who said their shouldn't be a problem if the dialysis claims were simply coded properly. This is also what an insurance specialist at Davita said. Soooooooooo. Here we are. Hopefully, all is well, my insurance company will do the obvious right thing, I will continue with home dialysis, feel better, and live a long time to be around for my amazing 10-year-old son.

Dori and Beth have been very helpful during this process. Thank you, Dori & Beth.

Wendy Ramsay
March 14, 2009, 11:53 AM
Dori:

The only option Carefirst gives me is to quit my job and choose Medicare...


Speaking of Medicare...when you begin dialysis, you can choose to go on Medicare immediately. You don't have to quit your job. You can go on Medicare and retain your other insurance as a secondary. As a matter of fact, I have maintained my current employer insurance as primary for the 6 months I have been on dialysis. The PROBLEM is that my insurance has been paying around $45,000/month. It's sickening how much they pay. I will reach my lifetime maximum in a year. I need to maintain my employer insurance for the excellent cancer treatment coverage. I should have switched over to Medicare a long time ago and saved at least $250,000 towards my lifetime maximum. Also, if I ever do get a transplant, I believe I will be forced off Medicare and back onto my employer insurance which would not be a good thing if I have it already maxed out.

If Medicare pays 80% of $45,000....I am responsible for the 20% or $9000/month? A secondary insurance will cover this but what do people do without secondary insurance?

Does medicare actually pay the exorbitant prices that private insurance companies pay? - or do they actually pay a lesser amount every month?

Dori Schatell
March 14, 2009, 06:24 PM
Hi Wendy,

Actually--and Beth will pop in and correct this if I'm wrong--Medicare will not become primary until after 30 months if you have an Employer Group Health Plan (EGHP. When you have an EGHP at the point where you start dialysis, it is primary. Medicare is secondary. This is called the "Coordination of Benefits (COB)" period. The dialysis industry is angling to extend this from 30 months to 60, because they make far more money from EGHPs than Medicare pays. In fact, they LOSE money on Medicare-only patients, and what they make from EGHP's keeps the whole industry afloat.

What I think you're saying, Wendy, is that you may have been advised not to take Medicare as a secondary payer, perhaps being told that you didn't need to pay those premiums until your EGHP coverage runs out. But when you DO take Medicare, your dialysis provider is required to accept Medicare assignment--which means lower out-of-pocket costs for you that usually outweigh the cost of the premiums.

You are right to be concerned about your lifetime benefit. Unfortunately, ESRD is a costly illness, and our healthcare "system" is not set up for costly chronic diseases.

One benefit of home dialysis that many folks don't know is that Medicare (as a Secondary payer if you have an EGHP--or a primary payer if you don't) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months--and those 3 months can be very costly and even push people into medical bankruptcy.

Wendy Ramsay
March 14, 2009, 09:06 PM
Hi Wendy,

Actually--and Beth will pop in and correct this if I'm wrong--Medicare will not become primary until after 30 months if you have an Employer Group Health Plan (EGHP. When you have an EGHP at the point where you start dialysis, it is primary. Medicare is secondary. This is called the "Coordination of Benefits (COB)" period. The dialysis industry is angling to extend this from 30 months to 60, because they make far more money from EGHPs than Medicare pays. In fact, they LOSE money on Medicare-only patients, and what they make from EGHP's keeps the whole industry afloat.

What I think you're saying, Wendy, is that you may have been advised not to take Medicare as a secondary payer, perhaps being told that you didn't need to pay those premiums until your EGHP coverage runs out. But when you DO take Medicare, your dialysis provider is required to accept Medicare assignment--which means lower out-of-pocket costs for you that usually outweigh the cost of the premiums.

You are right to be concerned about your lifetime benefit. Unfortunately, ESRD is a costly illness, and our healthcare "system" is not set up for costly chronic diseases.

One benefit of home dialysis that many folks don't know is that Medicare (as a Secondary payer if you have an EGHP--or a primary payer if you don't) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months--and those 3 months can be very costly and even push people into medical bankruptcy.

Oh no. I thought I had the choice of moving to Medicare before the 30 months is up and retain my employer insurance as secondary. Please tell me I don't have to exhaust my employer insurance. I will hit my lifetime max in 13 months at $45,000/month. I NEED the coverage for continued bladder cancer surveillance/treatment. AND if I max out my employer insurance, get a transplant 3 years down the road and am kicked off Medicare 36 months after the transplant, I will have zero insurance to go back to. This isn't good at all. I am alive today in huge part because I have an insurance company that didn't question any of the out-of-the-box treatment methods we used over the years.

Currently, I have no out-of-pocket expenses with my employer insurance. No premiums and 100% coverage on everything. There is an annual $200 deductible - that's it. Medicare, if I understand it, will require $94/month premium, $170? deductible and then they only pay 80% leaving me with 20%. How do people afford the 20%? That's $1000's a month - more than most people make who are working.


I am very stressed about this now. I have come so far in the fight to live and I am very afraid that this insurance situation could leave me in a bad predicament that could ultimately kill me. Am I missing something??????

Why should I be forced to max out my insurance leaving me with nothing to fall back on?

p.s. is there a spell check on this forum?

Wendy Ramsay
March 14, 2009, 09:17 PM
hi wendy,

one benefit of home dialysis that many folks don't know is that medicare (as a secondary payer if you have an eghp--or a primary payer if you don't) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months--and those 3 months can be very costly and even push people into medical bankruptcy.

then why aren't all dialysis centers morally and legally obligated to inform and start uninsured patients on home training right away? Even if patients can't do it after all is said and done, they can fall back on in-center dialysis and not be bankrupt. The fact that centers aren't even informing patients of this option and allowing them to lose their livelihoods without any way to recover it is shocking (to say the least) and evilminded.

Dori Schatell
March 14, 2009, 10:55 PM
Hi Wendy,

We really do need Beth to pop back in here--she is the reimbursement expert, not me. But please don't worry. You WILL have coverage, even if you do use up your EGHP plan.

Once you are eligible for Medicare due to ESRD, it covers all of your healthcare--not just kidney-related care. So, the issue won't be the 80% that Medicare pays; it will be the 20% that it doesn't pay. Depending on the state you live in, and your age, you may be eligible to buy a Medigap plan to handle that part of your healthcare costs.

You STAY eligible for Medicare as long as you are on dialysis--whether or not you keep your job. If you get a transplant, Medicare will pay for the drugs you need for 3 years (and beyond if, after that, you have a reason besides ESRD to be on disability).

I don't think these forums have a spellcheck.

