Advocacy: Reminder

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

I wanted let you all know about a recent letter I received from “Davita Patient Citizens” whom I am a member of. Here’s a copy…

Dear DPC Member,
Recently Congress passed the final Children’s Health and Medicare Protection (CHAMP) Act, and it did not include any ESRD provisions. This means that important pre-dialysis education for kidney patients was stripped from the bill. However, thanks in part to you, it also means that the ESRD benefit wasn’t hit with the proposed devastating cuts in funding.
As Congress takes up stand-alone Medicare reform in the fall, we must ensure that they are hearing from the patients they are trying to help. The ESRD provisions that will hopefully be included within this legislation are designed to help patients like you.
Make sure that Congress knows what they can do to actually help you and others within your community. Congressional support and adequate funding results in healthier patients, who can stay active and enjoy quality time with those they love.
Please take a moment to contact your Members of Congress and ensure that they are hearing from kidney patients during this critical time. If you don’t raise your voice, the kidney community will not receive the help it needs.
Make your voice heard. Speak up!
Warm regards,
DaVita Patient Citizens

…Continue sending letters to your Congressman!

2

You urgent action is needed this weekend!

Needed reforms to Medicare coverage for dialysis patients like those in the Kidney Care Quality and Education Act are in danger of not passing because some Members of Congress and Insurance companies are working to fight the extension of the Medicare Secondary Payer (MSP). End Stage Renal Disease is unique in the Medicare Program in that it provides coverage to ESRD patients, regardless of age. In addition for those with private coverage, Medicare steps in after a 30-month period. In today’s legislative environment every piece of legislation must be paid for. The MSP extension from 30 months to 42 months generates a modest savings in the Medicare program that can be used to implement many of the provisions in the KCQEA that would benefit kidney patients. An extension also allows those who wish to maintain their private insurance as their primary coverage longer the ability to do so for an extra 12 months.

For some of you, your private insurance may provide better coverage–lower premiums or expanded coverage. With your private insurance and with the MSP extension you could avoid paying both Medicare premiums and your private insurance premiums longer.

For others who prefer to opt into Medicare right away the MSP extension is also important because it will help Medicare save money on ESRD coverage and that savings could then be available to use for education and awareness that is needed to help prevent or delay the onset of dialysis for other people who are at risk of kidney failure. The savings could also help ensure better access and quality of care for current dialysis patients.

Your voice needs to be heard!

Here is the letter I recently sent:

[LEFT][FONT=Times-Roman, serif]October 20, 2007

Committee on Energy and Commerce
2125 Rayburn House Office Building
Washington, D.C. 20515

Dear Chairman Dingell and Senator Barton,

As an ESRD patient, I should have the right to stay with my private insurance instead of
being forced onto Medicare after a set timeframe. This can allow me to maintain the
same insurance as my family and reduces the need for me to pay double premiums (both
Medicare and private). Currently, ESRD is the only disease area within Medicare where
private insurance can limit coverage.

As steps are being taken to strengthen kidney care in the United States, we must ensure
that it is kidney patients who are benefiting. One of the most important steps is to
provide those individuals at risk of kidney failure with education about the factors
associated with kidney disease in the hopes of preventing them from reaching kidney
failure. In addition, when patients reach CKD IV, they should receive educational
sessions designed to help them remain healthier and possibly delay the need for dialysis.

Both of these measures would save Medicare and private insurance tremendous amounts
of money in the long run by preventing or delaying individuals from reaching ESRD and
teaching others to better manage the disease and reduce costly emergency room visits.
Additionally, dialysis reimbursement reform is important for current dialysis patients’
care, like me. For patients, updated reimbursement at a minimum means better access to
dialysis centers in both rural and urban areas that provide the best quality of care.

