Okay guys, I got my fistula installed just three days ago and it’s buzzing just fine.
This is where the bottom dropped out - I work for a bank who has Carefirst/Blue Choice as their insurance company. I was informed yesterday that they will NOT under any circumstances pay for home hemo dialysis. They will only pay for “in-clinic” dialysis.
Does anyone know where I can start in pushing for a change here?
Hi Unregistered,
In just the past couple of days, I’ve learned some interesting things about health insurance companies. One is that under the Federal ERISA law (Employee Retirement Income Security Act) of 1974, individuals are no longer allowed to win damages if they sue health insurance companies–they can only win the amount of the unpaid claim.
What this means in practice is that they have nothing to lose by turning you down. If they say “no” to everything, only a fraction of the folks they decline will take any action to get them to pay–so they win. The first answer from a health plan, then, will nearly always be no.
BUT…what health plans hate more than anything else is hospitalization. They make their money by collecting your premiums and paying out as little as possible. Cancer and ESRD are two of the diagnoses that cost them the most. So, the first point to make to them is that longer/more frequent HD cut the hospitalization rate.
Here is a new study showing significantly fewer hospital days in folks treated with nocturnal HD for 2 years vs. a group who stayed on standard in-center. (Bold is mine):
Clin Nephrol. 2008 Jan;69(1):33-9.
Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis.
Bergman A, Fenton SS, Richardson RM, Chan CT.
Department of Medicine, Division of Nephrology, The Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
BACKGROUND: Cardiovascular disease remains the leading cause of death among patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) (5 - 6 sessions per week; 6 - 8 hours per session) is a novel form of home-based renal replacement therapy, which has been shown to improve several cardiovascular risk factors. The impact of NHD on hospitalization rate has remained unclear. We hypothesized that augmentation of small and middle molecular clearance by NHD would result in a reduction of dialysis related or cardiovascular specific hospitalizations. METHODS AND RESULTS: In this controlled cohort study, we studied 32 NHD patients (age: 43 +/- 2 [mean +/- SEM]) 1 year before and 2 years after conversion to NHD and 42 CHD patients (mean age: 44 +/- 2) (matched for age, dialysis vintage and controlled for comorbidities) during the same time period. The primary outcome was the change in a composite of dialysis or cardiovascular related admissions rate before and after conversion to NHD. Secondary outcomes included changes in all cause hospitalization rate, visits to emergency, reasons and duration of hospitalization and dialysis-related biochemical parameters. During the study period, dialysis or cardiovascular-related admission rate was stable for the CHD control cohort (from 0.48 +/- 0.14 [baseline] to 0.40 +/- 0.12 [end of study] admission per patient year, p = NS). In contrast, conversion to NHD is associated with a decrease in our composite endpoint (from 0.50 +/- 0.15 to 0.17 +/- 0.06 admission per patient year, p = 0.04). Cardiovascular disease (37%) was the principal cause for hospitalization in the control population. In comparison, vascular access related admission was the primary cause of admission for the NHD cohort (56%), p = 0.001. Of the biochemical parameters, NHD is associated with a decrease in plasma phosphate (from 1.7 +/- 0.1 to 1.3 +/- 0.1 mM, p = 0.01) and an improved control of anemia (from 114 +/- 2 to 122 +/- 3 g/l, p = 0.02). CONCLUSION: Conversion to NHD is associated with a decrease in dialysis and cardiovascular-related hospital admission. The clinical and mechanistic relevance in uremic patients of improved phosphate and anemia management requires further examination.
Who have you talked to at the insurance company? You need to get past the “bean counters” – the folks with no medical backgrounds who just push papers around. Ask for a supervisor, and then a supervisor’s supervisor. See what you can get them to put in writing. If you haven’t read the fine print of the policy, it’s not a bad idea to do that as well–they may not know their own policy.
We are also happy to talk with insurance companies. So, if you can find your way to a real person with a medical background, put them in touch with us.