As far as folks not being told about their options and the implications for their finances of choosing home vs. in-center, I couldn't agree more, and we've advocated with some success to change this. A big part of the problem is doctors who aren't familiar with either home options OR how Medicare works, and who probably don't even notice whether folks are working (and want to stay that way) or not when they need dialysis. It's unconscionable, IMHO, that almost 92% of US dialyzors are using in-center HD 3x/week--the most costly care we have to offer, with the worst outcomes. In-center treatments push people into poverty, either because they are forced out of their jobs due to the cost of their healthcare to their employers, or because they feel so lousy they can't work. MAJOR, sweeping change to our healthcare "system" and how we pay for it is needed.

Fortunately, I think we're going to see a lot of that over the next few years.

Rich Berkowitz
March 15, 2009, 01:52 PM
Wendy's situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn't? If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.

Wendy's concern of attaining her lifetime benefits with her insurance is very real. Many policies have what seems to be a high limit — even a couple million dollars. One would be surprised how quickly they can reach that number. This becomes even more possible if the coordination of coverage period gets extended — yet another reason for universal coverage.

Wendy Ramsay
March 15, 2009, 02:56 PM
Wendy's situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn't? If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.



I began dialysis in September 2008. I started Home hemo 2 weeks ago. Because I am doing home hemo now, can I end the 30 month coordination period and go on medicare? Since my start date is before the October 14 date am I affected differently?

My insurance has a $1.5 million cap. Since September, $315,000 has been eaten up by dialysis alone. $285,000 has been used on bladder cancer treatments, surgeries, surveillance etc. That leaves me with about $600,000 lifetime left which will be eaten up in 13 months - actually sooner because I still face a major surgery in May.

Wendy Ramsay
March 15, 2009, 03:25 PM
Before I had surgery to remove my last kidney in September, I met with Mary Dooley, the CKD Program Manager for NorthWest Kidney Centers in Seattle. I am a very detailed, thorough person when it comes to managing all aspects of the bladder cancer which resulted in Dialysis. Mary did go over different dialysis options including home dialysis. AT THAT TIME in her office and several times after, I told her I wanted to do home dialysis from the start. She said no - they won't train home dialysis patients with a catheter. I was to have a catheter placed along with the first step of my fistula during the kidney removal a couple of weeks later. At that time, I had no idea of the insurance implications of NOT going onto home dialysis immediately nor did I have comprehension of the COST of dialysis for my employer insurance company and the implications of all of that. Even after beginning in-center treatment at NWKidney, I frequently mentioned my desire for home dialysis complaining that it wasn't right not to train me just because I had a catheter. I called Mary Dooley a couple of times after to again discuss moving to home hemo . It was always explained that re-training when I had a fistula would be an avoidable expense if I waited for my fistula to be ready. Again, I had no comprehension of the implications of remaining in-center. If I had, I probably would have sued.

Now I wonder if that was an intentional play by NWKidney. IF it's true that I would go immediately to Medicare upon initiation on home dialysis (someone please verify this) NWKidney would be losing $45,000/month. In that case there would be an absolute financial incentive to deny home dialysis and keep me in-center. I do know some centers train with catheters and I bet I could find someone at NWKidney. I asked them if they ever train with catheters and she said in 'special circumstances'.

Could this scenario be possible?

Rich Berkowitz
March 15, 2009, 04:56 PM
Wendy, these are very good questions and why I raised it in the first place. In a way I'm surprised your situation had occurred with NKC, who I have the utmost respect for. I'm sure Beth and Bill will be able to add something appropriate to this discussion.

Wendy Ramsay
March 15, 2009, 05:21 PM
I'm searching through the piles of info I have received from both NKC and Davita. In the NKC New Patient Handbook under "Treatment Options - Choosing Home Dialysis - COST", it says "Home dialysis is paid for in the same way as in-center dialysis - through Medicare, private insurance, and/or state funds."

That's what I need to find out...is Home Dial. paid for in the same way or are there some differences.

In the "Financial Services" section, it says a financial coordinator will be assigned to me when my doctor first refers me to NKC. Hmmm. I never had that I know of anyway. They were to 'talk to me about the COST of dialysis', help me 'understand my funding (Medicare, private insurance, Medicaid, NKC charity care, personal funds, etc.)', 'help me apply for all the funding for which I qualify', 'answer financial questions about permanent kidney disease'. Hmmmmm. Never got any of that from NKC. I never did from Davita when I switched to them either. My last day of home training a week ago, a gal from Davita did mention that if I had financial issues to talk to her right away but that was the extent of the info.

Who would you go to to get to the bottom of this? My insurance company (whom I've called many times) never gave me the impression that I had to wait to switch to Medicare as primary. I have called (several times) Medicare who told me to call Social Security who told me Medicare should have been able to help....I will set an appt this week to meet with the insurance coordinator at Davita. Any other suggestions?

Dori Schatell
March 15, 2009, 06:47 PM
Wendy, I've asked Beth to pop back in and help. MANY centers won't train folks who have catheters to do home HD. Centers differ in their policies, and NKC is one of the best in the US. So, I can't fault them for that, though in the Lynchburg nocturnal HD program in VA, most of their folks use catheters. Again, centers differ.

There is no way to protect your EGHP from being depleted--unless you find a center that will bill less. The 30-month COB period is 30 months; period. There is no way to opt in to Medicare as PRIMARY until the 30 month clock runs out.

So, at this point, if you have a fistula (sorry, I don't recall), you might check into how much NKC (a non-profit) would charge you vs. DaVita (a for-profit). If NKC charges less, your EGHP will last longer.

Beth Witten MSW ACSW
March 15, 2009, 07:05 PM
Dori is correct that Medicare is a secondary payer to an employer group health plan (EGHP) for the first 30 months that the patient could have Medicare whether he/she takes it or not. This has been a regulation in Medicare for many years and one that was intended to put more of the burden on private industry to save money in Medicare.

If someone starts home training before the 1st day of the 3rd full month of dialysis, the clock starts the month dialysis starts. If home training is delayed until after that time, the period that Medicare pays secondary is 30 months from the earliest month your Medicare could take effect (the 3rd full month of dialysis).

You say that the dialysis provider is billing $45,000 a month for dialysis. Was that what NKC was billing or what DaVita is billing? Do the statements from your insurance company say it has paid $45,000 a month to either or both providers? From what I've heard, most insurance companies negotiate a reduced payment from what is billed -- I've heard they typically pay 2-3 times what Medicare allows. The average Medicare allowable for dialysis now not counting drugs or physicians' bills is about $133 per HD treatment.

