Insurance Co. Will Not Support Home Hemo

Discussions for Patients, Family, and Friends HD For Patients
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It sounds like NKC informed Wendy of her options. She knew HHD was an option. NKC must have a policy that won’t allow a patient with a catheter to do HHD. Facilities can set policies for what they believe offers safe and effective treatment. Other facilities may have different policies. If patients want something their facility doesn’t offer, they have the right to change to a different facility and their original facility is supposed to provide information to help them do that.

NKC and some DaVita clinics offer more frequent dialysis treatments. They can and probably do bill the EGHP for each treatment the patient receives. This can nearly double the cost of dialysis from in-center dialysis which is done 3 times a week. Medicare will only routinely pay for 3 treatments so even with Medicare, a patient could have higher charges for more frequent treatments. However, the more frequent treatments could save money in the long run on hospital bills which can be much higher than dialysis charges.

Sadly, this is not true. The coordination of benefits period applies to anyone with an employer group health plan no matter what type of dialysis the patient chooses to do. The difference in treatment type makes a difference when Medicare can start as a secondary payer saving the patient 3 months of EGHP primary payments. Medicare secondary payer does NOT apply to individual plans that are not sponsored or contributed to by an employer.

IMO, extension of Medicare secondary payer would temporarily help facilities but harm patients because it would exhaust the lifetime benefits of more patients. If facilities do a good job taking care of patients and they do well on dialysis, in the long-run, facilities will lose out if their patients exhaust their lifetime benefits.

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Thanks Beth, I somehow get starting initially with home dialysis confused with transplantation. I won’t make this mistake again.

23

Beth,
Thank you for your suggestions which I will follow up on.
I also had a thought…Does anyone know in the event that my insurance company denies payment for home dialyis, could I switch to Medicare who does cover home dialysis or will I be forced back into in-center or forced to cover the bill for home dialysis myself.

I also wonder if I could opt out of my husband’s employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period. I guess that’s a question for my insurance company.

There’s something morally wrong with all this.

24

Your insurance company will pay for home, one way or another–I’d be willing to bet on it.

You don’t have the option to “switch” to Medicare as a primary payer–it’s the LAW that you are required to be covered by your EGHP (if you have one) for the first 30 months. You don’t get to opt in and out in that way. It’s not up to you.

You DO get to decide if you want to “accept” Medicare when you are eligible for it. Part A (hospitalization) is free. Part B (outpatient services including dialysis) has a premium. Never take Part A without Part B. Doing so can cause all sorts of problems down the road. Accepting Medicare reduces the amount you would need to pay out-of-pocket because dialysis providers can’t charge as much to your health plan (which may not cover everything) when Medicare is in place. Most likely, you would save enough to more than make up for the premium for Part B.

I also wonder if I could opt out of my husband’s employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period.

Sorry, Wendy, but I would strongly recommend against that. The chances that your EGHP would let you back in with the preexisting conditions of cancer + ESRD are basically zero. So, you could quit your job, go on disability, and become Medicare primary–but it doesn’t help you to do this. You’d lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less. [EDIT]Oops, it’s your husband who carries the policy. Be careful: some employers have managed to force out employees whose care (or loved one’s care) is very costly. If “opting out” is an option for him, again–I would strongly recommend against doing it. Opting “back in” will not be an option down the road.

Is there something wrong with this system? YES! IMHO, medicine for profit and inserting insurance companies between people and their healthcare is an unworkable model. For more on why, see this thread: http://forums.homedialysis.org/showthread.php?t=1998.

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Hmm. Apparently I got Part A back in September after surgery. I vaguely remember filling out forms in the haze of pain meds. I did not get Part B because I have 100% coverage with no premium through our EGHP. Accepting Medicare won’t reduce my out-of-pocket because I have 100% coverage no with zero out-of-pocket. Accepting Medicare will increase my out of pocket with the premiums, deductible and 20% copay - none of which I have now. Are you saying that if I accepted Medicare today with my 100%, zero out-of-pocket EGHP, that the dialysis unit could no longer charge my EGHP $45,000/month? They would be forced to charge less even while my EGHP is the primary? If so, paying the extra out-of-pocket for Medicare may be worth it.

Medicare also states that there is no penalty for not taking Part B if I have an EGHP in place. They suggested in their handbook that I may want to wait paying the Medicare premiums every month if I’m not using them while I have my no cost EGHP. What sort of problems are you thinking about that could arise down the road?

