Becoming your own Dialysis Provider

Discussions for Patients, Family, and Friends HD For Patients
1

IF anyone, mods included could, I would like to be directed to information about anyone having success at being their own provider ie: machine, supplies, without a facility and yet with a physician.

I find after doing this for 26 years my health is much better in my own hands than anywhere else.
I would like to seek as much independence from the medical establishment as possible and still dialyze legally in the U.S.

I knom this is an opinion ‘heavy’ board but I just would like some resources.
Thanks,
A Traveler

2

If you search George Harper, he wrote an article one time on becoming his own provider when the dialysis center he was in changed hands and wouldn’t allow him to travel in his motor home anymore and do dialysis. Something he had been doing for years. I don’t know just exactly what he got through being his own provider. I know he had to set up a durable medical equipment
business so he could get the supplies. If you find out anything I would be interested in hearing and this is something I have thought about for a long time.

3

Thanks, Country Girl, I had talked with George at one point in the late 90s and he was doing it with some difficulty and if my memory serves something happened where it fell apart, but I had forgot his name. So maybe I can check with him again. I may see if AAKP knows anything or anyone who is doing it successfully. I think that I could find a anti AMA physician that would be willing to help in my area. Again, thanks.

4

This is the article written by George Harper about why and how he set up his own Method II supply company so he could do dialysis while traveling in his motor vehicle.
http://www.globaldialysis.com/georgeharper.asp

To become a Method II patient, you’d have to sign a new Beneficiary Selection Form saying you want to change from Method I to Method II, assuming you’re a Method I patient. In most cases, a Method change takes effect the following January.

Medicare doesn’t reimburse in a lump sum so if you have to buy a dialysis machine and supplies, you’ll have a pretty hefty outlay at first and only be able to collect back your expenses through monthly Medicare reimbursement.

Patients who are Method II, get support services (nursing, dietitian, and social worker) through a dialysis clinic that bills Medicare separately for this. Medicare has established a set allowable for this monthly fee.

You would still need to have a doctor to prescribe your treatment and advise you about medical issues.

You can read about Method II reimbursement on Home Dialysis Central at http://www.homedialysis.org/v1/medicare/faqs-pros.shtml

5

I for one would appreciate some clarification of Method II for a daily home hemo dialyzor. It would help a great deal to imagine a good system of a truly dialyzor directed care team reimbursed by Medicare if we knew what the current system allows. My memory of George Harper’s experience is “It aint easy”. Well, I think it should be a viable option.

Currently this is what I think I know about Method II – the following should be read understanding I have little confidence that I really understand. I think there are intermediaries between the dialyzor and the manufacturer of our supplies. In other industries this person would be called a wholesaler or a jobber in our industry I believe the term is durable medical equipment provider (DME).

To access the services of a DME you would need the support of a doctor and the clinic where the doctor has privileges. If both the doc and the clinic agreed that they would follow you as a Method II dialyzor then you’d be in business. You would then have to find a DME that had your machine and would sell it or lease it and provide all the other supplies regularly for the price Medicare is willing to pay.

So if you wanted to use a Baby K you’d have to find a DME who could supply you with all you’d need to operate the machine for the charge allowed by Medicare, and you’d need a doc who would be paid I believe the same as for any home dialyzor but might perceive an increased liability and you’d need a clinic that is doing the same cost/benefit calculus as the doc only their reimbursement is a fraction of what they receive were you their Method I home dialyzor and basically they are providing the same service. I think this dynamic explains why we are not hearing about people using Method II to hemodialyze at home.

Traveler, assuming the above is true how would you design a system that would meet your needs and would either compel or reward the cooperation of the docs and providers? Would you or how would you control access to Method II? Dori, Beth or one of our PD brothers, can you explain if access is controlled to Method II for Pdialyzors?

This all puts aside the idea of more frequent dialysis. I doubt there are any DME who would either supply you with more supplies than Medicare is paying for (in the case of the Baby K) or who is contracted by NxStage. This may be a case where the manufacturer of your preferred machine providing your preferred modality would have to have a role in making Method II work.