As an ESRD patient, I rely on dialysis to live. I am very thankful that Congress had the
foresight to have Medicare cover the high cost of dialysis. This has benefited many
patients particularly those without adequate insurance coverage and those who are unable
to maintain their private insurance after kidney failure. Without this assistance, the
majority of ESRD patients would not receive this lifesaving treatment. I am looking
forward to many meaningful changes within Medicare to help increase the quality of care
and education available. However we must ensure that there is an appropriate level of
choice still provided to patients and their family members.

Sincerely,

Erich Ditschman

pc: Representative Mike Rogers[/LEFT]
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3

Hi Erich,

I agree with the argument hat Medicare reimbursement has not kept up with inflation and that there needs to be an annual update in Medicare reimbursement for ESRD, however, the failure of Medicare to keep up with inflation should not be borne by people with commercial insurance, including those with ESRD and the rest of us who are seeing our insurance premiums rise precipitously.

Medicare secondary payer (MSP) has been extended several times over the years. One argument for extending MSP is that it will allow providers to improve quality of care which they can’t do with Medicare shortfalls. I don’t buy this argument. Since MSP came into being, I have watched as RNs have been replaced by technicians and providers have asked one RN to handle more and sicker patients. I’ve also watched as dietitians and social workers have been required to cover more and more patients in multiple clinics often many miles apart leaving them virtually unavailable to patients. If extending MSP worked the way providers say it will, why hasn’t the staffing improved over the years?

Second, extension of Medicare secondary payer is not intended to help you save money on Medicare premiums. In fact, if you don’t sign up for Part B, providers can charge you the difference between what your EGHP pays and its negotiated rate or if there is no negotiated rate, the full charge. Dialysis providers charge multiple times Medicare’s allowed rate for dialysis and drugs. Dialysis providers have reported in conferences that they make on average double Medicare’s allowed amount for each dialysis treatment during the 30-month MSP period. Medicare has complained that providers are making too much profit from Medicare on drugs. I have heard that they make even more than double Medicare’s rate for drugs when they bill EGHPs. If you don’t sign up for Medicare, you will pay more out of pocket. Signing up for Medicare Part B limits what providers can charge you to any balance remaining of Medicare’s allowed charge after your EGHP pays. In most cases EGHPs pay more than Medicare’s allowable meaning you owe nothing if you have Medicare Part B.

Extending MSP another 12 months could increase the number of people whose lifetime benefits are exhausted by high provider (dialysis, doctor, and hospital) charges. With the 30-month MSP, I’ve talked with patients who exhausted their lifetime maximum benefit and had no coverage for drugs or any other medical services. If they were smart, they’d signed up for Medicare but they still could owe the 20% Part B coinsurance if their state didn’t allow people under 65 to buy Medigap (Medicare supplement) insurance. All states have not approved legislation to allow those under 65 the same access to Medigap plans that those 65 and older have. I’ve also talked with a social worker whose patient had a policy with a family lifetime benefit that his dialysis was exhausting quickly. He was planning to drop his EGHP coverage and have Medicare only so his wife could get life-saving chemo treatments for cancer. No one should be put in this dilemma.

I’ve known many patients who worked and felt their jobs were at risk because their employers saw premiums going up. Years ago, a study was done that looked at the impact of extending MSP from 12 to 18 months. Patients and spouses reported employers offering them incentives to not take the insurance, layoffs/terminations, not being hired because they needed coverage for themselves or a spouse with ESRD. Some employers even said the termination was due to high costs of treatment/premiums. I’ve heard that one way employers are limiting their premium costs is by setting a maximum benefit for ESRD treatments. This is legal under the Americans with Disabilities Act if they treat all employees the same.

Dialysis providers are lobbying hard for extension of MSP. They argue that premiums won’t go up that much because this 12-month extension would only apply to large employers. It remains to be seen what will happen with premiums, but I dare say that the insurance industry probably knows more about the effects of changes like this on premiums than the dialysis industry knows. I don’t want to see MSP extended if it will cost patients (or their spouses) their jobs or access to jobs with EGHP coverage.