If your company is paying $45,000 a month and it looks like you'll exhaust your benefits, talk with your dialysis social worker. You can also ask to talk with NKC's financial counselor about your past bills and with DaVita's "guest service specialist" who is supposed to work with people who have employer group health plans that pay significantly more than Medicare. Hopefully one of these people will be able to answer your questions about what they're billing. New regulations for dialysis require dalysis facilities to discuss costs of care with patients.

BTW, if the charges exhaust your health coverage, your clinic can start billing Medicare primary with proof of claim denial from your EGHP. Before this happens, talk with the state insurance department to find out if can enroll in a Medigap (Medicare supplement) plan that would pay the deductibles and 20% coinsurance left after Medicare pays if you lose your health coverage. Some states have regulations that provide this right to state residents in that situation.

Hope this helps!

Beth Witten MSW ACSW
March 15, 2009, 07:40 PM
Wendy's situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn't?
It sounds like NKC informed Wendy of her options. She knew HHD was an option. NKC must have a policy that won't allow a patient with a catheter to do HHD. Facilities can set policies for what they believe offers safe and effective treatment. Other facilities may have different policies. If patients want something their facility doesn't offer, they have the right to change to a different facility and their original facility is supposed to provide information to help them do that.

NKC and some DaVita clinics offer more frequent dialysis treatments. They can and probably do bill the EGHP for each treatment the patient receives. This can nearly double the cost of dialysis from in-center dialysis which is done 3 times a week. Medicare will only routinely pay for 3 treatments so even with Medicare, a patient could have higher charges for more frequent treatments. However, the more frequent treatments could save money in the long run on hospital bills which can be much higher than dialysis charges.


If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.
Sadly, this is not true. The coordination of benefits period applies to anyone with an employer group health plan no matter what type of dialysis the patient chooses to do. The difference in treatment type makes a difference when Medicare can start as a secondary payer saving the patient 3 months of EGHP primary payments. Medicare secondary payer does NOT apply to individual plans that are not sponsored or contributed to by an employer.


Wendy's concern of attaining her lifetime benefits with her insurance is very real. Many policies have what seems to be a high limit — even a couple million dollars. One would be surprised how quickly they can reach that number. This becomes even more possible if the coordination of coverage period gets extended — yet another reason for universal coverage.
IMO, extension of Medicare secondary payer would temporarily help facilities but harm patients because it would exhaust the lifetime benefits of more patients. If facilities do a good job taking care of patients and they do well on dialysis, in the long-run, facilities will lose out if their patients exhaust their lifetime benefits.

Rich Berkowitz
March 15, 2009, 08:06 PM
Sadly, this is not true. The coordination of benefits period applies to anyone with an employer group health plan no matter what type of dialysis the patient chooses to do. The difference in treatment type makes a difference when Medicare can start as a secondary payer saving the patient 3 months of EGHP primary payments. Medicare secondary payer does NOT apply to individual plans that are not sponsored or contributed to by an employer.

Thanks Beth, I somehow get starting initially with home dialysis confused with transplantation. I won't make this mistake again.

Wendy Ramsay
March 15, 2009, 08:50 PM
Beth,
Thank you for your suggestions which I will follow up on.
I also had a thought...Does anyone know in the event that my insurance company denies payment for home dialyis, could I switch to Medicare who does cover home dialysis or will I be forced back into in-center or forced to cover the bill for home dialysis myself.

I also wonder if I could opt out of my husband's employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period. I guess that's a question for my insurance company.

There's something morally wrong with all this.

Dori Schatell
March 15, 2009, 09:08 PM
Does anyone know in the event that my insurance company denies payment for home dialyis, could I switch to Medicare who does cover home dialysis or will I be forced back into in-center or forced to cover the bill for home dialysis myself.
Your insurance company will pay for home, one way or another--I'd be willing to bet on it.

You don't have the option to "switch" to Medicare as a primary payer--it's the LAW that you are required to be covered by your EGHP (if you have one) for the first 30 months. You don't get to opt in and out in that way. It's not up to you.

You DO get to decide if you want to "accept" Medicare when you are eligible for it. Part A (hospitalization) is free. Part B (outpatient services including dialysis) has a premium. Never take Part A without Part B. Doing so can cause all sorts of problems down the road. Accepting Medicare reduces the amount you would need to pay out-of-pocket because dialysis providers can't charge as much to your health plan (which may not cover everything) when Medicare is in place. Most likely, you would save enough to more than make up for the premium for Part B.


I also wonder if I could opt out of my husband's employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period.
Sorry, Wendy, but I would strongly recommend against that. The chances that your EGHP would let you back in with the preexisting conditions of cancer + ESRD are basically zero. So, you could quit your job, go on disability, and become Medicare primary--but it doesn't help you to do this. You'd lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less. [EDIT]Oops, it's your husband who carries the policy. Be careful: some employers have managed to force out employees whose care (or loved one's care) is very costly. If "opting out" is an option for him, again--I would strongly recommend against doing it. Opting "back in" will not be an option down the road.

Is there something wrong with this system? YES! IMHO, medicine for profit and inserting insurance companies between people and their healthcare is an unworkable model. For more on why, see this thread: http://forums.homedialysis.org/showthread.php?t=1998.

Wendy Ramsay
March 15, 2009, 09:40 PM
You DO get to decide if you want to "accept" Medicare when you are eligible for it. Part A (hospitalization) is free. Part B (outpatient services including dialysis) has a premium. Never take Part A without Part B. Doing so can cause all sorts of problems down the road. Accepting Medicare reduces the amount you would need to pay out-of-pocket because dialysis providers can't charge as much to your health plan (which may not cover everything) when Medicare is in place. Most likely, you would save enough to more than make up for the premium for Part B.


Hmm. Apparently I got Part A back in September after surgery. I vaguely remember filling out forms in the haze of pain meds. I did not get Part B because I have 100% coverage with no premium through our EGHP. Accepting Medicare won't reduce my out-of-pocket because I have 100% coverage no with zero out-of-pocket. Accepting Medicare will increase my out of pocket with the premiums, deductible and 20% copay - none of which I have now. Are you saying that if I accepted Medicare today with my 100%, zero out-of-pocket EGHP, that the dialysis unit could no longer charge my EGHP $45,000/month? They would be forced to charge less even while my EGHP is the primary? If so, paying the extra out-of-pocket for Medicare may be worth it.

Medicare also states that there is no penalty for not taking Part B if I have an EGHP in place. They suggested in their handbook that I may want to wait paying the Medicare premiums every month if I'm not using them while I have my no cost EGHP. What sort of problems are you thinking about that could arise down the road?