6

Bill, I could be way off base here but I had a different idea of the way being a DME and your own provider worked. I think you become a DME because that allows you to by the dialysis machine and supplies for resale. As a dialysis machine or RO or whatever cannot be bought by an individual. Then your Nephrologist writes you a script and you purchase the dialysis equipment from the DME. Then the DME submits a bill to Medicare for the items purchased.

I don’t think there would be a problem getting reimbursed for the supplies as this is what I think Method II is about. Paying for the cost, not a lump sum.

I agree you would have to have a Nephrologist go along with this. I don’t think this would necessarily be a problem because our nephrology visit at home is just another doctor appt. As far as the center goes, If the nephrologist had a good relationship with the center, I don’t think that would be a problem either. Whenever dad needs in-center dialysis, IV Vanco, Alteplase and even Iron if I didn’t do it at home. Our nephrologist at home just calls the dialysis center tells them he wants dad to come in for say Alteplase and sets up an appointment. The dialysis center then bills Medicare for just that service. And we are in no way connected to the home dialysis center as a patient. I’m not sure about this, but I almost think when we went on home hemo we were switched from Method I to Method II.

Probably becoming your own provider isn’t as hard to do as it is hard to understand. You are right, you would have to have enough cash on hand to lay out the money for supplies etc. until you sent the bill to Medicare and got reimbursed. I think the DME would be getting reimbursed by Medicare but I don’t know what all that would cover. I know DME’s bill Medicare for things such as Oxgen, Wheelchairs, Scooters, Neubulizer, Lifts etc. rather or not they got into gauze pads, alcohol preps, I don’t know. Would you still be a center patient, I don’t think so; dad is proof you don’t have to be a center patient to go to a center for some form of treatment. IV med, dialysis treatment whatever.

I think it would be a benefit, if we could know how this worked. It could open up the opportunity for patients to be on home hemo without a center having a program.

George’s article has let us know it’s possible, but it’s hard to move forward as he doesn’t mention the role of the nephrologist or the center in this endeavor.
I think to get anywhere with it, you’d have to be able to explain how it worked and what was required of the nephrologist if you were to do this. If you knew the answer to this ahead of time you may be able to get a nephrologist to work with you especially if he believed in home hemo but was
prohibited from offering it because the center didn’t have a program.

I think this is what bobeleanor was looking for. A way to have a relationship with his nephrologist and still get the in-center services he required without being forced to go to the center which home trained him. As his nephrologist and another center were much closer to where he lived. Maybe if he could be his own provider he could?

I suspect you won’t see this coming around for a long time. Just hearing someone could be a dialyzor and being connected to a center on an as needed basis would send chills up the spines of many in the field. Even thought you would be in constant touch with your nephrologist at least once a month.

7

I don’t think the equipment manufactures would worry about what Medicare paid. As a DME you would have to pay them the amount they asked and it would be up to the DME to be sure he got reimbursed enough. If Medicare failed to pay you what you paid for the equipment your loss as the DME not the company selling you the equipment.

I can assure you on the equipment I have known people to be involved with, the DME are making a good buck. It has also been my experience that when going to a DME they check with Medicare on reimbursement before they ever let the customer have the equipment be it a wheel chair, lift, oxgen machine, neublizer whatever. Especially when they purchase the medical device then rent it to you and bill Medicare the rental.

Marty

8

Marty we both may be off the base path but checking out Beth’s linked info (hey Dori how about a section on the patient side explaining Method II?) it states “In fact, under Method II, supply companies can charge $1,974.45 for APD (CCPD) and $1,490.85 for CAPD and HHD.”

I read this to mean that in total your suppliers could bill Medicare $1,490 per a month for your supplies. Is this enough? I really don’t know - well actually I may know too much because I am familiar with the books of a top 10 provider but I’m having trouble thinking how this would be enough to do daily hemo.

I don’t see how the example Beth gave – you put up the cash for a machine and then get a little back each month could work. For a standard machine you’d need about $750 a month for the machine disposables to do 25 treatments – so does the DME bill CMS directly for the $750? And then let’s imagine you are billed $250 from either a unit or another DME for needles, heparin, etc. So then does that mean you could collect the remaining $490 per month to pay you back for the initial expense of buying a machine/RO?