[QUOTE=Dori Schatell;17409]
So, you could quit your job, go on disability, and become Medicare primary–but it doesn’t help you to do this. You’d lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less. [/QUOTE]

Losing my EGHP completely and being Medicare-only is EXACTLY what I am afraid of. In less than 12 months, I will exhaust my EGHP completely - Not because I opted out but because the dialysis centers have stolen it from me - almost $1 million worth. I’m new to all of this. How in God’s name can an insurance company be forced to pay a $million in less than 2 years for dialysis when Medicare would have paid $33,000 for the same treatment during that same time period? Is there no cap on their charges to insurance companies at all?

I don’t expect you to keep answering all my questions. Obviously, I have more research to do. I just don’t get it - especially the fact that there is some sort of law that makes this type of extortion mandatory. Seems as though we EGHP and private insurance people (minority) rake out the $billions for dialysis for the rest of the majority of the population on Medicare while being stripped of insurance for the other critical parts of our life and health. My husband has worked very hard for this coverage for his family for years. This coverage has kept me alive and winning the fight against bladder cancer for 15 years. I pray that Medicare will not change that.

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First, even if you have Medicare, your dialysis clinic can charge your insurance company what it normally charges. If you had Part B, your dialysis clinic would not be able to charge you any deductibles or copays as long as your plan pays at least 100% of Medicare’s allowable. If you don’t have any of those cost-shares, you might not need Medicare at all. You may want to disenroll from Medicare Part A to avoid consequences that I describe in response to your next question.

If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn’t paid any claims for you, ask to disenroll from Part A. NOTE: If you are on the transplant list, sign up for Part A and ask Social Security to make it effective the month of the transplant. This will protect your right to have Medicare Part B cover your anti-rejection drugs.

The Medicare handbook (Medicare & You) is written for most of the people who have Medicare – those with Medicare due to age or disability. It refers people with ESRD to a more specific booklet called Medicare Coverage for Dialysis and Transplant Services (Medicare Pub. 10128).
http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf

If you had Medicare due to age or disability and did not have ESRD, you would have a “special enrollment period” to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a “special enrollment period” for Part B if someone has ESRD.

There are a number of problems that can occur when you take Part A and don’t take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
– Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You’ll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don’t yet have Medicare Part B in place.
– If you don’t sign up for Medicare Part B within 12 months of taking Part A, you’ll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.
– If you forget to sign up for Part A in time to have it cover you for a transplant (within 12 months after the transplant), Medicare Part B will never cover your anti-rejection drugs. And according to the law, Medicare Part D couldn’t pay for them either because Part B would cover them if you had it.

Believe me, I can understand your frustration and anger. I can’t imagine why your insurance company hasn’t negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare’s allowable for 3 treatments a week).

I wish people didn’t have to live with the situation that you’ve described. Check into the Medigap option to see if you can buy it any time you want in spite of your pre-existing conditions.

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[QUOTE=Beth Witten MSW ACSW;17411]
If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn’t paid any claims for you, ask to disenroll from Part A.

If you had Medicare due to age or disability and did not have ESRD, you would have a “special enrollment period” to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a “special enrollment period” for Part B if someone has ESRD.

There are a number of problems that can occur when you take Part A and don’t take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
– Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You’ll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don’t yet have Medicare Part B in place.
– If you don’t sign up for Medicare Part B within 12 months of taking Part A, you’ll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.

Believe me, I can understand your frustration and anger. I can’t imagine why your insurance company hasn’t negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare’s allowable for 3 treatments a week).

[/QUOTE]\

I’ve discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is “out-of-network”. I guess the other $35,000/month is all for meds? I’m not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn’t even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance ‘specialist’) why they didn’t tell me of the in-network unit down the road, they said they didn’t know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

Davita said my insurance company won’t contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.

As far a medicare, apparently, I got on medicare 2 years after claiming disability for my bladder cancer. I had part A Feb 2008. With my employer benefits, I am not penalized for not taking part B as long as I do so within 8 months of my employer benefits ending.

We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it’s investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x’s a week. I wasn’t getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So…more runs less time (3 hours). Training for home has been wonderful. Now on 15’s and have increased flow and dialysate. I think it will make a big difference. When my ‘training’ is done, I suppose I will have to go back in-center? Just doesn’t make any sense at all.

I have asked Davita for itemized printouts for all my treatments since November.

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Dialysis clinics only know what insurance companies they contract with. They would have no way of knowing what insurance companies other clinics contract with unless they called every clinic and unless those clinics shared that information with them. The staff at a particular clinic may not even know who their corporation contracts with unless an issue like yours arises. The one who was responsible for telling you who the network providers are is your BCBS plan. The fact that they didn’t know is appalling!

