Calling Epoman ,Bill Peckham , Marty ,anyone who cares

This person who you know Beth that works for Davita works in land of OZ, Here in great state of Pa davita works somewhat different.
Although I live in the land of Oz (Kansas), my friend works for DaVita in another state, so he doesn’t “work in the land of OZ” (ha!). However, his clinic has a different manager than PA clinics and I suspect his clinic is under a different regional office. I don’t know how DaVita divides up the country but do know that it’s in regions.

Like I said I just want to see my doctor if it once a month so be it ,but this going to hear the same lab report (THE SAME LAB REPORT) by three people looks like insurance fraud and medicare fraud

I don’t know how clinics bill commercial insurers for clinic visits, but it might be per visit. However, if you read about Medicare reimbursement in our Medicare FAQs posted on this site, you will see that Medicare billing by dialysis clinics isn’t based on the number of times the patient is seen by staff at a clinic visit. It’s based on the number of HD treatments performed (Method I) or they get a monthly fee for all support services provided no matter how many times the patient calls or visits the clinic (Method II). Medicare pays physicians a set amount monthly to see home patients unless the patient is hospitalized and the nephrologist sees the patient in the hospital.

I agree that corporate and clinic personnel need to understand that home dialysis patients have more active lives than many in-center HD patients. When staff are setting up home program protocols, it would make good customer service sense if they take the time to understand other demands that home patients may have. I would hope that they would try to accommodate their patients’ needs so dialysis interferes as little as possible with the rest of their patients’ lives.

What have you done so far as asking your clinic to accommodate your desire to come once a month and how the clinic reacted to your request?
– Have you explained to the clinic staff the difficulty of getting to clinic visits more than once a month?
– Have you asked your nurse if you could draw your own blood and send it to their designated lab?
– Have you asked the dietitian if you can get your lab report by mail or fax and set a time to go over it on the phone with him/her so you can learn if you need to make any changes in your medications or diet?
– Have you asked the social worker if you can set an appointment to talk with him/her by phone instead of in the clinic?

Pat wrote:

We are given all the blood tubes,
date to draw both pre and post, the centrafuse (sp) to spin and told to put everything in refrigerator. I put 2 ice packs in the freezer and then in the morning pack it up and either Ralph delivers to Fed X or they pick up at the house. We do this 2 times a month. The first one is done at the beggining of the month and the mid month so at clinic they have all the info. system works great.

I see you are able to collect blood at home eliminating extra trips to the unit, and not just once but twice a month. Others said they do it this way also. Why do you do blood work twice a month?

Beth Witten MSW ACSW wrote

What have you done so far as asking your clinic to accommodate your desire to come once a month and how the clinic reacted to your request?
– Have you explained to the clinic staff the difficulty of getting to clinic visits more than once a month?
– Have you asked your nurse if you could draw your own blood and send it to their designated lab?
– Have you asked the dietitian if you can get your lab report by mail or fax and set a time to go over it on the phone with him/her so you can learn if you need to make any changes in your medications or diet?
– Have you asked the social worker if you can set an appointment to talk with him/her by phone instead of in the clinic?

Hi Beth

Yes, I have talked with doctor I’ve talked with soc.worker I’ve talked to Dean Morris network4, The last person I talked with was the manger of davita home team in Phila. I was told that I was not a good pt for home program. I’ve been home since 4/28/06. I yet to miss a flow sheet , a lab draw or shipment. You know what made me a bad non compliant , was that my wife just under a bilateral mastectomy. So I had to drive her to cancer doctor and other such trips. And James Salas the manger of Davita home in Phila said this was not a good reason for a man of 50 to miss or postpone a trip to 6 and chestnut. And That he would end my home program. I asked the esrd who calls the shots, doctor or company it looks to me like the company knows more than the doctors. maybe I should drop the doctor