So, you could quit your job, go on disability, and become Medicare primary--but it doesn't help you to do this. You'd lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less.

Losing my EGHP completely and being Medicare-only is EXACTLY what I am afraid of. In less than 12 months, I will exhaust my EGHP completely - Not because I opted out but because the dialysis centers have stolen it from me - almost $1 million worth. I'm new to all of this. How in God's name can an insurance company be forced to pay a $million in less than 2 years for dialysis when Medicare would have paid $33,000 for the same treatment during that same time period? Is there no cap on their charges to insurance companies at all?

I don't expect you to keep answering all my questions. Obviously, I have more research to do. I just don't get it - especially the fact that there is some sort of law that makes this type of extortion mandatory. Seems as though we EGHP and private insurance people (minority) rake out the $billions for dialysis for the rest of the majority of the population on Medicare while being stripped of insurance for the other critical parts of our life and health. My husband has worked very hard for this coverage for his family for years. This coverage has kept me alive and winning the fight against bladder cancer for 15 years. I pray that Medicare will not change that.

Beth Witten MSW ACSW
March 16, 2009, 01:03 AM
Hmm. Apparently I got Part A back in September after surgery. I vaguely remember filling out forms in the haze of pain meds. I did not get Part B because I have 100% coverage with no premium through our EGHP. Accepting Medicare won't reduce my out-of-pocket because I have 100% coverage no with zero out-of-pocket. Accepting Medicare will increase my out of pocket with the premiums, deductible and 20% copay - none of which I have now. Are you saying that if I accepted Medicare today with my 100%, zero out-of-pocket EGHP, that the dialysis unit could no longer charge my EGHP $45,000/month? They would be forced to charge less even while my EGHP is the primary? If so, paying the extra out-of-pocket for Medicare may be worth it.
First, even if you have Medicare, your dialysis clinic can charge your insurance company what it normally charges. If you had Part B, your dialysis clinic would not be able to charge you any deductibles or copays as long as your plan pays at least 100% of Medicare's allowable. If you don't have any of those cost-shares, you might not need Medicare at all. You may want to disenroll from Medicare Part A to avoid consequences that I describe in response to your next question.

If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn't paid any claims for you, ask to disenroll from Part A. NOTE: If you are on the transplant list, sign up for Part A and ask Social Security to make it effective the month of the transplant. This will protect your right to have Medicare Part B cover your anti-rejection drugs.


Medicare also states that there is no penalty for not taking Part B if I have an EGHP in place. They suggested in their handbook that I may want to wait paying the Medicare premiums every month if I'm not using them while I have my no cost EGHP. What sort of problems are you thinking about that could arise down the road?
The Medicare handbook (Medicare & You) is written for most of the people who have Medicare -- those with Medicare due to age or disability. It refers people with ESRD to a more specific booklet called Medicare Coverage for Dialysis and Transplant Services (Medicare Pub. 10128).
http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf

If you had Medicare due to age or disability and did not have ESRD, you would have a "special enrollment period" to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a "special enrollment period" for Part B if someone has ESRD.

There are a number of problems that can occur when you take Part A and don't take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
-- Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You'll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don't yet have Medicare Part B in place.
-- If you don't sign up for Medicare Part B within 12 months of taking Part A, you'll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.
-- If you forget to sign up for Part A in time to have it cover you for a transplant (within 12 months after the transplant), Medicare Part B will never cover your anti-rejection drugs. And according to the law, Medicare Part D couldn't pay for them either because Part B would cover them if you had it.


Losing my EGHP completely and being Medicare-only is EXACTLY what I am afraid of. In less than 12 months, I will exhaust my EGHP completely - Not because I opted out but because the dialysis centers have stolen it from me - almost $1 million worth. I'm new to all of this. How in God's name can an insurance company be forced to pay a $million in less than 2 years for dialysis when Medicare would have paid $33,000 for the same treatment during that same time period? Is there no cap on their charges to insurance companies at all?
Believe me, I can understand your frustration and anger. I can't imagine why your insurance company hasn't negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare's allowable for 3 treatments a week).


I don't expect you to keep answering all my questions. Obviously, I have more research to do. I just don't get it - especially the fact that there is some sort of law that makes this type of extortion mandatory. Seems as though we EGHP and private insurance people (minority) rake out the $billions for dialysis for the rest of the majority of the population on Medicare while being stripped of insurance for the other critical parts of our life and health. My husband has worked very hard for this coverage for his family for years. This coverage has kept me alive and winning the fight against bladder cancer for 15 years. I pray that Medicare will not change that.
I wish people didn't have to live with the situation that you've described. Check into the Medigap option to see if you can buy it any time you want in spite of your pre-existing conditions.

Wendy Ramsay
March 20, 2009, 12:45 PM
If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn't paid any claims for you, ask to disenroll from Part A.

If you had Medicare due to age or disability and did not have ESRD, you would have a "special enrollment period" to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a "special enrollment period" for Part B if someone has ESRD.

There are a number of problems that can occur when you take Part A and don't take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
-- Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You'll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don't yet have Medicare Part B in place.
-- If you don't sign up for Medicare Part B within 12 months of taking Part A, you'll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.

Believe me, I can understand your frustration and anger. I can't imagine why your insurance company hasn't negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare's allowable for 3 treatments a week).

\


I've discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is "out-of-network". I guess the other $35,000/month is all for meds? I'm not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn't even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance 'specialist') why they didn't tell me of the in-network unit down the road, they said they didn't know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

Davita said my insurance company won't contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.

As far a medicare, apparently, I got on medicare 2 years after claiming disability for my bladder cancer. I had part A Feb 2008. With my employer benefits, I am not penalized for not taking part B as long as I do so within 8 months of my employer benefits ending.

We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it's investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x's a week. I wasn't getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So...more runs less time (3 hours). Training for home has been wonderful. Now on 15's and have increased flow and dialysate. I think it will make a big difference. When my 'training' is done, I suppose I will have to go back in-center? Just doesn't make any sense at all.

I have asked Davita for itemized printouts for all my treatments since November.

Beth Witten MSW ACSW
March 20, 2009, 01:39 PM
Dialysis clinics only know what insurance companies they contract with. They would have no way of knowing what insurance companies other clinics contract with unless they called every clinic and unless those clinics shared that information with them. The staff at a particular clinic may not even know who their corporation contracts with unless an issue like yours arises. The one who was responsible for telling you who the network providers are is your BCBS plan. The fact that they didn't know is appalling!