Does the in-network clinic offer home dialysis? Will your BCBS pay for home dialysis there? I still question whether the denial of BCBS coverage relates to frequency of dialysis or perhaps out-of-network provider. Northwest Kidney Centers is the oldest dialysis provider in the U.S. and has been doing conventional (3 times a week or every other day) home hemodialysis for more than 40 years in the northwest. It’s really hard to believe that Boeing’s BCBS plan denies coverage for home hemodialysis in Seattle where the Northwest Kidney Centers began training and following home hemodialysis patients in the 1960s. Boeing is a large employer in Seattle. Patients can do home hemo at night while they sleep 3 nights a week or every other day and report they feel better than doing 3-4 times a week in-center.

You may have been told that since you already have Part A, you have 8 months to sign up for Part B without penalty. However, there are quirks in the Social Security regulations that do not allow people with ESRD to have a “special enrollment period” even if they also qualify for Medicare due to age or disability. Here’s the policy from the Social Security that explains this. Some terms you’ll need to know to read this include R-HI (Part A), R-SMI (Part B).

[I]F. POLICY — EFFECT OF MSP PROVISIONS ON FILING
Because Medicare will not be paying full benefits in many cases where there is a group health insurance plan, some individuals may not wish to enroll in R-SMI when first eligible.

It is important to remember that the special enrollment period (SEP) rules applicable to aged and disabled individuals do not apply to people entitled to R-HI. Therefore, it is extremely important to properly inform ESRD patients (including dual eligibles) who have GHP coverage about their options with respect to filing an application for R-HI. An individual may wish to:

  • File for both R-HI and R-SMI at initial R-HI eligibility even though Medicare can only make secondary payments until the end of the ESRD coordination period. With expenses as high as those for treatment of ESRD, an individual may consider secondary Medicare payments to be well worth the monthly SMI premium.

  • Defer filing for R-HI (and R-SMI) until the end of the ESRD coordination period. This will permit the individual to defer paying for SMI until Medicare becomes the primary payer of benefits.

ESRD patients with GHP coverage should be discouraged from filing for R-HI while rejecting R-SMI at initial eligibility. Once R-SMI is refused, enrollment can only take place during a GEP, with coverage effective the following July. This will usually mean a gap in coverage between the end of primary payments by the GHP and the beginning of SMI in the month of July. It may also result in a premium surcharge for late enrollment. If an individual with GHP coverage files an application for R-HI in the mistaken belief that Medicare will be primary payer of benefits, the application may be withdrawn as provided for in HI 00801.197.[/I]

https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801247

According to the Central Office of Medicare (Baltimore), once someone has ESRD (kidney failure), even if he/she had the right to a special enrollment period due to age or disability, that right no longer exists. However, ask your local Social Security office…not the 1-800-772-1213 helpline…about this policy. You definitely don’t want to have a gap in primary coverage and the general enrollment period is from January 1 through March 31 each year with Medicare Part B becoming effective July 1 of that year.

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[QUOTE=Wendy Ramsay;17470]
I’ve discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is “out-of-network”. I guess the other $35,000/month is all for meds? I’m not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn’t even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance ‘specialist’) why they didn’t tell me of the in-network unit down the road, they said they didn’t know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

Davita said my insurance company won’t contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.
[/QUOTE]

I don’t understand. How could your insurance company not know which center they have a contract with. From the moment any paperwork went in regarding:DaVita, BC/BS should have notified you.

When my wife’s EGHP changed from Humana to Cigna, I was told I had to move from one center (RCG) to another (Fresenius) because the center I was with would have been out-of-network. I appealed to no avail.

What’s ironic is that RCG’s own EGHP for it’s emplyees was with Cigna, which meant if any of their own employees needed dialysis they would have to treat elsewhere.

[QUOTE=Wendy Ramsay;17470]
We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it’s investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x’s a week. I wasn’t getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So…more runs less time (3 hours). Training for home has been wonderful. Now on 15’s and have increased flow and dialysate. I think it will make a big difference. When my ‘training’ is done, I suppose I will have to go back in-center? Just doesn’t make any sense at all.[/QUOTE]

It’s hard to believe BC/BS is saying home dialysis is investigational, especially since NxStage is FDA approved, Something’s fishy.

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If you need someone with an economics background, I am happy to help.