Dori:
I seem to have a lot of irons in the first who are looking into this. First, my HR person, second my NxStage representative, third my medical consultant. However, all of them have gotten different stories as to what the situation is. A Davita Program Manager advised that Carefirst will only pay as an “out of network provider”. My medical consultant stated that Carefirst won’t pay at all. NxStage states they will work on it, but it will take time. I don’t know who to believe.
Also something that doesn’t make sense. Mid-Atlantic Nephrologists, one of the largest in the state of Maryland just opened up their own home dialysis training facility. What I don’t understand is if you have Carefirst as the largest in the state of Maryland as far as insurance, and then the largest nephrologists opening up a home dialysis center, wouldn’t you think at least ONE person would be covered under Carefirst?
I am tired and frustrated and do not know where to turn next. My GFR is down to 13%. The only option Carefirst gives me is to quit my job and choose Medicare…
Heh heh heh. Not too funny, but CareFirst (great name, eh?) also wins if you quit your job–then they don’t have to cover you. Don’t do it! What exactly is a “medical consultant”? Again, the key here is to make it to someone at “CareFirst” who knows their policy and is a medical professional. It’s also best, if possible, to coordinate things through ONE entity–not NxStage + HR + a “medical consultant.” You’re bound to get multiple opinions, as everyone is talking to someone else at “CareFirst.” Someone has to take the lead.
Hi Folks
Hi Unregistered
Are you saying your insurance company will not pay for any home dialysis by any provider? Do you have any choices on centers, or are you forced to deal with Davita? Have you filed a complaint with your state health dept. State AG , reps in state cap. your reps in DC. Youtube, can you send something to the news media.
Get and put everything in writing and get a phone voice recorder. I think Maryland is a state that lets a person record without letting other party know about.it
Sadly the medical world has become one in which the healthcare consumer must bring a lawyer or find ways or recording or getting everything on paper
[QUOTE=Unregistered;17370]Okay guys, I got my fistula installed just three days ago and it’s buzzing just fine.
This is where the bottom dropped out - I work for a bank who has Carefirst/Blue Choice as their insurance company. I was informed yesterday that they will NOT under any circumstances pay for home hemo dialysis. They will only pay for “in-clinic” dialysis.
Does anyone know where I can start in pushing for a change here?[/QUOTE]
Best Luck
Bob O’Brien
Interestingly, CareFirst has written information for patients about options for treatment for kidney failure including home hemodialysis:
The educational materials by this company provides information on PD and HHD. One section of the information on the HD information states:
At home, hemodialysis is done with the help of a partner, often a family member or friend. If you choose to do home hemodialysis, you and your partner will receive special training.
http://carefirst.staywellsolutionsonline.com/Search/85,P01474
A CareFirst Provider Manual states on page 24:
[I]Hemodialysis
Authorization from Care Management (page 3) is required for inpatient, outpatient or home hemodialysis services, unless the services are performed in a contracted freestanding facility. If hemodialysis services are rendered in a contracted, freestanding facility, the attending physician is responsible for a written prescription or order.[/I]
http://www.carefirst.com/providers/attachments/BlueChoiceProviderManual.pdf
On page 3 that is referred to above, it provides a phone number for Care Management - 866-PRE-AUTH(773-2884).
The insurance company may want medical justification to document that home hemodialysis is appropriate for you and may provide case-by-case approval for coverage for home hemodialysis.
You might want to call the number above and ask these questions:
– Why does the company’s educational materials for patients describe home hemodialysis as an option for treatment if it is not routinely covered?
– Will the company cover hemodialysis 3 times a week (or every other day) in the home if the charge for home hemodialysis is no more than for in-facility hemodialysis done the same number of times a week?
– Does the company require prior authorization 3 home hemodialysis treatments a week, home hemodialysis done every other day, home hemodialysis treatments 5 or more times a week?