I guess that could work financially if you had the means to carry your own paper or if a DME would lease you the machine/RO for $490 a month. So maybe the financials would work but I am doubtful that CMS ever cuts individuals a check. Is that how it works for Pdialyzors?

My idea that you could use Method II to use a machine/modality not available to you otherwise and Bob’s idea that he could avoid the monthly incenter visits or have a support relationship with a center nearby under Method II, seems to fall apart when you get down to details. You’d need the support of a unit that had experience with the machine you are choosing to use or at least had a home program you could plug into. I’m having trouble imagining a scenario that could work. How could your neighborhood unit support you if they hadn’t any experience with your preferred machine? Or even more so if they had no home program?

If someone could come up with a day to day summary of who would have to do what for this to happen I’d like to see it.

9

It may sound easy to do but in reality its not that easy, especially beeing on dialysis and adding an extra load. Just imagine all the paper work, regulations, and what not trying to find companies that will supply you with the lowest price in supplies and the neccessity to buy wholesale(large quantities per month!) unless your gonna settle for retail prices? I don’t think the re-imbursement rate will workout for just one patient dialyzing at home. I think it only works out when you can buy at low low wholesale prices, so that may mean BIG investment to start with. Maintaining, servicing the machine will prove to be a PAIN!

10

When we wrote the Medicare FAQs, we included information for patients about Method I and Method II that we could find in the Medicare manuals. When I copied and pasted the link yesterday, I must have copied the link to the professional FAQs by mistake. Patients and professionals are welcome to read information posted for either. Here’s the link to the Medicare FAQs for patients:
http://www.homedialysis.org/v1/medicare/faqs-pat.shtml

Here’s an article from 1998 that talks about Method II.
http://www.esrdnetwork.org/new%20docs/Professionals/Rediscover_Method2_as_reimburse.pdf

There is a difference between being a Method II patient who contracts with a supply company to obtain his/her equipment and supplies and becoming a DME (durable medical equipment supply company). I believe George Harper became a DME, not just a Method II patient. Here’s a fact sheet on becoming a DME:

So far as a patient choosing a Fresenius, Aksys, Nxstage or other machine he/she wants and contracting with that company to get it, I don’t know how often that happens. In my experience, my former clinic had Method I and Method II patients. We treated them basically the same. They all got training at our clinic. They all came in for clinic appointments once a month. It was just a difference in billing. For Method II patients, we linked them with the company that we contracted with for other equipment. The DME was able to bill Medicare up to $1,974.45 for CCPD patients and I suspect those were the only patients that were on Method II at our clinic, but I don’t remember for sure. I don’t know why the CCPD reimbursement is so much higher than CAPD or HHD. CCPD and HHD both have machines. Therefore, Baxter and Fresenius must have done a good job lobbying. If I ruled the world (or at least CMS), I’d reimburse all dialysis treatments requiring a machine at the higher rate.

Method II has been an option since the late 1980s. Method II took the financial burden off the clinics for CCPD equipment and supplies for Medicare primary patients, but not CAPD or HHD. I’m providing the data from the earliest date reported in the 2006 USRDS Annual Data Report about how many people were using various treatment options as of December 31, 1994 and December 31, 2004.
– HHD (1993) - 3,850 (2.1%); HHD (2004) - 1,954 (0.6%)
– CAPD (1993) - 22641 (12.3%); CAPD (2004) - 10,858 (3.2%)
– CCPD (1993) - 4,321 (2.4%); CCPD (2004) - 14,907 (4.4%)
So…does anyone have any question that reimbursement influences treatment options?

There have been real and perceived abuses among Method II providers since Day 1. I think CMS would like to only have the composite rate and not have any Method II suppliers. Method II suppliers cost Medicare more and are outside the regulatory system set up for ESRD. They are not monitored by the ESRD surveyors or Networks. The folks working at CMS in the ESRD area and ESRD Networks don’t even know who the companies are or where they operate. Even USRDS doesn’t track how many patients are Method I or II and tells clinics to count them all as home dialysis patients.

From talking with a couple of these Method II supply companies, I gather to bill Medicare they use the Medicare provider number of the dialysis facility that refers the patient(s). They don’t bill the Medicare Intermediary like dialysis clinics. They bill the Medicare contracted payor that used to be called the DMERC (Durable Medical Equipment Regional Carrier) but is now called the DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies). Medicare still reimburses at 80% of the allowed charge. However, because the Method II charge is higher for CCPD, patients or their other insurers could be obligated to pay more.