This from the esrd Hi Mr. O’Brien,

[i]Please don’t misunderstand my email. There may not be a law, but if you decide not to follow the nephrologist’s or facility’s prescription for follow-up care, they can decide to terminate your home care because you were non-compliant with the protocol. They may suggest that you come to have dialysis at the facility. That is why it is important to play by the rules. Please do not jeopardize your relationship with the facility or nephrologist. I make the suggestion that a compromise of some sort be made. Please remember that maintaining your health is the most important thing to everyone.
Sincerely,

David Moskovitz[/i]
bobeleanor :smiley:

Hi Heather,
The reason we do it 2 times a month to keep a good eye on PTH and the HGB. The second one is done as a fasting and after a night off, to get a little different perspective. We do ours on Sunday morning. I just put a needle in his Anterial and draw the blood. Spin it and put it in the refrigerator. It goes out on Monday and the Clinic has the results for our regular clinic meeting on Wednesday.
Hope this helps.
Pat

I thought PTH testing was only paid for once per quarter. Has that changed?

Doris,
I may have misspoke. It may only be taken on the quarter. I do know that Hgb is taken. I will check the next time I have to draw. This month is not a good month to check because it is the quartly reports.
But I will let you know.
Pat

Your experience is upsetting. In all of my years working in dialysis, I’ve never worked at a clinic that would not have made some effort to work with someone in a situation like yours.
– How much did your doctor and/or clinic staff know about your wife’s breast cancer, mastectomy and follow-up appointments?
– Did your home training nurse and physician offer to try to accommodate your need to take her to appointments?
– Did your doctor offer to let you come to his/her office instead of going to the dialysis clinic for the time you needed to focus on her health.
– Did your wife tell her doctors about your clinic appointments and ask if there was any way to accommodate your need to be at the dialysis clinic for your appointment?
– Did anyone talk with you and her about other ways she could get to her appointments if they overlapped your clinic appointments and couldn’t be changed?
– Did you appeal Mr. Salas’ decision to anyone higher up the chain of command in DaVita, citing your wife’s illness and the apparent lack of flexibility at your clinic to accommodate your need to make sure she got the healthcare she needed.
– Did anyone ask how your wife’s illness was affecting your and her will to live and to take care of yourselves?

If not, I would say that at several points interventions could have been done that would probably have reduced the conflict between you and the dialysis clinic. Did the clinic make you go in-center? If you’re doing in-center hemodialysis, how is that working with your wife’s healthcare appointments?

Not knowing exactly where you live, but looking for non-DaVita clinics, there is a clinic in Newark, DE that is about 45 miles from Lancaster, PA. It is owned by Fresenius. It offers conventional and nocturnal home hemodialysis. I suspect that it offers both of these 3 days a week unless someone has medical reasons for more treatments.

Fresenius Medical Care (FMC) - Christiana
Address: 63 University Plaza
University Plaza Shopping Center
City: Newark
State: Delaware
Zip: 19702
Phone: 302-453-8834
Fax: 302-454-1485

I’d contact that clinic’s home training nurse if you haven’t already done so to see if you could get home dialysis through them. When talking with any other clinic, be honest about what happened at the DaVita clinic. Explain the double-bind situation that you faced with your wife’s health and what you did to inform the clinic of that scheduling conflict. Ask the training nurse how he/she would have handled that situation.

If this or any other clinic certified to offer home hemo gives you a chance, it would need to spend much less time assessing your ability to do home dialysis since you’re already trained and you’ve already done dialysis at home. Any clinic that would accept you would not have the expense of 3-6 weeks of training costs that must be recouped before a clinic can come out ahead on home dialysis. If your DaVita clinic made you return to in-center dialysis, that clinic would be the one losing out on the opportunity to recoup its training costs because patients on in-center dialysis are more expensive to treat.

Thank you, Pat. Does anyone know, are units/home programs required by Medicare to do a 2nd blood test per month for hgb and pth or is this just something some units do? Does it make a critical difference in how carefully these values are managed?