– If prior authorization is required before coverage is provided for home hemodialysis, what kind of data does the company need to make a determination - medical benefits, cost benefits, other?
– Does the coverage decision make any difference which dialysis facility is providing home dialysis training and support services ?
If anyone else has other questions to ask, feel free to add them.
Go Beth! It never occurred to me that the company would have their policy in a document you could find online. Awesome sleuthing skills, as usual. 
I suspect that the folks helping you haven’t seen this document, either, so it’s definitely something to share with the crew. I also suspect that the issue really is how MANY treatments per week–more so than whether they are done in the center or at home.
Unregistered, you haven’t mentioned which “flavor” of home HD you might be interested in, but Medicare–and health plans–will pay for 3 treatments routinely, 3.5 (every other day) usually without too much hassle, and with a letter of medical justification from a doctor, will most often pay for at least a 4th treatment each week, which can be enough to make short daily HD possible–or nocturnal more than 3.5 nights/week.
It can be a big learning curve to start with nocturnal (even if that’s your ultimate goal), but once you get the training, the various types are not all that different. You may want to sign up for our Webinar with Dr. John Agar next Weds. evening to learn more background about HD. Here’s the link: http://www.instantpresenter.com/PIID=E156DA82 .
I thought I was reading my own story when I read yours. Currently I am holding my breath praying my insurance company will pay for home dialysis. I did the training (which they pay for) and began at home last week. Inititally, they mailed me a statement of coverage letter saying frequent daily and nocturnal dialysis (quotidian) done at home is investigational and not covered. I called the insurance company several times and talked to a different person each time. None seemed to know anything about it at all. They couldn’t make any sense as to why they would pay for the training and not the dialysis. Davita never heard of such a thing since they have many patients on Home dialysis and their insurance companies pay without problem. They also have patients with the same insurance on home dialysis. Mistakenly, someone at Davita thought the statement of coverage letter was a denial and we were to begin an appeal. Another call by me to the insurance company connected me with a woman who said their shouldn’t be a problem if the dialysis claims were simply coded properly. This is also what an insurance specialist at Davita said. Soooooooooo. Here we are. Hopefully, all is well, my insurance company will do the obvious right thing, I will continue with home dialysis, feel better, and live a long time to be around for my amazing 10-year-old son.
Dori and Beth have been very helpful during this process. Thank you, Dori & Beth.
[QUOTE=Unregistered;17376]Dori:
The only option Carefirst gives me is to quit my job and choose Medicare…[/QUOTE]
Speaking of Medicare…when you begin dialysis, you can choose to go on Medicare immediately. You don’t have to quit your job. You can go on Medicare and retain your other insurance as a secondary. As a matter of fact, I have maintained my current employer insurance as primary for the 6 months I have been on dialysis. The PROBLEM is that my insurance has been paying around $45,000/month. It’s sickening how much they pay. I will reach my lifetime maximum in a year. I need to maintain my employer insurance for the excellent cancer treatment coverage. I should have switched over to Medicare a long time ago and saved at least $250,000 towards my lifetime maximum. Also, if I ever do get a transplant, I believe I will be forced off Medicare and back onto my employer insurance which would not be a good thing if I have it already maxed out.
If Medicare pays 80% of $45,000…I am responsible for the 20% or $9000/month? A secondary insurance will cover this but what do people do without secondary insurance?
Does medicare actually pay the exorbitant prices that private insurance companies pay? - or do they actually pay a lesser amount every month?
Hi Wendy,
Actually–and Beth will pop in and correct this if I’m wrong–Medicare will not become primary until after 30 months if you have an Employer Group Health Plan (EGHP. When you have an EGHP at the point where you start dialysis, it is primary. Medicare is secondary. This is called the “Coordination of Benefits (COB)” period. The dialysis industry is angling to extend this from 30 months to 60, because they make far more money from EGHPs than Medicare pays. In fact, they LOSE money on Medicare-only patients, and what they make from EGHP’s keeps the whole industry afloat.