Since the Method II HHD reimbursement is $1,490/month, this is less than a clinic would charge under Method I (composite rate). I can’t imagine any DME/Method II supply company providing HHD even 3 times a week for this rate of reimbursement. I have heard of some DME/Method II companies that only take patients with commercial insurance and in that case, they could offer a variety of services, including staff-assisted HHD.

11

Thank you Beth that was a good post.

12

OK Bill I’ll see if I can shed some light on this for you.

First of all our needs for dialysis issues are met by our home nephrologist and the center he is connected too. They don’t have a home program and they don’t use the machine I do.

Our nephrologist goes over our labs, (just like your home training nurse does)
if he sees a problem like we need to increase our EPO he calls us or has someone on the staff call us to tell us to increase the dose. If the white blood cell count was low, he would call us or have someone on his staff call us and tell us to come to the center at such and such a time to have a blood culture done. We would go to the center he is affilated with and have it done. If I know I have a machine problem and need a backup treatment, I call the nephrologist near our home and tell him. I suspect you call the home training nurse. He then calls the center and arrangements are made for us to come in. We have been doing this for so long the center now is very familiar with us as being home patients through the Rubin but taken care of by them. IF I can’t get a hold of the nephrologist I just call the head nurse at the center she makes the arrangements and then calls the nephrologist for him to OK it. It doesn’t matter that they don’t have a home program or use the same machine we use they provide us the service all dialyzers get. Home dialyzers are no different than in-center when it comes to what medical issues come up so they are well equipped to handle the medical issues.

Once you are throughly trained on a machine, having someone besides yourself knowing the machine is kind of irrevelant. I can’t remember how many years it has been since I asked a questions in regards to setting up the machine and running a treatment. I am also just as good at calling for service on a machine as someone from the center is.

I have a Nephrologist
I have my labs drawn and sent to my home nephrologist or to whoever he has look over the labs of his in-center patients.
I have a center the Nephrologist can send me to.
What am I lacking by not being connected to a specific center, or home program?
The big difference is, the nephrologist and I take on the responsiblity that most home hemo nurses carry and instead of giving my supply list to the home hemo nurse I’d be purchasing them some other way.

If you can give me an example of the details that concern you, I think I can probably be more specific.

If I had away of getting the machine and the supplies we needed, I don’t actually know why I would need our home training center. In reality because of the distance from our home training center, I have had to find a way to meet our needs without them. This was done by establishing a relationship with a Nephrologist closer to our home.

I don’t want anyone to get carried away with this thinking our home dialysis center doesn’t do anything for us they do. They go over our labs and call me on them. They provide me with a way to draw labs and send them in. They write prescriptions for us. They give us our supplies. Our home nephrologist let’s the home program nephrologist make most of the decisions regarding dad’s labs. They monitor us at night. I was just trying to explain to Bill why you wouldn’t really need to be connected to a home program to accomplish home dialysis as long as you had a nephrologist. I clearly see how it can work.

Gus in response to your post. I don’t think it’s as bad as you think it would be. I don’t think there is anything hard to do, I just am having a whole lot of trouble understanding what’s actually required to do it. I do agree you would need to have some cash to lay out until you could get reimbursed.

I agree with Bill, being your own provider should be a viable option. Giving credit to each dialyzor being different with different life styles and needs this would be 1 more way to help patients become home patients and become more independent.

13

[quote=Country Girl;11882]

Gus in response to your post. I don’t think it’s as bad as you think it would be. I don’t think there is anything hard to do, I just am having a whole lot of trouble understanding what’s actually required to do it. I do agree you would need to have some cash to lay out until you could get reimbursed.

I agree with Bill, being your own provider should be a viable option. Giving credit to each dialyzor being different with different life styles and needs this would be 1 more way to help patients become home patients and become more independent.[/quote]

I understand, but what I’ve read looks like and I speculate its not an easy thing to deal with and doing dialysis at the same time. If you look at method I there’s more hand holding and support. Someone else takes care of your needed supplies, someone else takes care of the paper work, someone else takes care of the phone calls, someone else takes care of the machine maintenance and repairs…see what I mean?