Beware of unintended consequences that could accompany a 12-months extension of MSP. How many of you want to face exhaustion of your EGHP coverage, high copays/coinsurance for 12 more months, and potential loss of employment or limits in your EGHP coverage for dialysis or transplant? If this doesn’t worry you, think about others who might face these hardships. There is a better way. Dialysis providers could make more money if they staffed their facilities appropriately to improve symptom management, nutritional status, and patient and employer education/advocacy to help more people keep their jobs or find new ones. The higher percentage of working patients they have, the more profitable their clinics would be even if MSP is never extended. Plus, charging rational commercial rates would allow more patients to keep health benefits that could pay secondary to Medicare and would pay as a primary payer for those medical services that Medicare does not cover.

Bottom line…This is probably the first and only time that the insurance industry and I will agree on something 100%. They are lobbying to save money in their plans. I am not supportive of this because I don’t want to see patients harmed.

4

Beth,

What about the argument that bills need to be revenue neutral and that the Medicare savings will be used to educate people so that they delay dialysis or prevent it. Surely on a macro scale that would be much better for all taxpayers and insurance buyers?

Your arguements seem focused only examples of people already with ESRD. How about the tens of thousands people that we could keep from having ESRD? Or do you not think the KCQEA of 2007 will not really help prevent of delay kidney disease?

Curious, Erch

5

Extending the MSP is a giveaway to dialysis providers it strikes me as disingenuous to say it is for the benefit of dialyzors.

According to the KCP press release extending another 12 months would impact 10,000 people a year. So on the one hand CMS would save about $25,000 a year in payments to dialysis providers (see USRDS pdf). That 25K/dialyzor/year savings is the pay-for money that can be counted to fund improvements to the program. I’m in favor of program improvements.

However, for providers keeping those 10,000 dialyzors on private insurance means a vastly greater amount of revenue. The rate charged EGHPs are truly jaw dropping. All providers charge EGHP multiples of the CMS rate but some aggressive for profit providers charge six figures a month for dialysis and medications. Extending the MSP will hasten the collapse of the US ESRD program and accelerate the ongoing provider consolidation.

It is a bitter pill to swallow the MSP extension as the price of a composite rate update framework. But to spin the extension as being good for dialyzors is wrong. Before we break the current reimbursement system I’d like to know what we have in mind to replace it.

6

Erich the proposed ckd program has a five year cost on the order of $50 million/5 years. The MSP extension is thought to create a 1.5 to 2.5 billion dollar/5 year credit. The tech certification, ckd 4 outreach, etc is fluff. Those items are important and should be incorporated into the program administratively - my understanding is that CMS could mandate those things if the administration was so inclined.

MSP in exchange for the update framework is barely acceptable; the spin that the extension is for the benefit of dialyzors is specious.

7

[quote=TheRiverdude;14775]How about the tens of thousands people that we could keep from having ESRD? Or do you not think the KCQEA of 2007 will not really help prevent of delay kidney disease?

Curious, Erch[/quote]

The perverse thing about this is that a successful ckd 3/4 program would increase the number of people on dialysis. The vast majority of people with ckd 3/4 die of heart/stroke. Better care would keep them alive to reach ckd 5. Erich the truth is we’re the success stories. We made it to dialysis.

8

Thanks, Bill.

But until there is an increase in Medicare reibursement to providers what is so wrong with them making additional profit from private insurance? There are more for profit providers than there are not for profit providers like yours. I know that most providers aren’t on the brink of bankruptcy, but they do need to show a profit or they will not stay in business.

I know you are much better versed on this, especially since you are on the board of a provider. But if a bit more profit keeps more providers in business, isn’t that good for the dialysis community?

Erich

9

That’s just it Erich - it has nothing to do with what’s best for dialyzors, it’s about what’s best for the providers. Obviously from the point of view of my organization the more money the better. Keeping the doors open through operations means we can use donations to benefit the kidney health of the community: through health screening (I think we’ll screen over 200 people on Saturday at the Expo), community outreach events (like the Expo), dialyzor education opportunities (like the Expo) and research (NKC funds renal fellows at the University of Washington and is in partnership to build a Kidney research Institute).