Heather, I do not know if there is a policy by medicare or not perhaps one of our great ladies, either Dori (Sorry or calling you Doris- the fingers slip) or Beth can answer that.
I do know that we have to be very careful to do bloods after the 1st of the month.
Pat

Oh I see somemore posts have come in on this and it may not be that pth is taken more than quarterly. Could it be that phos./cal. is the other value taken 2x per month? Also, I’ve never heard anyone say before that they do a 2nd test after fasting and the day off. I would be interested to know if this is a test just done in your program, and more specifically, what info. it provides.

Dialysis clinics are very concerned that a patient’s hemoglobin not go above the allowed level (13) without the clinic knowing to reduce the dose of EPO 25%. This is probably why clinics draw Hgb more than once a month.

[i]30.2 - Laboratory Services Included Under Composite Rate
(Rev. 1, 10-01-03)
A3-3167.1, RDF-207.1, PR 1-2710.1

The costs of certain ESRD laboratory services performed by either the facility’s staff, or an independent laboratory, are included in the composite rate calculations. These laboratory tests are listed in §§30.2.1 and 70.2.A. (See §§50.1, 60.1, and 80 of the Medicare Claims Processing Manual, Chapter 8, “Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims,” for payment instructions.) Therefore, payment for all of the tests is included in the facility’s composite rate, and the tests may not be billed separately to the Medicare program. Laboratory tests are performed either by the facility, in which case payment is included in the composite rate, or by an outside laboratory for the facility, in which case the laboratory bills the facility and is paid under the composite rate. (See the Medicare Claims Processing Manual, Chapter 1, “Inpatient Hospital Services,” §§40.)

30.2.1 - Laboratory Tests for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous Cycling Peritoneal Dialysis (CCPD), and Hemofiltration
(Rev. 1, 10-01-03)
A3-3167.3, RDF-207.3

A. Routinely Covered Tests Paid Under Composite Rate
The tests listed below are usually performed for dialysis patients and are routinely covered at the frequency specified in the absence of indications to the contrary, i.e., no documentation of medical necessity is required other than knowledge of the patient’s status as an ESRD beneficiary. When any of these tests is performed at a frequency greater than that specified, the additional tests are separately billable and are covered only if they are medically justified by accompanying documentation. A diagnosis of ESRD alone is not sufficient medical evidence to warrant coverage of the additional tests. The nature of the illness or injury (diagnosis, complaint, or symptom) requiring the performance of the test(s) must be present on the claim. Such information must be furnished using the ICD-9-CM coding system.

  • Per Treatment - All hematocrit, hemoglobin, and clotting time tests furnished incident to dialysis treatments;
  • Weekly - (1) Prothrombin time for patients on anticoagulant therapy, and (2) Serum Creatinine;
  • Weekly or Thirteen Per Quarter - BUN;
  • Monthly - Serum Calcium, Serum Potassium, Serum Chloride, CBC, Serum Bicarbonate, Serum Phosphorous, Total Protein, Serum Albumin, Alkaline Phosphatase, aspartate amino transferase (AST) (SGOT) and LDH; and
  • Automated Battery of Tests - If an automated battery of tests, such as the SMA-12, is performed and contains most of the tests listed in one of the weekly or monthly categories, it is not necessary to separately identify any tests in the battery that are not listed. Further information concerning automated tests and the “50 percent rule” can be found in the Medicare Claims Processing Manual, Chapter 16, “Laboratory Services,” §160.

B. Separately Billable Tests
The following list identifies certain separately billable laboratory tests that are covered routinely, i.e., without documentation of medical necessity other than knowledge of the patient’s status as an ESRD beneficiary, when furnished at the specified frequencies. If they are performed at a frequency greater than that specified, they are covered only if accompanied by medical documentation. A diagnosis of ESRD alone is not sufficient documentation. The medical necessity of the test(s), the nature of the illness or injury (diagnosis, complaint or symptom) requiring the performance of the test(s) must be present on the claim. Such information must be furnished using the ICD-9-CM coding system.