14

Gus, I do see what you mean. The supplies don’t create extra work. We are required to fill out a supply form for our center so the same thing would be done and sent to someone else if we were our own provider. Machine maintenance and repair is the same scenario. We have to call our center when were having a problem we would just call the machine co. direct. Phone calls I think do increase. If you can call your home training nurse and she arranges appointments and contacts the nephrologist or center for you, it’s easier. I don’t think there would be a lot of paperwork once your set up but having none is better than having a little.

Having said this, if I weigh it against the option of not having home hemo because a center isn’t close enough I think it would be a time saver. The 3 to 4 hrs. you spend sitting in-center for treatments you could spend at home doing your paperwork while your dialyzing and still have plenty of time to spare.

I also think that as dialyzors we are so used to someone holding our hand as you mentioned that we tend to make mountains out of molehills. The thought of changing the way things are done always brings on some anxiety and fear and its normally not until you work through it that you realize it’s a whole lot simplier than you thought it was going to be.

I don’t think patients who are content with their travel or home programs would have any reason to even consider being their own provider but for those like George Harper who was having his travel taken away by a center or for those who have to travel miles to be in a program it could be the answer they are looking for.

15

Beth, I can imagine a DME Method II supply company providing daily HHD for this amount. The reason I say this is because even though NxStage may not be a DME or Method II supplier, I read they charge centers 1500.00 per month for the NxStage and all it’s supplies. This fits real close to the 1490.00 amount allowed by Medicare to DME’s.

Marty

16

After reading George Harper’s accounts on his experience again and having heard of patients going to home hemo without the center having a home hemo program I wonder if this is how it was done.

George was doing fine as a Method II patient getting his machine and supplies through a DME. It wasn’t until the DME was going out of business that George had trouble. The trouble became because the center wouldn’t supply him with a machine if he was going to travel. Thus his motivation to become a DME and supply himself with the machine and supplies.

Now for the question.

If I were a dialysis patient and my center didn’t have a home program and I wanted to become a home patient with the consent of my nephrologist could it be done this way.

I am put in as a Method II patient. I get my dialysis machine and supplies through a DME.

The nephrologist asks someone at the center to train me.

I now have a machine and am trained.

I still have my nephrologist and center.

Is there a law that says you can’t do this if the center doesn’t have a home program?

17

My brain has been certainly spinning on this this morning. I came up with another scenario.

I read where Medicare pays DME for dialysis equipment by rental payments.
So lets suppose I became a DME bought a Fresenius Machine for $30,000.
I have had my machine for 7 years.

I have billed Medicare the 1490 per month for 7 years. Suppose I allowed
$990.00 for supplies. Dialyzers, Acid, Bicarb, Saline, Tubing. I put $500.00 per month toward the cost of the machine. In 5 years I would recoup the machine cost.
I have had the machine now for 7 years and am still able to bill the rental so aren’t I now $12,000 ahead. This would allow supplies of $200.00 per week seems to me that should cover weekly supplies.

Perhaps the reason dialysis centers have more patients under Method I as that they realize the profit from the machines once they have gotten back their initial investment? Nothing wrong with this I think it’s called return on investment.

18

Hi Marty,
That would be a good question to ask NxStage or other suppliers of equipment. Remember, Medicare only pays 80% of the allowed charge after the annual deductible is met. If the patient has supplemental insurance or can afford to pay the $300 a month, and if NxStage is truly charging clinics $1500, the clinic will just recoup its cost for supplies and equipment which doesn’t do anything to recoup the high costs of training a patient for home dialysis.

In my opinion, facilities probably do better financially if those patients on more frequent treatments who have Medicare have chosen Method I (composite rate). Clinics may bill for all treatments and may send the Fiscal Intermediary a letter of medical necessity that states why the patient needs additional treatments. These letters may also include statements from members of other disciplines and even state what the patient says about why he/she believes additional treatments would be best. FIs have the discretion to pay for more treatments when they are deemed medically necessary. I don’t think there is any consistency from FI to FI about payment for extra treatments.

