There are providers that would provide NxStage for three payments a week - three Medicare payments, let alone three private pay payments. DaVita is being greedy IMO. I’m surprised that you’re not Medicare Primary though.
Mark,
I just don’t see how that can be legal! I know people much more versed in this will jump in. What a sickening situation.
Group Health should be sued.
Hi Mark,
Boy, we hate to hear this kind of scenario. Unfortunately, DaVita can charge insurance companies so much per treatment (each company negotiates its own deal with a network of providers) that doubling the costs of 3x/week may just not be something Group Health is willing to do. And DaVita did warn you ahead of time that Group Health wasn’t a wise choice.
There have to be ways to put pressure on them, however. I know that Beth will chime in here, and she deals more with the insurance side than I do. But some possibilities include (in no particular order:
– Go up higher in the company. There has to be a process to appeal their decision. “Doctors at Group Health have told me that it will not be overturned” is not an appeal, it is an opinion. There is a formal appeals process. And, with the Frequent Hemodialysis Network trials offering proof that more frequent HD is better–and TONS of other info we could bring to bear–it could be argued that the “standard of care” (3x/week) is inadequate. We’re happy to help you with this.
– Get a lawyer. If there is no tort reform in your state, an attorney may be willing to take a case like this on a contingency basis (they get paid if you win).
– Shine a light on them. Does your area still have a newspaper? A consumer TV show? Get Group Health some very bad press (heartless insurance company doesn’t care about people having quality of life and being able to work…) and raise awareness of better dialysis at the same time. Get friends together, picket their building, and call the media. Guerilla PR techniques could help.
What is your primary payer – Medicare or Group Health? An employer group plan is only supposed to be a patient’s primary health insurance for 30 months from when the patient became eligible for Medicare. That should have been your third full month of dialysis, whether you enrolled in Medicare or not. If you’ve been on dialysis since 2006, Medicare should be your primary payer with your employer plan being your secondary payer. Dialysis corporations bill much higher charges to employer group plans than Medicare allows so dialysis corporation prefer to bill employer plans primary vs. Medicare. Is DaVita still billing your employer plan or Medicare primary? If billing Medicare primary, has DaVita provided Medicare medical justification for additional treatments? I’ve heard that more Medicare Administrative Contractors (insurance companies that pay Medicare claims) are approving Medicare payment for the extra treatments with medical justification. If it hasn’t done so already, perhaps DaVita needs to bill Medicare with medical justification for more treatments. OR is DaVita billing Medicare primary for the 3 treatments and Group Health primary for the extra treatments without trying to bill Medicare for extra treatments believing it will make more money if Group Health pays for those treatments as your primary payer? There could be many things that are coming into play in your situation.
Have you reported your problem to your ESRD Network? Perhaps their staff could go to bat for you and other patients who would like to have the improved health than more frequent dialysis can bring. I’m sure we at MEI would be willing to advocate for you. Even the most rigorous government-funded research is showing that more frequent treatment is better. Do you live in the Northwest? I know Group Health is big there. If so, here’s the link to the Northwest Renal Network’s website. I know that their patient services coordinator is a strong rehabilitation advocate and helping you feel well enough to keep your job would be something she’d support. If you don’t live within their service area, let us know what state you live in and we can point you to the right ESRD Network.
http://www.nwrenalnetwork.org/
Finally, you say you can’t do PD. However, rather than returning to 3x/week in-center dialysis, have you considered nocturnal dialysis at home (or even in-center)? People who do nocturnal dialysis feel better, have improved labs, reduced hospitalizations, and more are able to work. I’ve heard that even 3 nights a week nocturnal dialysis helps patients do well. This number of treatments is within the allowed number that Medicare covers. If your clinic doesn’t offer this, others do. Check out the “Find a clinic near you” database on the homepage of Home Dialysis Central.
Finally, you might want to talk with another dialysis provider in your area to find out if Group Health pays for their patients to do more frequent treatments. It’s possible that your clinic’s charges are contributing to Group Health’s decision.
Dear Mark,
I spent most of the last year up in Idaho and found Group Health to be a TERRIBLE company period in my opinion. They did not cover my zemplar and wanted over 700 dollars to refill it. They would not even acknowledge I was a doctor calling me Peter when calling up on the phone about prescriptions I had written myself. In the nearly 20 years of practice, I never once had a pharmacist call me by my first name, but Group Health did. Most people do call me Peter, but the point is it was a lack of respect and lack of professionalism on their part as far as I was concerned.
If I was in the same position, I would seek legal council in my opinion. The data for home hemodialysis is now overwhelming period. It is better especially with the FHN results which are well documented now. Group Health is my default health care when I am in Idaho so this issue needs to be clarified. They are living in the dark ages of medicine in my opinion and they give medicine a bad name in my opinion. They are no Kaiser sad to say.
I would contact an experienced attorney.
Mark, send me an email at Hemodoc.com and I will be happy to write up your case and post it.