What I think you’re saying, Wendy, is that you may have been advised not to take Medicare as a secondary payer, perhaps being told that you didn’t need to pay those premiums until your EGHP coverage runs out. But when you DO take Medicare, your dialysis provider is required to accept Medicare assignment–which means lower out-of-pocket costs for you that usually outweigh the cost of the premiums.
You are right to be concerned about your lifetime benefit. Unfortunately, ESRD is a costly illness, and our healthcare “system” is not set up for costly chronic diseases.
One benefit of home dialysis that many folks don’t know is that Medicare (as a Secondary payer if you have an EGHP–or a primary payer if you don’t) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months–and those 3 months can be very costly and even push people into medical bankruptcy.
[QUOTE=Dori Schatell;17391]Hi Wendy,
Actually–and Beth will pop in and correct this if I’m wrong–Medicare will not become primary until after 30 months if you have an Employer Group Health Plan (EGHP. When you have an EGHP at the point where you start dialysis, it is primary. Medicare is secondary. This is called the “Coordination of Benefits (COB)” period. The dialysis industry is angling to extend this from 30 months to 60, because they make far more money from EGHPs than Medicare pays. In fact, they LOSE money on Medicare-only patients, and what they make from EGHP’s keeps the whole industry afloat.
What I think you’re saying, Wendy, is that you may have been advised not to take Medicare as a secondary payer, perhaps being told that you didn’t need to pay those premiums until your EGHP coverage runs out. But when you DO take Medicare, your dialysis provider is required to accept Medicare assignment–which means lower out-of-pocket costs for you that usually outweigh the cost of the premiums.
You are right to be concerned about your lifetime benefit. Unfortunately, ESRD is a costly illness, and our healthcare “system” is not set up for costly chronic diseases.
One benefit of home dialysis that many folks don’t know is that Medicare (as a Secondary payer if you have an EGHP–or a primary payer if you don’t) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months–and those 3 months can be very costly and even push people into medical bankruptcy.[/QUOTE]
Oh no. I thought I had the choice of moving to Medicare before the 30 months is up and retain my employer insurance as secondary. Please tell me I don’t have to exhaust my employer insurance. I will hit my lifetime max in 13 months at $45,000/month. I NEED the coverage for continued bladder cancer surveillance/treatment. AND if I max out my employer insurance, get a transplant 3 years down the road and am kicked off Medicare 36 months after the transplant, I will have zero insurance to go back to. This isn’t good at all. I am alive today in huge part because I have an insurance company that didn’t question any of the out-of-the-box treatment methods we used over the years.
Currently, I have no out-of-pocket expenses with my employer insurance. No premiums and 100% coverage on everything. There is an annual $200 deductible - that’s it. Medicare, if I understand it, will require $94/month premium, $170? deductible and then they only pay 80% leaving me with 20%. How do people afford the 20%? That’s $1000’s a month - more than most people make who are working.
I am very stressed about this now. I have come so far in the fight to live and I am very afraid that this insurance situation could leave me in a bad predicament that could ultimately kill me. Am I missing something???
Why should I be forced to max out my insurance leaving me with nothing to fall back on?
p.s. is there a spell check on this forum?
[quote=dori schatell;17391]hi wendy,
one benefit of home dialysis that many folks don’t know is that medicare (as a secondary payer if you have an eghp–or a primary payer if you don’t) will kick in immediately if you train for a home treatment. But folks who do in-center have to wait 3 months–and those 3 months can be very costly and even push people into medical bankruptcy.[/quote]
then why aren’t all dialysis centers morally and legally obligated to inform and start uninsured patients on home training right away? Even if patients can’t do it after all is said and done, they can fall back on in-center dialysis and not be bankrupt. The fact that centers aren’t even informing patients of this option and allowing them to lose their livelihoods without any way to recover it is shocking (to say the least) and evilminded.
