Back Bill for Fistula?

We were told that Medicare can be back billed for the fistula surgery if my husband starts home training within 3 months of the surgery date. How can he comply w/ Medicare requirement, yet allow the fistula to mature? Has anyone here been involved in back billing for a fistula, and if so, how difficult was it to do?

If your husband has good insurance, this may not be an issue for you. However, if your husband has no insurance, having Medicare coverage for fistula placement can save money. You might want to ask your vascular surgeon what a fistula placement costs with and without Medicare.

The way Medicare works is that even though Medicare normally has a 3-month waiting period for those that do dialysis in-center, the waiting period is waived if home training starts before the 1st day of the 3rd full month of dialysis. The 3-months starts with the first day of dialysis. Find out from your state insurance department if your husband can get a Medicare supplement (called Medigap) plan in your state once he gets Medicare. If so, you’ll pay premiums, but premiums will be much less than than you’d pay for 20% of all the medical services.

Any time a patient starts home dialysis training for PD or HD, Medicare is backdated. This is something that doctors and hospitals are used to. Alert the surgeon and his/her biller of your husband’s plan to start home dialysis training to get Medicare backdated. They may ask you to for payment and most of the time they will negotiate with you on how much.

Because fistulas usually take 3-6 months to develop, your husband may need to have a temporary catheter to do dialysis at first until the fistula develops. Ask the doctor and vascular surgeon which one has the fewest problems and follow care instructions to the “t.” Depending on what he and the clinic decide, he could start home hemodialysis training with the catheter or wait until the fistula develops. If it get close to the 1st day fo the 3rd full month after dialysis starts, I’d suggest starting training with a catheter. You and he can learn the basics of the machine and some people do home dialysis with catheters. Hopefully his fistula will develop quickly. Doing fistula exercise may help the fistula to mature faster. Ask your husband’s doctor, nurse, or vascular surgeon for instructions on how to do exercises to increase the size of the fistula. There are instructions in the patient tips on

Here’s an abstract of a study that found that these exercises that we’ve all been recommending for years really do work:

[i]Effect of Exercise on the Diameter of Arteriovenous Fistulae in Hemodialysis Patients.
ASAIO Journal. 49(5):554-555, September/October 2003.
Oder, Terrence F.; Teodorescu, Victoria; Uribarri, Jaime

Physicians routinely recommend hand squeezing exercises for end-stage renal disease patients with newly placed arteriovenous fistulae (AVF) to increase the rate of fistula maturation. However, this practice has never been shown to actually work. To determine whether hand squeezing has an acute effect on fistula diameter, we examined 23 patients with newly created AVF (1 week to 10 months before study, mean 2.8 months). Using duplex ultrasound, we measured the diameter of the fistula three times before and three times after 5 min of squeezing a rubber ball. Fistula diameter increased in 20 of 23 patients; the mean change in fistula diameter was 9.3% (p < .0001). These data suggest that fistulae do dilate acutely after hand squeezing exercise and that this exercise should continue to be recommended.[/i]

Thanks, Beth. I saved your post to refer to later. I’m trying to get the dialysis clinic and the nephrologist to coordinate timing, in order to minimize our expenses and to minimize my husband’s discomfort.

We did get some really good news this week – our hospital is not only writing off all of his hospital bills, but also has made arrangements for him to go there for all of his blood work at no charge!! Previously when he had his parathyroid checked, in addition to the usual panel, it has cost almost $300. Whew! That’s a relief. I hope the hospital made enough money off of my two surgeries, back when we still had insurance, that they aren’t really losing anything now.