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Hi Rich.
From what the insurance company told me, when I called to verify insurance coverage for Davita, I was told they are covered at 100%. I didn’t know then that it was 100% of charges 7 times greater than a different (in-network) center. My insurance said when they check Davita, the Federal Way center doesn’t even show up. When they check Total Renal Care which Davita bills as, they do show up but not as in-network. Davita said they bought the Federal Way center from another company. At the time of the purchase, the other company was in-network with my insurance company so they just kept the contract going when Davita took over. Obviously, there is some communication problems that they are hopefully sorting out now. I’m in the process of transfering to the Federal Way unit and Davita is ‘making sure’ they are in-network with my insurance company.

And yes, Boeing BC/BS is saying home dialysis is investigational. Apparently, they are conducting their own studies and will consider that plus other information and studies for a review of that decision in August. But until then, they will pay for the home dialysis training and not home dialyisis. What the heck. Makes no sense to anyone.

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Wendy, we are happy to talk to Boeing, if it would help. I know there are several parties involved already.

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[QUOTE=Wendy Ramsay;17401]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?[/QUOTE]

To say you cannot obtain home training with a catheter is alot of nonsense. You might want to speak to an attorney and sue for malpractice.

Mark
NDXUFan12

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I have talked with many people both in Davita and in my insurance company. It’s very frustrating talking to so many people who simply don’t understand. I hate to say this, but I honestly think I know more than they do much of the time. Even after a 2 hour meeting with Davita staff about this issue, there was still an incorrect understanding. The facts are that the Puyallup facility I had dialyzed at for 5 months is NOT contracted with my insurance company. Because of a special ruling (or coding 89) dialysis falls into a special category and my insurance company is forced to pay at my in-network RATE of 100% of their billed amount. Dialysis alone was $1500 per session at the Puyallup center because they do not have a contract with my insurance company to pay less.

The Federal Way center DOES have a contract with my insurance that was in place before Davita bought them out and has not yet been re-negotiated. The allowed amount per session with the Federal Way center is $294. I think the home hemo charge is $86 (still waiting to verify). The Federal Way Davita charge is also considerably less than NWKidney charge of $688 per session. NWKidney also has a contract with my insurnance company. I am surprised they are more than Davita. There is a big difference between $1500 and $294 (or $86 for home hemo)! I’ll be saving my insurance company at least $23,000 a month!

The both (Davita and my insurance company) say there is nothing they can do to correct the exorbitant charges to my lifetime max that have already occured because I was going to Puyallup Davita instead of Federal Way Davita. Maybe my insurance company should give me some kind of award for saving them so much money here on out. Right. Sounds good to me.

It astounds me how many people (that should know) know so little when it comes to things like this. A patient should be able to be directed properly initially so this should never happen. Davita said I am the ONLY patient that has ever expressed concern over what their insurance is paying. That’s sad. Patients need to know where they stand at all times and avoid things like this before it’s too late. I do know people who have maxed out their insurance and it probably could have been prevented.

Also, Davita said they got the approval for home hemo. It falls under the home care category? I don’t quite understand it yet but apparently, it’s approved with no limits on number of days to dialyze. This is in stark contrast to the benefit letter from my insurance company which stated home hemo is not a covered service. It shouldn’t be this convoluted.
It looks as though things are finally on the right track.

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Hi Wendy,

I’m sorry you’ve had to go through all this–especially the high billing against your lifetime insurance benefit–but glad you’ve finally gotten home HD approved. IMHO, our “system” of care is badly broken if someone who needs healthcare has to figure out all of the pieces, who has a contract with whom, and how much is being billed. Since I’m not quite sure how it could get worse, I like to hope that it will get better.

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Wendy, quite frankly I think the insurance company should credit your lifetime limit because they didn’t tell you the original dialysis center wasn’t in-network, especially since they were putting out more money. It really seems like somebody was sleeping at the switch and you shouldn’t be penalized.

BTW, how did you end up at the first one/ Were you referred to it by your neph? I remember when I first went in-center the hospital social worker did all of the arrangements. I did go to a center my neph was associated with, but he goes to a couple. When my insurance changed and the center I was in was no longer in-network I also had to change centers. So obviously I was notified.