Does the in-network clinic offer home dialysis? Will your BCBS pay for home dialysis there? I still question whether the denial of BCBS coverage relates to frequency of dialysis or perhaps out-of-network provider. Northwest Kidney Centers is the oldest dialysis provider in the U.S. and has been doing conventional (3 times a week or every other day) home hemodialysis for more than 40 years in the northwest. It's really hard to believe that Boeing's BCBS plan denies coverage for home hemodialysis in Seattle where the Northwest Kidney Centers began training and following home hemodialysis patients in the 1960s. Boeing is a large employer in Seattle. Patients can do home hemo at night while they sleep 3 nights a week or every other day and report they feel better than doing 3-4 times a week in-center.

You may have been told that since you already have Part A, you have 8 months to sign up for Part B without penalty. However, there are quirks in the Social Security regulations that do not allow people with ESRD to have a "special enrollment period" even if they also qualify for Medicare due to age or disability. Here's the policy from the Social Security that explains this. Some terms you'll need to know to read this include R-HI (Part A), R-SMI (Part B).

F. POLICY — EFFECT OF MSP PROVISIONS ON FILING
Because Medicare will not be paying full benefits in many cases where there is a group health insurance plan, some individuals may not wish to enroll in R-SMI when first eligible.

It is important to remember that the special enrollment period (SEP) rules applicable to aged and disabled individuals do not apply to people entitled to R-HI. Therefore, it is extremely important to properly inform ESRD patients (including dual eligibles) who have GHP coverage about their options with respect to filing an application for R-HI. An individual may wish to:

* File for both R-HI and R-SMI at initial R-HI eligibility even though Medicare can only make secondary payments until the end of the ESRD coordination period. With expenses as high as those for treatment of ESRD, an individual may consider secondary Medicare payments to be well worth the monthly SMI premium.

* Defer filing for R-HI (and R-SMI) until the end of the ESRD coordination period. This will permit the individual to defer paying for SMI until Medicare becomes the primary payer of benefits.

ESRD patients with GHP coverage should be discouraged from filing for R-HI while rejecting R-SMI at initial eligibility. Once R-SMI is refused, enrollment can only take place during a GEP, with coverage effective the following July. This will usually mean a gap in coverage between the end of primary payments by the GHP and the beginning of SMI in the month of July. It may also result in a premium surcharge for late enrollment. If an individual with GHP coverage files an application for R-HI in the mistaken belief that Medicare will be primary payer of benefits, the application may be withdrawn as provided for in HI 00801.197.

https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801247

According to the Central Office of Medicare (Baltimore), once someone has ESRD (kidney failure), even if he/she had the right to a special enrollment period due to age or disability, that right no longer exists. However, ask your local Social Security office...not the 1-800-772-1213 helpline...about this policy. You definitely don't want to have a gap in primary coverage and the general enrollment period is from January 1 through March 31 each year with Medicare Part B becoming effective July 1 of that year.

Rich Berkowitz
March 20, 2009, 03:42 PM
\
I've discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is "out-of-network". I guess the other $35,000/month is all for meds? I'm not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn't even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance 'specialist') why they didn't tell me of the in-network unit down the road, they said they didn't know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

Davita said my insurance company won't contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.


I don't understand. How could your insurance company not know which center they have a contract with. From the moment any paperwork went in regarding:DaVita, BC/BS should have notified you.

When my wife's EGHP changed from Humana to Cigna, I was told I had to move from one center (RCG) to another (Fresenius) because the center I was with would have been out-of-network. I appealed to no avail.

What's ironic is that RCG's own EGHP for it's emplyees was with Cigna, which meant if any of their own employees needed dialysis they would have to treat elsewhere.


\
We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it's investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x's a week. I wasn't getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So...more runs less time (3 hours). Training for home has been wonderful. Now on 15's and have increased flow and dialysate. I think it will make a big difference. When my 'training' is done, I suppose I will have to go back in-center? Just doesn't make any sense at all.

It's hard to believe BC/BS is saying home dialysis is investigational, especially since NxStage is FDA approved, Something's fishy.

NDXUFan12
March 25, 2009, 06:33 PM
If you need someone with an economics background, I am happy to help.

Wendy Ramsay
March 25, 2009, 06:45 PM
Hi Rich.
From what the insurance company told me, when I called to verify insurance coverage for Davita, I was told they are covered at 100%. I didn't know then that it was 100% of charges 7 times greater than a different (in-network) center. My insurance said when they check Davita, the Federal Way center doesn't even show up. When they check Total Renal Care which Davita bills as, they do show up but not as in-network. Davita said they bought the Federal Way center from another company. At the time of the purchase, the other company was in-network with my insurance company so they just kept the contract going when Davita took over. Obviously, there is some communication problems that they are hopefully sorting out now. I'm in the process of transfering to the Federal Way unit and Davita is 'making sure' they are in-network with my insurance company.

And yes, Boeing BC/BS is saying home dialysis is investigational. Apparently, they are conducting their own studies and will consider that plus other information and studies for a review of that decision in August. But until then, they will pay for the home dialysis training and not home dialyisis. What the heck. Makes no sense to anyone.

Dori Schatell
March 25, 2009, 09:03 PM
Wendy, we are happy to talk to Boeing, if it would help. I know there are several parties involved already.

Unregistered
March 25, 2009, 11:36 PM
Before I had surgery to remove my last kidney in September, I met with Mary Dooley, the CKD Program Manager for NorthWest Kidney Centers in Seattle. I am a very detailed, thorough person when it comes to managing all aspects of the bladder cancer which resulted in Dialysis. Mary did go over different dialysis options including home dialysis. AT THAT TIME in her office and several times after, I told her I wanted to do home dialysis from the start. She said no - they won't train home dialysis patients with a catheter. I was to have a catheter placed along with the first step of my fistula during the kidney removal a couple of weeks later. At that time, I had no idea of the insurance implications of NOT going onto home dialysis immediately nor did I have comprehension of the COST of dialysis for my employer insurance company and the implications of all of that. Even after beginning in-center treatment at NWKidney, I frequently mentioned my desire for home dialysis complaining that it wasn't right not to train me just because I had a catheter. I called Mary Dooley a couple of times after to again discuss moving to home hemo . It was always explained that re-training when I had a fistula would be an avoidable expense if I waited for my fistula to be ready. Again, I had no comprehension of the implications of remaining in-center. If I had, I probably would have sued.