I see two issues. 1) Medicare, by law, is suppose to pay its own way. By allowing the composite rate to wither while mandating an increase in the revenue from EGHP Medicare is paying less then the cost of providing the care that they demand. This is cost shifting - shifting the cost of Medicare mandated care from the federal government to private payors. By federal law this is not suppose to happen.

  1. As Beth said by driving up the cost of employing a dialyzor you are going to push dialyzors out of the work place and even impact the employability of spouses.

Like I said it may be required as part of a overall fix to the reimbursement system but it is disingenuous to say it is for the benefit of dialyzors.

10

I can’t believe that dialysis providers are telling patients that increasing the number of months Medicare is the secondary payer will improve the care they can provide to patients. Most patients don’t know the history of MSP, but having worked in dialysis since 1978, I do. If it was true that extending MSP would improve the care the facilities provided, why is it that before 1981 most dialysis clinics were staffed by more RNs with a few technicians. Social workers and dietitians routinely had smaller caseloads and most worked full-time at one clinic. In 1981, Medicare became the secondary payer for 12 months and that was extended to 18 months in 1990 and 30 months in 1996. Since MSP, staffing in dialysis clinics has changed dramatically with a higher ratio of technicians to RNs and social workers and dietitians being required to follow more patients in multiple clinics.

It appears that profits made from MSP payments have gone to building more dialysis facilities (which wouldn’t be needed as much if more patients were encouraged to do home dialysis), buying up competitors to move higher on the list of the top 10 dialysis providers, paying multi-million dollar salaries and giving stock options to corporate leaders, and paying stockholders dividends.

So far as the care provided, as a social worker, I used to pretty routinely see patients before they started dialysis. Dietitians used also saw patients before and could advise people how to begin to modify their diet to protect their kidneys. Today staff don’t see patients before they start dialysis because that would take limited time away from patients who are on dialysis. Patients start dialysis without having seen a dietitian which could have slowed the progression of kidney disease. They don’t see a social worker to help relieve their fears about how they’ll pay for treatment, how to keep their jobs, and to choose the best treatment to fit with their lifestyle. More patients are doing in-center dialysis and fewer patients are doing home dialysis. Once they start on dialysis, staff don’t have time to sit with patients and educate them about why they should follow the treatment plan. Instead of talking with patients about how to cope with kidney failure and dialysis, facility administration make social workers responsible for assuring that patients keep their employer plans giving them a black mark if someone drops or loses EGHP coverage. This takes most of their time so they have limited time to counsel with patients. Providers donate to American Kidney Fund’s Health Insurance Premium Program so AKF will pay premiums for employer plans so providers will make back what they donated plus much, much more.

Businesses need to make a profit. However, even though most patients do not have employer group coverage, it doesn’t take many patients with employer group coverage to make dialysis profitable. How can dialysis providers tell Congress with a straight face that they can’t make any money when they report how much more profit they made this quarter or this year than last to stockholders. Do providers believe that legislators and government employees don’t have access to financial news that makes them question advocacy efforts to get an annual update in the composite rate which would cost Medicare more? On MSP, legislators and providers are aligned with legislators motivated to save Medicare money and providers knowing that the motivation to save Medicare money could put more significantly more money in their pockets.

As a social worker, I remember what I did when I worked in dialysis and what patients and their families wanted, needed, and appreciated. Today I hear patients’ frustration when they don’t see their social worker and believe he/she is more interested in making sure that bills will be paid. I hear frustration from social workers who got masters degrees to counsel patients and help them deal with emotional issues but are dealing primarily with keeping patients privately insured as long as possible. If MSP is extended another 12 months, will social workers have more time to counsel with patients OR will providers expect them to spend even more time making sure patients keep their employer plans for the extra 12 months so they can make more money, build and/or buy more clinics, pay corporate leaders higher salaries and benefits, and get more people to buy their stock?

