I have been doing daily home HD for three years. I just received a letter from my clinic stating that I will be cut off from home dialysis on Sept. 30 due to a billing dispute. The clinic claims it has to bill my Medicare HMO for 26 treatments per month whereas the Medicare HMO is only willing to pay for 13 treatments.
They said I can either pay out-of-pocket for the difference or cease dialysing at home and return to a regular clinic. Obviously, I cannot afford to pay $1,750 per month.
Does anyone know the Medicare law on this subject? Can a clinic provide me with daily dialysis and then stop it over a billing dispute? I have written to the HMO and asked for the dispute to be resolved. I have faxed the info to my neph. I plan on calling Medicare in Atlanta and ESRD Network. I don’t know what else to do.
Why do clinics offer daily home dialysis and then change the rules after three years?
Mmiller, what has your nephrologist said about this? Often (usually), an MD has to write a letter of medical justification to get Medicare to pay for more treatments than the usual 3 per week. If your doctor hasn’t done this yet, he or she needs to get involved ASAP.
A couple of other thoughts that have occurred to me:
– Contact NxStage & see what they say (or your doctor may need to do this)
– Consider contacting the local press–a media story on your plight may embarrass the Medicare HMO into relenting.
I’ve also asked Beth to weigh in on this–I think your impulse to call the Network is a good one; they can often intervene on your behalf. We’ll certainly do all we can on our end to help you.
Something like this happened to me in early years of dialysis, but mine was resolved quickly…
The Dr. in most cases has to provide written medical justification that you require more dialysis and 2nd to that is your lawyer to help you fight the insurance company…I speculate that your in a for profit clinic?
I thinkl Beth or Dori can give you a better answer to your problem, just hang in there…
Medicare, including any Medicare Advantage (HMO) plan, is only obligated to pay for 3 hemodialysis treatments a week without medical justification based on someone’s medical need for additional treatments. As Dori said, if there is a medical reason (usually cardiac or fluid related) for additional treatments, Medicare will allow at least one more treatment a week. Rather than trying to embarrass the Medicare HMO into paying for more treatments – which may not be successful since Medicare is not obligated to pay for more treatments – I’d probably suggest a story on how much better patients like you do with daily dialysis. For instance if you’re taking fewer medications that Medicare would normally have to pay more for or if you’re working and paying taxes, these things could show lower costs (or higher tax revenues) to the federal government overall.
I’d be curious to know where your dialysis clinic is (state). Medicare rules have not changed and are listed in the Medicare manual and we include this information in our Medicare FAQs. If Medicare intermediaries (payers) paid for extra treatments before, they may have decided to pay only what is required. If you’ve been doing daily dialysis for 3 years and your dialysis clinic was collecting extra for the extra days without medical justification for that long, your clinic was just lucky. Dialysis clinics in most areas that provide extra treatments do so because they have found that patients who do more frequent dialysis are healthier, need fewer drugs, and are not hospitalized as often so they don’t lose money for dialysis days that patients are hospitalized. Perhaps your clinic should look at the hospitalization days and drugs for in-center patients doing 3 times a week dialysis compared with hospitalization days and drugs for daily home hemo patients to see how cost effective daily dialysis is.
Before returning to in-center HD, another option would be to do nocturnal home hemodialysis every other day or at least 3 times a week. The clinic could bill for the treatments and you would get the next best thing to daily dialysis because longer gentler dialysis often helps patients feel better and do better. Plus your days would be free to do other activities.
That really sounds like a plan…3x a week at home on Nocturnal? That would probably mean some additions to the machine like a heparin pump…
mmiller, if there’s no other choice but to do 3x a week I’d talk to the Dr. and clinic that you’d rather stay home and just do Nocturnal 3x a week…its still better than going to clinic and dialyzing less…
My neph did indeed write a prescription requiring daily dialysis. I live in Florida, but I don’t think that makes a difference to Medicare.
I was with a Medicare HMO which was purchased twice since I starting dialyzing at home. The first two versions of the HMO apparently paid the clinic for 26 treatments per month, or the clinic overlooked the lower payments due to money received from the dialysis-machine manufacturer. The latest HMO owner has refused to pay for the additional 13 treatments each month. Early in the year, this same HMO cut off my Epogen and blood tests, which were only restored after a lengthy battle.