Hi Wendy,
We really do need Beth to pop back in here–she is the reimbursement expert, not me. But please don’t worry. You WILL have coverage, even if you do use up your EGHP plan.
Once you are eligible for Medicare due to ESRD, it covers all of your healthcare–not just kidney-related care. So, the issue won’t be the 80% that Medicare pays; it will be the 20% that it doesn’t pay. Depending on the state you live in, and your age, you may be eligible to buy a Medigap plan to handle that part of your healthcare costs.
You STAY eligible for Medicare as long as you are on dialysis–whether or not you keep your job. If you get a transplant, Medicare will pay for the drugs you need for 3 years (and beyond if, after that, you have a reason besides ESRD to be on disability).
I don’t think these forums have a spellcheck.
As far as folks not being told about their options and the implications for their finances of choosing home vs. in-center, I couldn’t agree more, and we’ve advocated with some success to change this. A big part of the problem is doctors who aren’t familiar with either home options OR how Medicare works, and who probably don’t even notice whether folks are working (and want to stay that way) or not when they need dialysis. It’s unconscionable, IMHO, that almost 92% of US dialyzors are using in-center HD 3x/week–the most costly care we have to offer, with the worst outcomes. In-center treatments push people into poverty, either because they are forced out of their jobs due to the cost of their healthcare to their employers, or because they feel so lousy they can’t work. MAJOR, sweeping change to our healthcare “system” and how we pay for it is needed.
Fortunately, I think we’re going to see a lot of that over the next few years.
Wendy’s situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn’t? If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.
Wendy’s concern of attaining her lifetime benefits with her insurance is very real. Many policies have what seems to be a high limit — even a couple million dollars. One would be surprised how quickly they can reach that number. This becomes even more possible if the coordination of coverage period gets extended — yet another reason for universal coverage.
[QUOTE=Rich Berkowitz;17399]Wendy’s situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn’t? If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.
[/QUOTE]
I began dialysis in September 2008. I started Home hemo 2 weeks ago. Because I am doing home hemo now, can I end the 30 month coordination period and go on medicare? Since my start date is before the October 14 date am I affected differently?
My insurance has a $1.5 million cap. Since September, $315,000 has been eaten up by dialysis alone. $285,000 has been used on bladder cancer treatments, surgeries, surveillance etc. That leaves me with about $600,000 lifetime left which will be eaten up in 13 months - actually sooner because I still face a major surgery in May.
Before I had surgery to remove my last kidney in September, I met with Mary Dooley, the CKD Program Manager for NorthWest Kidney Centers in Seattle. I am a very detailed, thorough person when it comes to managing all aspects of the bladder cancer which resulted in Dialysis. Mary did go over different dialysis options including home dialysis. AT THAT TIME in her office and several times after, I told her I wanted to do home dialysis from the start. She said no - they won’t train home dialysis patients with a catheter. I was to have a catheter placed along with the first step of my fistula during the kidney removal a couple of weeks later. At that time, I had no idea of the insurance implications of NOT going onto home dialysis immediately nor did I have comprehension of the COST of dialysis for my employer insurance company and the implications of all of that. Even after beginning in-center treatment at NWKidney, I frequently mentioned my desire for home dialysis complaining that it wasn’t right not to train me just because I had a catheter. I called Mary Dooley a couple of times after to again discuss moving to home hemo . It was always explained that re-training when I had a fistula would be an avoidable expense if I waited for my fistula to be ready. Again, I had no comprehension of the implications of remaining in-center. If I had, I probably would have sued.
Now I wonder if that was an intentional play by NWKidney. IF it’s true that I would go immediately to Medicare upon initiation on home dialysis (someone please verify this) NWKidney would be losing $45,000/month. In that case there would be an absolute financial incentive to deny home dialysis and keep me in-center. I do know some centers train with catheters and I bet I could find someone at NWKidney. I asked them if they ever train with catheters and she said in ‘special circumstances’.
Could this scenario be possible?