As Bill said, the Congressional Budget Office estimated it would save Medicare $100 million a year from 2009-2015 if MSP was extended another year. Costs of all the improvements in quality care (patient education, technician certification, a study of modalities, etc.) were too low to be reported on the chart (linked below). Other ESRD provisions (changing reimbursement for EPO, bundling, making payments for hospital facilities which get paid more the same as for free-standing facilities) were expected to save Medicare $3.4 billion from 2009-2015. So, tell me where in this report it says that it’s necessary to extend MSP to provide services that could improve care quality?

http://www.cbo.gov/ftpdocs/85xx/doc8519/HR3162.pdf

11

Beth,

I appreciate your enthusiasm and information. Thank you. Considering I do short term daily by myself, I don’t see where there is a problem in switching staffing from RNs to technicians. I’m not a trained technician and I administer dialysis six times a week.

I just don’t feel that for profit dialysis providers are as evil as you make them out to be. I’m appreciative that they are there to provide me the services I need. Without them, I would still be driving an hour to the University of Michigan and would not be on home hemo which I adore.

Thanks for your comments. I’ve been sharing them with my friends at DPC. We are scheduled to chat today. Afterward, I’ll report on how they respond.

I’m learning so much. Erich

12

Hi Erich,

I don’t think that either Beth or I view dialysis providers as evil–they save the lives of hundreds of thousands of folks each year, and most of them are supporting home dialysis!

However, we do believe that an extension to the MSP would be a mistake, because:
– Each time it is extended, more patients lose their jobs
– Patients are being advised to not take Medicare–which means they may pay more out of pocket (and if they don’t have Medicare at the time of a transplant, it will NEVER cover the drugs)
– Enormous dialysis charges are using people’s family lifetime insurance benefits. This is just wrong.

Educating new patients can’t be put on the backs of current ones. Medicare is not paying its own freight, and this needs to be addressed by getting the industry an annual inflation adjustment–just as nursing homes, hospitals, home health, and every other sector of Medicare has–except dialysis.

p.s. - There are certainly motivated, caring techs out there who provide quality treatments. But techs are only licensed in a minority of states, and no-one even knows how many there are, let alone what sorts of background they have. When I was in college, I trained full-time for 4 weeks to be a nursing assistant–and was not allowed to touch dressings, drugs, or needles. These days, we don’t know how much training techs get (we did write a training manual for them, but don’t know how it’s used in practice), but they are generally the ones cannulating accesses. Research has shown that the more nurses on staff, the better patient outcomes are. Being your own tech is different, because you are motivated to take good care of yourself.

13

Hi Erich,

I’m thrilled that DaVita has its DaVita at Home program and that the other LDOs are starting to recognize that home dialysis can be profitable. Research shows that costs are less to provide care to home patients and that they stay healthier. I’ve been saying for years that if they help more patients keep their jobs, providers will make more money than they would ever make from a small annual update in the composite rate.

When you’re talking with DPC today (assuming DaVita staff who are also board members are on the call), please share the message that I’ve tried to share with corporate folks whenever I speak about rehabilitation. Set a reasonable charge for dialysis and drugs. Joe Pulliam from Fresenius has said at presentations that when the employer plan pays on average double Medicare’s rate, having a very few commercial payers can make a clinic profitable. Charging double is not unreasonable. If Medicare’s rate had kept up with inflation, it would be double what it is today. However, high costs of dialysis care has jeopardized current jobs and potential jobs. No study has been done on this since the December 1992 when the GAO studied extending MSP and concluded that since so few ESRD patients worked, the impact of an extension of MSP would be insignifiant. Read the sections of the report that discuss working patients or patients or spouses looking for employment and you will see an impact on them.
http://archive.gao.gov/d36t11/148207.pdf

Some insurance companies are no longer contracting with certain dialysis providers because of high charges. This is upsetting to patients who are having to leave their clinics and doctors because of this. If that happens with DaVita, Fresenius, or others, it will leaving them with fewer employer group patients and more Medicare patients making it harder to make a profit. You’re happy now, but how would you feel if your insurer told you that it was no longer contracting with your provider and you’d have to go somewhere else where daily home hemodialysis wasn’t an option?