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I started dialysis in September with Northwest Kidney from my nephrologist’s referral. I did not agree with some of their practices and requested a switch to the Puyallup Davita which happened to be a few minutes closer. As always, I called to confirm that my insurance covered the Davita unit and was told it was covered at 100%. There was no mention of the high charges and if they said it was out of network (which I don’t remember) I wouldn’t have any comprehension of the extent or impact of the high charges on my lifetime max. Even today, it was very very difficult to get the charges I will be charged for the Federal Way office. That info is not easily obtained by patients as it should be. No one mentioned the Davita office in Federal Way as an in-network option. No one even mentioned there was a Federal Way unit in existance during the 6 months I was with Davita. Three weeks ago, I got an insurance case worker after I notified them of these high charges. She told me they were not aware of the in-network unit in Federal Way. There is some confusion apparently because Davita goes by the name of Total Renal Care for billing and insurance purposes.

Either way, I agree. Someone was asleep. A friend of mine suggested a short media story to bring up this issue in these ‘hard economic times’. I may let this rest a little and see if my insurance has any kind of response on their own before I do that.

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Another thing you can do is complain to the state agency that oversees insurance. But I agree that you should first try to wotk it out with Boeing’s BC/BS.

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Hi guys - I believe I was the original poster here, but I still won’t register yet as I’m not on dialysis just yet. The story on my side was (a) my HR person didn’t know what the BC/BS policy entailed; (b) my insurance broker didn’t know what my policy entailed and © the new facility that Davita opened has yet to be contracted with BC/BS (my specific company policy). After going through a slew of people at BC/BS, I did find out that our company policy did, in fact, cover home hemo. Now, the interesting part - Davita would not give me an answer as to whether I could do home hemo as I was not a patient of Davita yet. You either know or you don’t know if you have a contract with BC/BS (and the specific policy I have). Nope, to this day, I was told by the Administrator that they will simply have to wait until my doctor gives the go-ahead with the prescription before they can accept me or not. That surely doesn’t give me a warm and fuzzy feeling when I have the need to start dialysis.

Of course, by the time I need to start dialysis, my place of business is likely not to be standing anyway the way the ecomony keeps swaying.

Good luck to all who are looking at home hemo as an option. However, just remember, that Davita doesn’t contract through every insurance company out there and to this day, find it rather wierd that I couldn’t get an answer as to whether I could start in that home hemo training facility.

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For several years, I have suffered from Kidney Disease. In July of 2006, I was placed on in-center hemodialysis. This treatment was a mixed blessing. On the positive side, my overall health greatly improved. On the minus side, I suffered numerous infections – including a bout with osteomyelitis of the spine that almost claimed my life and left me disabled. Additionally, the 3 time per week, in-center dialysis would frequently leave me feeling tired and wrung out. This caused difficulty on my job and added stress to my family.
In December of 2009, my wife and I attended training and became certified to perform home hemodialysis. This 5 time per week schedule allowed for more gentle cleansing of my blood and greatly reduced the side-effects I’d felt in-center. My employer was delighted as dialysis no longer controlled my schedule and I could even work during dialysis. Also, since the machine is portable, we took the first long vacation in years last summer, camping in the Olympic Peninsula in our travel-trailer.

In January of 2911, various concerns prompted me to change my employer-provided health insurance to Group Health. The Dialysis support staff at DaVita warned me that Group Health did not cover this treatment. However, that seemed contrary to the Group Health reputation as an innovator in the medical care field. Additionally, I was in great need of the managed care for my diabetes that Group Health could provide.

On January 23’rd, I received notice that my request for Group Health coverage of my frequent home hemodialysis was denied and that I would have to switch back to 3 day per week in-center dialysis.
I have appealed this decision, but doctors at Group Health have told me that it will not be overturned.

I find this unreasonable, unfair, and outrageous for the following reasons:

  1. This decision is made by a review board that does not have a Kidney specialist as a member
  2. Their decision is based on antiquated research( please see instead http://www.nature.com/ki/journal/v62/n6/full/4493344a.html, http://www.davita.com/home/physicians/research/1657 )
  3. I will not be able to keep my job if I have to transition to in-center dialysis. My responsibilities include conducting many teleconferences during business hours. This is simply not possible from a dialysis center.
  4. While on in-center dialysis, I was hospitalized 6 times over the space of less than 18 months for a total of more than 25 days. In the year since transitioning to home hemodialysis, I have been hospitalized a total of 4 days – quite an improvement
    Group Health does cover daily peritoneal dialysis but I am not a good candidate for that. Nor am I a good candidate for kidney transplant at this time – hemodialysis is my only option.
    If I am denied frequent home hemodialysis I firmly believe that my quality of life will be severely degraded, I will lose my job and perhaps my life

Mark R. Pennington
mrmarkus41@yahoo.com