Now I wonder if that was an intentional play by NWKidney. IF it's true that I would go immediately to Medicare upon initiation on home dialysis (someone please verify this) NWKidney would be losing $45,000/month. In that case there would be an absolute financial incentive to deny home dialysis and keep me in-center. I do know some centers train with catheters and I bet I could find someone at NWKidney. I asked them if they ever train with catheters and she said in 'special circumstances'.

Could this scenario be possible?

To say you cannot obtain home training with a catheter is alot of nonsense. You might want to speak to an attorney and sue for malpractice.

Mark
NDXUFan12

Wendy Ramsay
April 3, 2009, 07:21 PM
I have talked with many people both in Davita and in my insurance company. It's very frustrating talking to so many people who simply don't understand. I hate to say this, but I honestly think I know more than they do much of the time. Even after a 2 hour meeting with Davita staff about this issue, there was still an incorrect understanding. The facts are that the Puyallup facility I had dialyzed at for 5 months is NOT contracted with my insurance company. Because of a special ruling (or coding 89) dialysis falls into a special category and my insurance company is forced to pay at my in-network RATE of 100% of their billed amount. Dialysis alone was $1500 per session at the Puyallup center because they do not have a contract with my insurance company to pay less.

The Federal Way center DOES have a contract with my insurance that was in place before Davita bought them out and has not yet been re-negotiated. The allowed amount per session with the Federal Way center is $294. I think the home hemo charge is $86 (still waiting to verify). The Federal Way Davita charge is also considerably less than NWKidney charge of $688 per session. NWKidney also has a contract with my insurnance company. I am surprised they are more than Davita. There is a big difference between $1500 and $294 (or $86 for home hemo)! I'll be saving my insurance company at least $23,000 a month!

The both (Davita and my insurance company) say there is nothing they can do to correct the exorbitant charges to my lifetime max that have already occured because I was going to Puyallup Davita instead of Federal Way Davita. Maybe my insurance company should give me some kind of award for saving them so much money here on out. Right. Sounds good to me.

It astounds me how many people (that should know) know so little when it comes to things like this. A patient should be able to be directed properly initially so this should never happen. Davita said I am the ONLY patient that has ever expressed concern over what their insurance is paying. That's sad. Patients need to know where they stand at all times and avoid things like this before it's too late. I do know people who have maxed out their insurance and it probably could have been prevented.

Also, Davita said they got the approval for home hemo. It falls under the home care category? I don't quite understand it yet but apparently, it's approved with no limits on number of days to dialyze. This is in stark contrast to the benefit letter from my insurance company which stated home hemo is not a covered service. It shouldn't be this convoluted.
It looks as though things are finally on the right track.

Dori Schatell
April 4, 2009, 09:52 PM
Hi Wendy,

I'm sorry you've had to go through all this--especially the high billing against your lifetime insurance benefit--but glad you've finally gotten home HD approved. IMHO, our "system" of care is badly broken if someone who needs healthcare has to figure out all of the pieces, who has a contract with whom, and how much is being billed. Since I'm not quite sure how it could get worse, I like to hope that it will get better.

Rich Berkowitz
April 4, 2009, 11:51 PM
Wendy, quite frankly I think the insurance company should credit your lifetime limit because they didn't tell you the original dialysis center wasn't in-network, especially since they were putting out more money. It really seems like somebody was sleeping at the switch and you shouldn't be penalized.

BTW, how did you end up at the first one/ Were you referred to it by your neph? I remember when I first went in-center the hospital social worker did all of the arrangements. I did go to a center my neph was associated with, but he goes to a couple. When my insurance changed and the center I was in was no longer in-network I also had to change centers. So obviously I was notified.

Wendy Ramsay
April 5, 2009, 11:22 AM
I started dialysis in September with Northwest Kidney from my nephrologist's referral. I did not agree with some of their practices and requested a switch to the Puyallup Davita which happened to be a few minutes closer. As always, I called to confirm that my insurance covered the Davita unit and was told it was covered at 100%. There was no mention of the high charges and if they said it was out of network (which I don't remember) I wouldn't have any comprehension of the extent or impact of the high charges on my lifetime max. Even today, it was very very difficult to get the charges I will be charged for the Federal Way office. That info is not easily obtained by patients as it should be. No one mentioned the Davita office in Federal Way as an in-network option. No one even mentioned there was a Federal Way unit in existance during the 6 months I was with Davita. Three weeks ago, I got an insurance case worker after I notified them of these high charges. She told me they were not aware of the in-network unit in Federal Way. There is some confusion apparently because Davita goes by the name of Total Renal Care for billing and insurance purposes.

Either way, I agree. Someone was asleep. A friend of mine suggested a short media story to bring up this issue in these 'hard economic times'. I may let this rest a little and see if my insurance has any kind of response on their own before I do that.

Rich Berkowitz
April 5, 2009, 01:53 PM
Another thing you can do is complain to the state agency that oversees insurance. But I agree that you should first try to wotk it out with Boeing's BC/BS.

Unregistered
April 5, 2009, 02:48 PM
Hi guys - I believe I was the original poster here, but I still won't register yet as I'm not on dialysis just yet. The story on my side was (a) my HR person didn't know what the BC/BS policy entailed; (b) my insurance broker didn't know what my policy entailed and (c) the new facility that Davita opened has yet to be contracted with BC/BS (my specific company policy). After going through a slew of people at BC/BS, I did find out that our company policy did, in fact, cover home hemo. Now, the interesting part - Davita would not give me an answer as to whether I could do home hemo as I was not a patient of Davita yet. You either know or you don't know if you have a contract with BC/BS (and the specific policy I have). Nope, to this day, I was told by the Administrator that they will simply have to wait until my doctor gives the go-ahead with the prescription before they can accept me or not. That surely doesn't give me a warm and fuzzy feeling when I have the need to start dialysis.

Of course, by the time I need to start dialysis, my place of business is likely not to be standing anyway the way the ecomony keeps swaying.

Good luck to all who are looking at home hemo as an option. However, just remember, that Davita doesn't contract through every insurance company out there and to this day, find it rather wierd that I couldn't get an answer as to whether I could start in that home hemo training facility.

Unregistered
January 26, 2011, 11:25 PM
For several years, I have suffered from Kidney Disease. In July of 2006, I was placed on in-center hemodialysis. This treatment was a mixed blessing. On the positive side, my overall health greatly improved. On the minus side, I suffered numerous infections – including a bout with osteomyelitis of the spine that almost claimed my life and left me disabled. Additionally, the 3 time per week, in-center dialysis would frequently leave me feeling tired and wrung out. This caused difficulty on my job and added stress to my family.
In December of 2009, my wife and I attended training and became certified to perform home hemodialysis. This 5 time per week schedule allowed for more gentle cleansing of my blood and greatly reduced the side-effects I’d felt in-center. My employer was delighted as dialysis no longer controlled my schedule and I could even work during dialysis. Also, since the machine is portable, we took the first long vacation in years last summer, camping in the Olympic Peninsula in our travel-trailer.

