So in my current job we are looking at changing healthcare providers. My gracious boss has offered to look at which providers would provide greatest value benefit for our situation ( me and my wife who has just started home PD treatment with Fresenius ). My boss tells me the insurance broker for our company is asking for the billing codes, I assume CPT codes, for all my wife’s needs. I have called multiple people from Fresenius, multiple times and I always either get “I can’t give you that information” or “You need to call so and so for that information”. This is assuming anybody answers or bothers to return my call after leaving a voicemail. The time period for choosing a new healthcare provider is coming soon and I have already been trying to resolve this for a month now.
Is there anyone who could spare some info or advice on a way to obtain this info?
I’ve been going in circles far to long now with something I would think would be an easy request to fill.
Thanks in advance for anything anybody could help with,
Ryan
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The Medicare Claims Processing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf tells dialysis clinics how to bill Medicare for dialysis. I suspect you need the revenue code for your wife’s type of dialysis. If she’s doing CAPD, the “revenue code” is 0841 and the revenue code for CCPD (cycler) is “0851.” You or the insurance broker might want to call Renal Billing at 1-877-947-6700 to ask if they will help. Their leaders have run dialysis clinics and I bet they can provide the codes the insurance broker needs to help your company get the insurance that will cover what she needs.
Patients on dialysis often are prescribed drugs for anemia, phosphate binders, vitamin d analogs to prevent/manage of renal bone disease, and a few others. It would be important for the broker to find out if the insurance plan covers the medications she takes. She will also need regular lab tests to monitor how well she’s doing. Knowing how the plan covers labs is important too.
If the insurance broker hasn’t dealt with someone on dialysis before, he/she should know that your job-based insurance company will be liable as a primary payer for only 30 months from when your wife became eligible for Medicare. If she started training for PD before the end of the 3rd month of dialysis, she is eligible for Medicare the first day of the first month of dialysis. Some people with job-based plans don’t take Medicare. Having Medicare Part A and B prevents providers that “accept Medicare assignment” from “balance billing” patients the difference between the job-based plan payment and the full charge as long as the job-based plan has paid at leat 100% of Medicare’s allowed charge. If she decides not to take Medicare, I’d advise her not to take Part A or B to avoid being limited in when she can enroll in Part B and having a late enrollment premium penalty for Part B that is 10% per 12 months someone delays enrolling in Part B after enrolling in Part A.
Thank you so much Beth!
Well both me and my wife are 41 so while she may be entitled to Medicare because of ESRD I don’t think the A + B penalty applies. I’m going to have her call social security today to see if she has enough work credits because I’m still to young ( never thought 41 would be to young for something ) for her to use my work history.
I read over the linked document regarding Medicare billing. I’m guessing those codes wouldn’t apply to a private insurer?
The work credit requirement is less for Medicare due to kidney failure when you’re younger. An adult with ESRD needs to be “fully or currently insured” on their own work record or on the record of a spouse. Here’s the SSA policy that describes that. https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801201
Here’s the policy on how SSA staff are to advise those with job-based plans about the Medicare secondary payer period and its affect on decision-making related to enrollment in Medicare in section F at the end of the policy.
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801247
As you can see from that policy, there is a penalty if she takes Part A without B, but there is no penalty if she chooses to waive both Medicare Part A and B and take them later. If she chooses to do that, I’d suggest she ask Social Security how long before the end of the 30-month Medicare secondary payer (MSP) period she should apply for Medicare A and B so both are effective the month following the end of the MSP period. At that time your plan will become a secondary payer. It might be worthwhile for the broker to also ask how each plan pays as a secondary payer to Medicare. Some pay the balance for Medicare-covered services. Some have their own allowable which can leave you the a balance to pay.
I found a MN Blue Cross Blue Shield document listing codes. Some are physician billing codes. Even if the insurance broker isn’t looking at a BCBS policy, this should give him/her a starting point so far as codes to look up.
https://www.bluecrossmn.com/healthy/public/portalcomponents/PublicContentServlet?contentId=P11GA_15879403