So far as the statement that you don’t see a problem with facilities having more technicians because you aren’t a nurse, were trained in a way as a technician to do home dialysis, and feel comfortable in that role. Keep in mind that your life depends on you doing a good job so you were highly motivated to learn how to do the best job you could do. You have only one person to take care of so in a sense the ratio in your “facility” is 1 technician to 1 patient. You’re not a new technician with a few weeks of training taking care of 4-5 chronically ill people who are unhappy because they have to do dialysis. You don’t have to worry about maintaining your composure when someone snaps at you. You don’t have to worry about having someone new assigned to you when staff you trusted leave. You don’t have to worry about who’s going to stick you or whether that person has had a bad day. If having overworked staff isn’t an issue for you because you do home dialysis, consider how it’s affecting those who weren’t offered home dialysis or can’t do it for some reason.

If I believed that the money that facilities would make from extending MSP would go to providing more staff with better working conditions and a better treatment environment for patients with more home dialysis options, I’d probably feel differently. But history paints a much different picture.

14

Anyone who is following this advocacy needs to read this article about what is really behind DaVita & Fresenius wanting patients to stay on their insurance longer! http://www.alternet.org/healthwellness/68187/

15

That article is not well researched - the information on this thread would provide a deeper understanding of the situation. I am a bit baffled (amused) that the author writes that the legislation “would [allow the providers to] cash in a $2 billion windfall over the next decade” as the horrific consequence of extending the MSP. If that was what we’re talking about it wouldn’t have showed up on his union’s radar. It’s a 3 to 5 billion dollar 5 year windfall to all providers - some providers whose charges are magnitudes higher than Medicare (i.e. they add zeros) are the real problem and don’t even figure in that number.

Putting aside the oddly subdued costs presented this paragraph was the biggest disappointment

Usually, patients need to be 65 years old before they qualify for Medicare. But in 1972, because the high cost of dialysis put care out of reach for all but the wealthiest patients, Congress made the historic decision to extend Medicare coverage to dialysis patients of all ages. But patients who need dialysis have to stay on private insurance for 30 months before they are eligible for Medicare.
People usually qualify for Medicare when they are 65. The unique thing about the dialysis entitlement is not that it was expensive - all diseases are expensive. There were plenty of expensive diseases in 1972 that did not get a unique Congressional program. Dialysis is unique because it is like a switch: with it one lives; without it one dies. It is more like emergency room care than anything else. No other disease at the time could be so successfully treated. The program was sold (oversold) by saying with treatment people could get back to their lives (this would have been more true if the program would have started with daily treatments rather than three times a week).

The other obvious point left unsaid by the author is that it was only relatively recently that there was a waiting period at all. This paragraph reads as if the original legislation included the 30 month waiting period (which is actually 33 months since there is a three month lag before the clock starts).

Then the author can not resist the temptation to bring in CEO salary which is a pointless distraction. Unless the author is a Davita stockholder it is a moot point, and if he is a Davita stockholder he would probably reckon Thiry earned his stock options.

“Anyone who is following this advocacy needs to read this article…” Was the reason I needed to read this because I wasn’t irritated enough with the positions being put forward by the unions? Because I was already pretty irritated.

16

“But patients who need dialysis have to stay on private insurance for 30 months before they are eligible for Medicare. DaVita and Fresenius want to make patients wait longer-another year-before they can get access to the program.”