Guidelines for Separately Billable Tests for Hemodialysis, IPD, CCPD, and
Hemofiltration

  • Serum Aluminum - one every three months
  • Serum Ferritin - one every three months
    (See §70.2 Item 1 for laboratory tests rendered to CAPD patients.)[/i]

Since other labs are to bill dialysis clinics for the labs they perform, this might explain why clinics don’t want patients to get labs drawn elsewhere. I’m sure they have contracts with certain labs that charge a set amount per patient per lab for those labs they do under the composite rate. Interestingly, PTH isn’t listed as under the composite rate or separately billable.

Here’s the Medicare Benefit Policy Manual for ESRD.

Hi Beth
Everyone was aware of my wife story. Her thing did not happen over night. Her story started back in Jan06 with a routine breast exam. And just took off from there, I keep people up to speed. I told the people in the center while I was in center that I may need to miss a tx in order to go doctors office to be there for my Wife. It is a shitty company that only thinks of the company bottom line. Like I said I 'm 50 years old and very aware of the risk of life. They (the center people would say if you miss a tx you will die) and I would say i could hop in a car and get hit by a mack truck or a drunk driver and die, that isn’t going to stop me from driving. Just Living has risk everyday where your life could end in the blink of a eye. That why I always tell my wife that I love everyday when we wake and before we go to bed.

Yes the doctor try to get Mr. Salas to let me go to a davita center 5 miles from my house where I started , just to get what was needed. But Mr. Salas flat out said no. I do not know who his boss is, and I’m tired, of davita big thumb on home consumers. The only way out that I see is to take this whole thing out into the open. Let the chips fall where they may. I will not go back into a davita center once was too much. Here in Pa davita centers treat pt/consumers like dog meat.
bobeleanor :smiley:
PS, this not OZ it is not even Kansas

Beth wrote:

Dialysis clinics are very concerned that a patient’s hemoglobin not go above the allowed level (13) without the clinic knowing to reduce the dose of EPO 25%. This is probably why clinics draw Hgb more than once a month.

Oh so it is for the clinic’s benefit, not the patient’s. But when it comes to home patients, didn’t they just allow for the higher hct so that it is not necessary for home patients to do labs 2x month for hgb?

I shared the payment so people could see the Medicare policy for lab tests. I didn’t post in this thread the EPO monitoring policy which says that Medicare payment is not supposed to be automatically reduced 25% for home patients whose Hgb (Hct) goes over 13 (39). I assume this policy differential was because home patients aren’t seen as often and because the staff can’t as easily monitor their Hgb (Hct). However, I can’t guarantee that every dialysis clinic knows this distinction and some may be asking patients to get their blood drawn more often because they believe the EPO monitoring applies to all dialysis patients.

As to the patient quality of care issue, even knowing that the EPO monitoring is different for home patients, doctors may want to know home patients’ Hgb (Hct) to be sure that it’s not too high. There have been studies that reported negative outcomes in patients who had higher higher Hgb (Hct) levels.

Were you doing home dialysis at this time? One of the advantages of home dialysis is that you can shift your treatment time and days around as long as you get in the number of treatments and the amount of time you’re supposed to get. Did anyone tell you that?

Are you saying that you asked Mr. Salas for in-center dialysis at the clinic near your home and he refused that? Did you call that clinic? Was there space for you there? If you were doing home dialysis and you needed backup in-center dialysis because of your wife’s health, the Medicare certification that your home program has requires that it have arrangements for in-center backup treatments for home dialysis patients when needed. Because DaVita is a chain with multiple clinics, this should make it very easy for the clinic to back you up either at the training clinic or at a closer clinic to your home. To arrange dialysis for you at another DaVita clinic would have been no worse than arranging for a traveling DaVita patient to go to another DaVita clinic. I suspect your treatment prescription and most recent dialysis treatment sheets could have been electronically transferred and you could have run your own treatment at the dialysis clinic assuming they let home patients do that. Why didn’t your doctor order dialysis at that clinic? As far as I know, as long as there is space at the clinic, a clinic cannot refuse a doctor’s order.