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Becoming your own Dialysis Provider

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  1. #1
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    Default Becoming your own Dialysis Provider

    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. #2
    Country Girl Guest

    Default Done Once

    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. #3
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    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. #4
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    Default

    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
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

  5. #5
    Join Date
    07-02-04
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    Seattle, WA
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    Default

    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.
    [FONT=Times New Roman]
    [/FONT][FONT=Times New Roman]Dialysis from the sharp end of the needle
    tracking industry news and trends, in advocacy, reimbursement, politics and the provision of dialysis
    -------- -
    [/FONT][FONT=Times New Roman]-------- [/FONT]
    [FONT=Times New Roman]Home Hemodialysis: 2001 - Present [/FONT][FONT=Times New Roman]
    NxStage System One Cycler 2007 - Present
    [/FONT][FONT=Times New Roman]2days on/1day off, 30 Liters @ 250Qb ~ 8 hour per treatment FF28[/FONT][FONT=Times New Roman]
    Incenter Hemodialysis: 1990 - 2001
    [/FONT]

  6. #6
    Country Girl Guest

    Default

    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. #7
    Country Girl Guest

    Default Sales

    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. #8
    Join Date
    07-02-04
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    Default

    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.
    Last edited by Bill Peckham; January 5, 2007 at 05:53 PM.
    [FONT=Times New Roman]
    [/FONT][FONT=Times New Roman]Dialysis from the sharp end of the needle
    tracking industry news and trends, in advocacy, reimbursement, politics and the provision of dialysis
    -------- -
    [/FONT][FONT=Times New Roman]-------- [/FONT]
    [FONT=Times New Roman]Home Hemodialysis: 2001 - Present [/FONT][FONT=Times New Roman]
    NxStage System One Cycler 2007 - Present
    [/FONT][FONT=Times New Roman]2days on/1day off, 30 Liters @ 250Qb ~ 8 hour per treatment FF28[/FONT][FONT=Times New Roman]
    Incenter Hemodialysis: 1990 - 2001
    [/FONT]

  9. #9
    Join Date
    07-02-04
    Location
    USA
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    1,940

    Default

    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!
    Gus Castaneda
    Hemodialysis initial Start: 1978
    Home Hemodialysis: 11/2004 - Present
    Http://www.dailyhemo.org



  10. #10
    Join Date
    06-25-04
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    Default

    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%20doc..._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:
    http://www.cms.hhs.gov/MedicareProvi...dicalEquip.pdf

    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.
    Last edited by Beth Witten MSW ACSW; January 6, 2007 at 09:05 AM. Reason: typos
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

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