Wendy, these are very good questions and why I raised it in the first place. In a way I’m surprised your situation had occurred with NKC, who I have the utmost respect for. I’m sure Beth and Bill will be able to add something appropriate to this discussion.
I’m searching through the piles of info I have received from both NKC and Davita. In the NKC New Patient Handbook under “Treatment Options - Choosing Home Dialysis - COST”, it says “Home dialysis is paid for in the same way as in-center dialysis - through Medicare, private insurance, and/or state funds.”
That’s what I need to find out…is Home Dial. paid for in the same way or are there some differences.
In the “Financial Services” section, it says a financial coordinator will be assigned to me when my doctor first refers me to NKC. Hmmm. I never had that I know of anyway. They were to ‘talk to me about the COST of dialysis’, help me ‘understand my funding (Medicare, private insurance, Medicaid, NKC charity care, personal funds, etc.)’, ‘help me apply for all the funding for which I qualify’, ‘answer financial questions about permanent kidney disease’. Hmmmmm. Never got any of that from NKC. I never did from Davita when I switched to them either. My last day of home training a week ago, a gal from Davita did mention that if I had financial issues to talk to her right away but that was the extent of the info.
Who would you go to to get to the bottom of this? My insurance company (whom I’ve called many times) never gave me the impression that I had to wait to switch to Medicare as primary. I have called (several times) Medicare who told me to call Social Security who told me Medicare should have been able to help…I will set an appt this week to meet with the insurance coordinator at Davita. Any other suggestions?
Wendy, I’ve asked Beth to pop back in and help. MANY centers won’t train folks who have catheters to do home HD. Centers differ in their policies, and NKC is one of the best in the US. So, I can’t fault them for that, though in the Lynchburg nocturnal HD program in VA, most of their folks use catheters. Again, centers differ.
There is no way to protect your EGHP from being depleted–unless you find a center that will bill less. The 30-month COB period is 30 months; period. There is no way to opt in to Medicare as PRIMARY until the 30 month clock runs out.
So, at this point, if you have a fistula (sorry, I don’t recall), you might check into how much NKC (a non-profit) would charge you vs. DaVita (a for-profit). If NKC charges less, your EGHP will last longer.
Dori is correct that Medicare is a secondary payer to an employer group health plan (EGHP) for the first 30 months that the patient could have Medicare whether he/she takes it or not. This has been a regulation in Medicare for many years and one that was intended to put more of the burden on private industry to save money in Medicare.
If someone starts home training before the 1st day of the 3rd full month of dialysis, the clock starts the month dialysis starts. If home training is delayed until after that time, the period that Medicare pays secondary is 30 months from the earliest month your Medicare could take effect (the 3rd full month of dialysis).
You say that the dialysis provider is billing $45,000 a month for dialysis. Was that what NKC was billing or what DaVita is billing? Do the statements from your insurance company say it has paid $45,000 a month to either or both providers? From what I’ve heard, most insurance companies negotiate a reduced payment from what is billed – I’ve heard they typically pay 2-3 times what Medicare allows. The average Medicare allowable for dialysis now not counting drugs or physicians’ bills is about $133 per HD treatment.
If your company is paying $45,000 a month and it looks like you’ll exhaust your benefits, talk with your dialysis social worker. You can also ask to talk with NKC’s financial counselor about your past bills and with DaVita’s “guest service specialist” who is supposed to work with people who have employer group health plans that pay significantly more than Medicare. Hopefully one of these people will be able to answer your questions about what they’re billing. New regulations for dialysis require dalysis facilities to discuss costs of care with patients.
BTW, if the charges exhaust your health coverage, your clinic can start billing Medicare primary with proof of claim denial from your EGHP. Before this happens, talk with the state insurance department to find out if can enroll in a Medigap (Medicare supplement) plan that would pay the deductibles and 20% coinsurance left after Medicare pays if you lose your health coverage. Some states have regulations that provide this right to state residents in that situation.
Hope this helps!