God bless,
Peter
Here is the Group Health evaluation of home hemo and daily hemo. It is a very flawed document in my opinion. I sent them an email today asking if they have updated their policy since the FHN.
thanks, bill.
I’m still working and my employer provides my health insurance
I work too but Medicare has been my primary since 1988 when I was 24. As Beth said after 33 months of dialysis treatment Medicare should be your primary payer and then work would pay secondary.
[QUOTE=Dori Schatell;20621]Hi Mark,
Boy, we hate to hear this kind of scenario. Unfortunately, DaVita can charge insurance companies so much per treatment (each company negotiates its own deal with a network of providers) that doubling the costs of 3x/week may just not be something Group Health is willing to do. And DaVita did warn you ahead of time that Group Health wasn’t a wise choice.
There have to be ways to put pressure on them, however. I know that Beth will chime in here, and she deals more with the insurance side than I do. But some possibilities include (in no particular order:
– Go up higher in the company. There has to be a process to appeal their decision. “Doctors at Group Health have told me that it will not be overturned” is not an appeal, it is an opinion. There is a formal appeals process. And, with the Frequent Hemodialysis Network trials offering proof that more frequent HD is better–and TONS of other info we could bring to bear–it could be argued that the “standard of care” (3x/week) is inadequate. We’re happy to help you with this.
– Get a lawyer. If there is no tort reform in your state, an attorney may be willing to take a case like this on a contingency basis (they get paid if you win).
– Shine a light on them. Does your area still have a newspaper? A consumer TV show? Get Group Health some very bad press (heartless insurance company doesn’t care about people having quality of life and being able to work…) and raise awareness of better dialysis at the same time. Get friends together, picket their building, and call the media. Guerilla PR techniques could help.[/QUOTE]
Thank you,
I have submitted an appeal, contacted my representatives and senators, and one local newsman. Not a lot of response yet, but I’m going to have to expand my broadcast area. 
More on the Group Health front:
After speaking with Medicare, Group Health and Davita, it seem that Medicare pays a portion of my Group Health premium and that means they get to make decisions regarding my care.
Mark
Do you have Group Health as a former employee/retiree? Or do you have it as a “Medicare Advantage” plan? If Medicare is subsidizing Group Health for your health or drugs, it makes me wonder if you have a plan through a current or former employer that’s operating as a Medicare Advantage plan. Do your plan materials say Medicare Advantage (or Medicare Private Fee-for-Service, another type of MA plan) on them? Medicare rules require Medicare Advantage plans to provide the same coverage as Original Medicare at minimum. Unfortunately, original Medicare routinely covers 3 treatments a week…sometimes more with medical justification. I wish it covered more because that would give you a stronger leg to stand on.
I found this document linked below on the Group Health website that shows the basis for their decision for its Medicare patients. The document was first created in 2008 and reviewed for Medicare in 2010. The bibliography listed shows studies as old as 2001 and no study more recent than 2008. About more frequent dialysis, it states: There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies (and/or) provides better long-term outcomes than current standard services/therapies. The document indicates the reviewers don’t seem to know about the Frequent Hemodialysis Network study of daily dialysis even though the document mentions the FHN study of nocturnal dialysis as still recruiting. There is a link at the end of document to the Clinical Criteria Documentation Team. I wonder if any of the authors of the FHN would be willing to contact Group Health. This insurer has >654,000 members in WA and ID. If truly 1 in 9 people in the U.S. have chronic kidney disease and Group Health has >654,000 members, >72,000 of Group Health’s members may be facing inadequate dialysis in the future unless someone gets Group Health to consider the recent literature that is clear that there is a benefit of more frequent dialysis. Medicare Advantage plans should care because there is no Part A/Part B wall and savings from fewer hospitalizations and not having to treat other health problems that don’t occur with better dialysis could offset higher costs of dialysis.
https://provider.ghc.org/all-sites/clinical/criteria/pdf/dialysis_home.pdf;jsessionid=3XRKNKTZ5JOUTJCISQ4CGWQ
This thread has become very confusing to follow. Is there any way to arrange the posts in chronological order? They seem to be all over the place. Just wondering…
They’re in chronological order, Wendy. I’m not quite sure what you mean.
kindof in order but not really…If you start at the original post and scroll down there are some 2011 posts in the middle of the 2009 posts. I guess there are just so many posts that were posted as replies to different comments that they are difficult to track. For instance, I couldn’t find your reply just now by searching the thread. I had to go back to the email and click so I went directly to it. No big deal by any means but it does become difficult to look for specific comments with so many offshoots from the original comment.
Hi Wendy,
I looked through the posts starting with the one from March 2009 on page 1. On page 4 the thread goes from post #39 on April 5, 2009 to post #40 on January 26, 2011. It looks like the person who posted #40 must have found the old thread related to insurance not paying for home hemo and posted to it bringing that whole thread into 2011. I was confused at first when I saw the 2011 post after a 2009 one too until I noticed that the next post on page 5 is in date order from this year too.