In January of 2911, various concerns prompted me to change my employer-provided health insurance to Group Health. The Dialysis support staff at DaVita warned me that Group Health did not cover this treatment. However, that seemed contrary to the Group Health reputation as an innovator in the medical care field. Additionally, I was in great need of the managed care for my diabetes that Group Health could provide.

On January 23’rd, I received notice that my request for Group Health coverage of my frequent home hemodialysis was denied and that I would have to switch back to 3 day per week in-center dialysis.
I have appealed this decision, but doctors at Group Health have told me that it will not be overturned.

I find this unreasonable, unfair, and outrageous for the following reasons:
1) This decision is made by a review board that does not have a Kidney specialist as a member
2) Their decision is based on antiquated research( please see instead http://www.nature.com/ki/journal/v62/n6/full/4493344a.html, http://www.davita.com/home/physicians/research/1657 )
3) I will not be able to keep my job if I have to transition to in-center dialysis. My responsibilities include conducting many teleconferences during business hours. This is simply not possible from a dialysis center.
4) While on in-center dialysis, I was hospitalized 6 times over the space of less than 18 months for a total of more than 25 days. In the year since transitioning to home hemodialysis, I have been hospitalized a total of 4 days – quite an improvement
Group Health does cover daily peritoneal dialysis but I am not a good candidate for that. Nor am I a good candidate for kidney transplant at this time – hemodialysis is my only option.
If I am denied frequent home hemodialysis I firmly believe that my quality of life will be severely degraded, I will lose my job and perhaps my life

Mark R. Pennington
mrmarkus41@yahoo.com

Bill Peckham
January 27, 2011, 12:17 AM
There are providers that would provide NxStage for three payments a week - three Medicare payments, let alone three private pay payments. DaVita is being greedy IMO. I'm surprised that you're not Medicare Primary though.

Wendy Ramsay
January 27, 2011, 12:41 AM
Mark,
I just don't see how that can be legal! I know people much more versed in this will jump in. What a sickening situation.
Group Health should be sued.

Dori Schatell
January 27, 2011, 08:52 AM
Hi Mark,

Boy, we hate to hear this kind of scenario. Unfortunately, DaVita can charge insurance companies so much per treatment (each company negotiates its own deal with a network of providers) that doubling the costs of 3x/week may just not be something Group Health is willing to do. And DaVita did warn you ahead of time that Group Health wasn't a wise choice.

There have to be ways to put pressure on them, however. I know that Beth will chime in here, and she deals more with the insurance side than I do. But some possibilities include (in no particular order:
-- Go up higher in the company. There has to be a process to appeal their decision. "Doctors at Group Health have told me that it will not be overturned" is not an appeal, it is an opinion. There is a formal appeals process. And, with the Frequent Hemodialysis Network trials offering proof that more frequent HD is better--and TONS of other info we could bring to bear--it could be argued that the "standard of care" (3x/week) is inadequate. We're happy to help you with this.
-- Get a lawyer. If there is no tort reform in your state, an attorney may be willing to take a case like this on a contingency basis (they get paid if you win).
-- Shine a light on them. Does your area still have a newspaper? A consumer TV show? Get Group Health some very bad press (heartless insurance company doesn't care about people having quality of life and being able to work...) and raise awareness of better dialysis at the same time. Get friends together, picket their building, and call the media. Guerilla PR techniques could help.

Beth Witten MSW ACSW
January 27, 2011, 09:16 AM
What is your primary payer -- Medicare or Group Health? An employer group plan is only supposed to be a patient's primary health insurance for 30 months from when the patient became eligible for Medicare. That should have been your third full month of dialysis, whether you enrolled in Medicare or not. If you've been on dialysis since 2006, Medicare should be your primary payer with your employer plan being your secondary payer. Dialysis corporations bill much higher charges to employer group plans than Medicare allows so dialysis corporation prefer to bill employer plans primary vs. Medicare. Is DaVita still billing your employer plan or Medicare primary? If billing Medicare primary, has DaVita provided Medicare medical justification for additional treatments? I've heard that more Medicare Administrative Contractors (insurance companies that pay Medicare claims) are approving Medicare payment for the extra treatments with medical justification. If it hasn't done so already, perhaps DaVita needs to bill Medicare with medical justification for more treatments. OR is DaVita billing Medicare primary for the 3 treatments and Group Health primary for the extra treatments without trying to bill Medicare for extra treatments believing it will make more money if Group Health pays for those treatments as your primary payer? There could be many things that are coming into play in your situation.

Have you reported your problem to your ESRD Network? Perhaps their staff could go to bat for you and other patients who would like to have the improved health than more frequent dialysis can bring. I'm sure we at MEI would be willing to advocate for you. Even the most rigorous government-funded research is showing that more frequent treatment is better. Do you live in the Northwest? I know Group Health is big there. If so, here's the link to the Northwest Renal Network's website. I know that their patient services coordinator is a strong rehabilitation advocate and helping you feel well enough to keep your job would be something she'd support. If you don't live within their service area, let us know what state you live in and we can point you to the right ESRD Network.
http://www.nwrenalnetwork.org/

Finally, you say you can't do PD. However, rather than returning to 3x/week in-center dialysis, have you considered nocturnal dialysis at home (or even in-center)? People who do nocturnal dialysis feel better, have improved labs, reduced hospitalizations, and more are able to work. I've heard that even 3 nights a week nocturnal dialysis helps patients do well. This number of treatments is within the allowed number that Medicare covers. If your clinic doesn't offer this, others do. Check out the "Find a clinic near you" database on the homepage of Home Dialysis Central.

Finally, you might want to talk with another dialysis provider in your area to find out if Group Health pays for their patients to do more frequent treatments. It's possible that your clinic's charges are contributing to Group Health's decision.

PeterLairdMD
January 27, 2011, 04:08 PM
Dear Mark,

I spent most of the last year up in Idaho and found Group Health to be a TERRIBLE company period in my opinion. They did not cover my zemplar and wanted over 700 dollars to refill it. They would not even acknowledge I was a doctor calling me Peter when calling up on the phone about prescriptions I had written myself. In the nearly 20 years of practice, I never once had a pharmacist call me by my first name, but Group Health did. Most people do call me Peter, but the point is it was a lack of respect and lack of professionalism on their part as far as I was concerned.