Some new patients who are started on daily treatments have EGHP coverage. Dialysis providers typically bill EGHPs several times Medicare’s composite rate for each treatment. As I see it, here are some of the incentives for clinics to offer more frequent dialysis:
– Helping more working patients keep their jobs (and EGHP coverage) by training them to do dialysis at home;
– Allowing the clinic to treat more patients without having to expand or hire more staff;
– Improving patient and staff satisfaction;
– Proving better toxin removal with more frequent dialysis so patients get all their treatments at home instead of being hospitalized and losing money to the hospital for dialysis treatments done there;
– Spending less on drugs and requiring less time to administer IV/injectible drugs if patients need fewer drugs because of fewer toxins in the blood;
– Billing (and potentially collecting) twice as much weekly for an EGHP patient who dialyzes 6 days a week compared to the patient who dialyzes 3 days a week.

I hope that dialysis clinics that start patients on more frequent treatments when they have primary EGHP coverage will allow them to remain on these treatments when their coverage switches to Medicare primary. I also hope that EGHP lifetime benefits will not be exhauseted for patients on more frequent treatments because providers charge EGHPs so much for each treatment.

19

[QUOTE=Country Girl;11895]My brain has been certainly spinning on this this morning. I came up with another scenario.

I read where Medicare pays DME for dialysis equipment by rental payments.
So lets suppose I became a DME bought a Fresenius Machine for $30,000.
I have had my machine for 7 years.

I have billed Medicare the 1490 per month for 7 years. Suppose I allowed
$990.00 for supplies. Dialyzers, Acid, Bicarb, Saline, Tubing. I put $500.00 per month toward the cost of the machine. In 5 years I would recoup the machine cost.
I have had the machine now for 7 years and am still able to bill the rental so aren’t I now $12,000 ahead. This would allow supplies of $200.00 per week seems to me that should cover weekly supplies.

Perhaps the reason dialysis centers have more patients under Method I as that they realize the profit from the machines once they have gotten back their initial investment? Nothing wrong with this I think it’s called return on investment.[/QUOTE]
I don’t know how much the dialysis clinic is charged for equipment vs. the supplies each month or how much a DME would be charged for that same equipment/supplies if it was buying one vs. many. This might be something to ask one of the companies that makes machines. I suspect the more machines you buy, the better the deal you get per machine.

I suspect you’d be a lot better off if you had lots of money so you could buy the machine outright and not have to take out a loan and pay interest on it. Another thing to consider is how long do you want to keep that dialysis machine and what do you do with it when newer technology makes it obsolete. A lot can happen in 7 years and you’d probably hate to be stuck with an older machine if a new one comes along that’s more efficient and smaller or that you can wear. Clinics that upgrade their purchased equipment have to find a place to get rid of their old equipment and some donate it because they’ve been able to depreciate it over time.

You can read Medicare’s payment policies related to the machine and supplies for home dialysis in the Medicare Benefit Policy Manual, Chapter 11 – ESRD (Section 50)

20

Beth,

I don’t want to get into money rangling. I was just pointing out that I think if you were your own DME supplier you probably could make money. As far as to how long I would want to hold on to the machine. If my dialysis were good and I was making money, I probably wouldn’t complain if I used the same machine for 10 years. Also depending on how good the new technology was “I” could make the choice to take a loss and go to the new technology.
As a dialysis patient working through a center, I am stuck with the machine they gave me until they decide to trade it in. So far going on 7 years, I heard one time they started exchanging them at 10 years but I don’t know if this is true. Also as an in-center patient there is no guarantee I would be able to utilize the new technology. The Rubin is not letting all the Fresenius patients change to NxStage and a center closer to home isn’t going to use NxStage at all simply because of cost or so that’s what they tell me.

George Harpers reason for becoming a DME was to have more independence. He was going to travel with the Dialysis Machine and the center wouldn’t furnish him one when they heard this.
Traveler started this post, pointing out he was looking for more independence.
I would also like to know there is away dialysis patients can be more independent if they don’t have available to them through a center what they are looking for.
If the only way you can get home hemo and not have to travel 100 miles is to become a DME why wouldn’t you want this to be a viable option.

I don’t see any point in comparing being a DME to being center connected. Patients who think in these lines are looking for more independence and less restrictions imposed by what a center offers and doesn’t offer.