This quote is incorrect. Extending Medicare Secondary Payer does not affect when someone with kidney failure can get access to Medicare. Patients with employer plans become eligible for Medicare just like those who don’t have employer plans. The earliest date is the first of the month Medicare starts if someone starts home dialysis or has a transplant before the first day of the third month of dialysis. People who do in-center dialysis have to wait up to 3 months for Medicare. All the MSP provision would do is extend how long Medicare is secondary to the employer plan and it applies to those with coverage through employers with 100 or more employees.

I talk with patients who are on dialysis and who have employer group health coverage. I’m always surprised to talk with those who don’t know they can sign up for Medicare. This is something every patient should be told, in my opinion. The other thing that patients should be told is “what’s in it for me (the patient).” Even if Medicare is your secondary payer, if you get services from a provider that accepts assignment (bills and is paid directly by Medicare), the provider has agreed to accept what Medicare allows as payment in full. This means if your employer plan pays at least 100% of Medicare’s allowable (which it generally does), you will owe nothing for Medicare covered services. Employer payments count toward the Medicare deductible too if the provider bills Medicare as a secondary payer. The amount you’ll save is likely to be much more that the monthly Medicare premium.

NOTE: You could still be liable for services Medicare doesn’t allow. This would include charges not paid by your employer plan for more than the Medicare approved number of treatments per month – 13 in a 30-day month or 14 in a 31-day month unless medically justified and approved for more by the fiscal intermediary (Medicare contracted insurance company).

17

That’s good stuff Beth.

18

Forgot to mention that Medicare providers that want to bill Medicare beneficiaries for services that will probably not be paid by Medicare should inform the patient of the charge for that service so the patient can make an informed decision about whether to receive the recommended service of not. This would include charges for more frequent dialysis than routinely allowed by Medicare.

Providers would inform Medicare patients through the Advance Beneficiary Notice of Nonpayment. The form that dialysis providers would use is CMS R131-G (see below). A recent Federal Register notice announcing a public comment period for changes to the Advance Beneficiary Notice of Nonpayment states:

Under section 1879 of the Social Security Act, a physician, provider, practitioner or supplier of items or services participating in the Medicare Program, or taking a claim on
assignment, may bill a Medicare beneficiary for items or services usually covered under Medicare, but denied in an individual case under specific statutory exclusions, if they inform the beneficiary, prior to furnishing the service, that Medicare is likely to deny
payment. 42 CFR 411.404(b) and ©, and 411.408(d)(2) and (f), require written notice be provided to inform beneficiaries in advance of their (or their other insurance, like their employer plan’s) potential liability for payment.
http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/E7-3026.pdf

For more information about the Advance Beneficiary Notice:
http://www.cms.hhs.gov/BNI/

The current version (2002) of the CMS R131-G in English and Spanish can be found at:
– English - http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf
– Spanish - http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf

Here’s a new Medicare booklet that I just found on Medicare Benefits which explains the Advance Beneficiary Notice (page 12):
http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf

19

Hi Folks

Here is a story from the NYTimes. The three sections of the story might help ,but would need a ton of work on all parties . This shows us how complex the problem really is, just take this board. I’m not sure how many people post ,but since I’ve been here the one that is clear is the folks on this board can’t agree on what might be best to help the overall healthcare story.

Emphasize Primary Care. In a health system as uncoordinated as ours, many experts believe we could get better health results, possibly for less cost, if we changed reimbursement formulas and medical education programs to reward and produce more primary care doctors and fewer specialists inclined to proliferate high-cost services. It would be a long-term project.

Skin in the Game. The solution favored by many conservatives is to force consumers to shell out more money when they seek medical care so that they will think harder about whether it is really necessary. The “consumer-directed health care” movement calls for providing people with enough information about doctors and treatments so that they can make wise decisions.

Pay Providers Less With doctors dreadfully unhappy under the heavy hand of insurers, it would seem shortsighted to make them even unhappier by cutting their compensation to levels paid in other countries. But many experts believe it should be possible to tap into the vast flow of money sluicing through hospitals, nursing homes and other health care facilities to find savings.


bob obrien

20

Thanks for that link bobleanor. Pretty good article.