If I was in the same position, I would seek legal council in my opinion. The data for home hemodialysis is now overwhelming period. It is better especially with the FHN results which are well documented now. Group Health is my default health care when I am in Idaho so this issue needs to be clarified. They are living in the dark ages of medicine in my opinion and they give medicine a bad name in my opinion. They are no Kaiser sad to say.

NDXUFan12
January 27, 2011, 04:14 PM
I would contact an experienced attorney.

PeterLairdMD
January 27, 2011, 04:16 PM
Mark, send me an email at Hemodoc.com and I will be happy to write up your case and post it.

God bless,

Peter

PeterLairdMD
January 27, 2011, 04:32 PM
Here is the Group Health evaluation of home hemo and daily hemo. It is a very flawed document in my opinion. I sent them an email today asking if they have updated their policy since the FHN.

https://provider.ghc.org/all-sites/clinical/criteria/pdf/dialysis_home.pdf;jsessionid=3XRKNKTZ5JOUTJCISQ4CG WQ

Unregistered
January 28, 2011, 11:53 AM
There are providers that would provide NxStage for three payments a week - three Medicare payments, let alone three private pay payments. DaVita is being greedy IMO. I'm surprised that you're not Medicare Primary though.

thanks, bill.
I'm still working and my employer provides my health insurance

Bill Peckham
January 28, 2011, 03:43 PM
I work too but Medicare has been my primary since 1988 when I was 24. As Beth said after 33 months of dialysis treatment Medicare should be your primary payer and then work would pay secondary.

Unregistered
January 28, 2011, 06:22 PM
Hi Mark,

Boy, we hate to hear this kind of scenario. Unfortunately, DaVita can charge insurance companies so much per treatment (each company negotiates its own deal with a network of providers) that doubling the costs of 3x/week may just not be something Group Health is willing to do. And DaVita did warn you ahead of time that Group Health wasn't a wise choice.

There have to be ways to put pressure on them, however. I know that Beth will chime in here, and she deals more with the insurance side than I do. But some possibilities include (in no particular order:
-- Go up higher in the company. There has to be a process to appeal their decision. "Doctors at Group Health have told me that it will not be overturned" is not an appeal, it is an opinion. There is a formal appeals process. And, with the Frequent Hemodialysis Network trials offering proof that more frequent HD is better--and TONS of other info we could bring to bear--it could be argued that the "standard of care" (3x/week) is inadequate. We're happy to help you with this.
-- Get a lawyer. If there is no tort reform in your state, an attorney may be willing to take a case like this on a contingency basis (they get paid if you win).
-- Shine a light on them. Does your area still have a newspaper? A consumer TV show? Get Group Health some very bad press (heartless insurance company doesn't care about people having quality of life and being able to work...) and raise awareness of better dialysis at the same time. Get friends together, picket their building, and call the media. Guerilla PR techniques could help.

Thank you,
I have submitted an appeal, contacted my representatives and senators, and one local newsman. Not a lot of response yet, but I'm going to have to expand my broadcast area. :)

Unregistered
January 31, 2011, 12:35 PM
More on the Group Health front:
After speaking with Medicare, Group Health and Davita, it seem that Medicare pays a portion of my Group Health premium and that means they get to make decisions regarding my care.

Mark

Beth Witten MSW ACSW
January 31, 2011, 10:31 PM
Do you have Group Health as a former employee/retiree? Or do you have it as a "Medicare Advantage" plan? If Medicare is subsidizing Group Health for your health or drugs, it makes me wonder if you have a plan through a current or former employer that's operating as a Medicare Advantage plan. Do your plan materials say Medicare Advantage (or Medicare Private Fee-for-Service, another type of MA plan) on them? Medicare rules require Medicare Advantage plans to provide the same coverage as Original Medicare at minimum. Unfortunately, original Medicare routinely covers 3 treatments a week...sometimes more with medical justification. I wish it covered more because that would give you a stronger leg to stand on.

I found this document linked below on the Group Health website that shows the basis for their decision for its Medicare patients. The document was first created in 2008 and reviewed for Medicare in 2010. The bibliography listed shows studies as old as 2001 and no study more recent than 2008. About more frequent dialysis, it states: There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies (and/or) provides better long-term outcomes than current standard services/therapies. The document indicates the reviewers don't seem to know about the Frequent Hemodialysis Network study of daily dialysis even though the document mentions the FHN study of nocturnal dialysis as still recruiting. There is a link at the end of document to the Clinical Criteria Documentation Team. I wonder if any of the authors of the FHN would be willing to contact Group Health. This insurer has >654,000 members in WA and ID. If truly 1 in 9 people in the U.S. have chronic kidney disease and Group Health has >654,000 members, >72,000 of Group Health's members may be facing inadequate dialysis in the future unless someone gets Group Health to consider the recent literature that is clear that there is a benefit of more frequent dialysis. Medicare Advantage plans should care because there is no Part A/Part B wall and savings from fewer hospitalizations and not having to treat other health problems that don't occur with better dialysis could offset higher costs of dialysis.
https://provider.ghc.org/all-sites/clinical/criteria/pdf/dialysis_home.pdf;jsessionid=3XRKNKTZ5JOUTJCISQ4CG WQ

Wendy Ramsay
February 1, 2011, 06:27 PM
This thread has become very confusing to follow. Is there any way to arrange the posts in chronological order? They seem to be all over the place. Just wondering...

Dori Schatell
February 1, 2011, 06:53 PM
They're in chronological order, Wendy. I'm not quite sure what you mean.

Wendy Ramsay
February 1, 2011, 08:19 PM
kindof in order but not really...If you start at the original post and scroll down there are some 2011 posts in the middle of the 2009 posts. I guess there are just so many posts that were posted as replies to different comments that they are difficult to track. For instance, I couldn't find your reply just now by searching the thread. I had to go back to the email and click so I went directly to it. No big deal by any means but it does become difficult to look for specific comments with so many offshoots from the original comment.

Beth Witten MSW ACSW
February 1, 2011, 10:06 PM
Hi Wendy,

I looked through the posts starting with the one from March 2009 on page 1. On page 4 the thread goes from post #39 on April 5, 2009 to post #40 on January 26, 2011. It looks like the person who posted #40 must have found the old thread related to insurance not paying for home hemo and posted to it bringing that whole thread into 2011. I was confused at first when I saw the 2011 post after a 2009 one too until I noticed that the next post on page 5 is in date order from this year too.