The clinic is for-profit and does not care about hospitalizations or lower drug use or anything else. It only cares about money.
I am not a candidate for nocturnal dialysis. I do not have enough money to hire lawyers.
These clinics basically go out and recruit ESRD patients to daily home dialysis. They promise that daily home dialysis does not cost anymore than in-clinic dialysis. What a lie!
In the early days, Aksys used to pay the clinics big money under the table to keep the machines in the homes. This allowed the clinics to look the other way on other charges. Now, with most people switching to NxStage, the clinics aren’t getting the extra money. Another factor is that NxStage is pushing more clinics to use the Pure Flow SL system, which drastically reduces the cost of the treatments. There will be no more huge, expensive deliveries of dialysate to pass along to insurers.
It looks like I will be going back to the old clinic, which was slowly killing me. I appreciate your help. But I think your website should avoid suggesting that anyone can dialyze at home. As I have seen, sometimes you get the rug ripped out from under you. Medicare simply has not shown any inclination to support daily home dialysis.
It looks like your HMO itself is causing problems, and the other factor is that your clinic is in for a profit…
Awhile back I posted about for profit clinics and non-profit and even the clinic I left was a for profit clinic that didn’t want to consider NxStage for training so I left to a non-profit clinic…
However, it feels like we’re all headed to the same situation your in…simply they don’t want to pay for the extra dialysis…with the national deficit quite bad and medicare running out of funds its scary to think about!
This just stinks!!! Canada and Australia can pay for home programs and we have to get caught up in the insurance mess and Medicare. Lets hope the networks can do something about this and help patients to get into home hemo if they want it. After all they are suppose to be patient advocates.
I’m glad that you have been able to daily dialysis for three years and am sorry that your Medicare Advantage plan is no longer paying for the extra days or it has changed the amount that it is paying and your dialysis clinic is not willing to accept what your MA plan is paying for dialysis as payment in full. It’s possible that if you had a commercial insurance as a primary or secondary payer, you might not be in this situation. Although that’s not fair, that’s the way things are in the U.S. today. I encourage patients who are unhappy with our current healthcare system to contact their federal and state legislators and suggest other ways to provide healthcare.
In fact, there is a bill in Congress right now that you can write your representative and ask him/her to support. See our Legislative Action Center. On that site, there is a link to a bill that would provide federal funding for a pilot study of more frequent dialysis. If this were to pass, patients on Medicare could get more treatments because there would be funding for them. Click on the link below, then click on the HR 5321 link and use the letter we drafted or write your own. This program will send your message to your representative if you enter your personal information including your zip code. http://capwiz.com/meiresearch/home/
Home hemodialysis does not cost a patient more than in-center dialysis when it’s done the number of treatments Medicare pays for – usually three time a week (or four with medical justification). You say your clinic isn’t looking at reduced hospitalizations. If this is true, it is very shortsighted. Another way clinics should be looking at daily dialysis (or home dialysis) is that providing a more “work-friendly” dialysis treatment allows more patients to keep their jobs and their commercial insurance. Commercial insurance pays more than Medicare as a primary payer for the first 30 months the person could have Medicare. This brings additional revenue into the clinic.
Assuming Medicare won’t pay for more treatments and you are doing daily dialysis, if your clinic wants to charge you for the extra treatments that Medicare doesn’t cover, it must inform you of what the Medicare non-covered charges will be so you can choose whether you want that service and are willing to pay for it. It sounds like this is what your clinic is doing. As I see it, your choices are:
Go back in-center for 3 times a week dialysis where you say it was killing you (this doesn’t seem the best option to me);
Do 3 times a week dialysis at home for longer each time so you’re getting more dialysis even if you’re not getting it daily;
Find out other clinics that your MA plan contracts with and change to one that does daily dialysis and will accept your MA plan’s payment and not bill you for the non-covered days;
Change from your MA plan to Original Medicare as soon as you can so you can go to any dialysis provider and not be limited to those that contract with your MA plan.
So far as this last option, there are some things to consider:
You won’t be able to join any MA plan as long you’re on dialysis but you can join one again if you get a transplant and don’t need dialysis down the road.
You may have to pay more out of pocket if you can’t get a Medigap plan. Ask your state insurance department or your state health insurance assistance program what your options are for Medigap coverage before you disenroll from your MA plan: http://www.floridashine.org/
So far as Aksys paying clinics under the table, I’ve never heard that and would be really surprised if it was true because there are very large fines for any company that engages in kickbacks. Here’s Aksys’ code of ethics that specifically prohibits any kind of kickback or unethical behavior: http://www.aksys.com/corp/images/ethics.pdf
It is my understanding from the Aksys website and from a friend of mine who owns Aksys stock and regularly listens to company teleconferences that Aksys has pulled back from some markets to focus more on a few markets and on developing a new machine.
I think your website should avoid suggesting that anyone can dialyze at home.
Our website is pretty clear that insurance is a factor in what treatments people have access to–just read our downloadable descriptions of daily home hemo & nocturnal home hemo to see. But please do try some of the suggestions you’ve received, before just giving up and going in-center three times a week.
First of all, don’t just give up. If they will pay for three treatments in-center then why not do three treatments at home? What machine do you use? Maybe you should look for a clinic that uses the NxStage. It doesn’t sound like you are with a $1750 monthly bill. As far as companies paying kickbacks to keep machines in homes. I am part of a research group and it pays for what medicare won’t for 18 months. When the research group is over I am to start making up the difference. I was told for NxStage it is around $50 a treatment. Yes medicare will only pay for three treatments a week. So that would mean I would be paying $150 a week or $600 a month. I really don’t think that is to bad really. I could probably make that much holding a sign at a stop light?? :twisted: Trust me I would try everything I know to make that $600 a month. Also there are secondary insurance plans that can run around $300 a month that would pay for it. Don’t let them take you down, there is a way you just have to find it. Good luck and best wishes to you…
The information coming out in this discussion is making us VERY nervous! We spoke with both the NxStage rep and our unit management months ago and were told that daily txs are essentially the same cost as 3x incenter txs since there is no nurse to pay or energy costs . Management went through the proper channels to start a program. Two gentleman have been trained already, both Medicare, and are home doing well with more lined up to be trained. So, how can this be a national situation? I can’t imagine our doc and corporation would of started a program if they were going to loose $$$. I’ve read posts where Dori said Medicare payments did not cover daily txs, but that’s not what NxStage and our management said. I think they said they are able to get the 4th payment when one is on daily txs. and that’s how they make ends meet, but I’m not sure how this works. With all the many patients on dailly txs. surely a percentage are Medicare, so what is the true story here?
If it were me, I would just try finding another center that had home hemo even if it were a couple of hrs away. It would be cheaper than paying the extra. Your already trained so training time wouldn’t be bad and usually clinic visits are only once a month. Heather I agree one can get nervous when you see how the rug can get pulled out from under you. Take a look at George Harpers story. He was traveling with his dialysis machine for YEARS. His clinic was bought out and he was told no more traveling. As far as writing to the government, kiss it good-bye, we will all likely be gone before any changes are made. I’d get a new center then get involved in writing to legislators it’s not going to help you now to waste your time on that stuff. Does your social worker have any ideas? Sorry for the pessimism but when it comes to dialysis the patient gets what the center says; and that is just about it. I have yet to hear of a patient who successfully changed their plight without finding a different center.
Currently Medicare does NOT routinely pay for more than 3 treatments unless someone has medical justification for more treatments. Some clinics may be charging for extra treatments it provides, but it doesn’t mean that all do.
Some clinics that are involved in a study through the National Institutes of Health which is comparing 3 times a week incenter treatments with daily treatments in-center and at home (daily and nocturnal). Others are involved in NxStage’s FREEDOM study which is looking at cost benefits of more frequent treatments.
You can read about the NxStage FREEDOM study here:
There is hope in the dialysis industry that data will prove to Medicare that more frequent treatments yield better outcomes and lower costs to the entire system. After all inpatient admissions are very costly to Medicare and if patients doing more frequent dialysis are not hospitalized as often or for as many days, it will save Medicare and other payers money. To prove this requires that patients participate. I hope that patients will choose to try more frequent treatments.
If patients feel better maybe they will feel well enough to not stop working and will keep their health insurance that way. Or if they’ve stopped working, maybe they’ll feel well enough to return to work if they’re on disability.
If you receive disability payments from Social Security there are work incentive programs that are frequently not understood or used. One of the ones that could help in this situation is called “impairment related work expenses.” It lets someone earn wht they need to to cover added costs related to their disabling condition plus up to $860/month (in 2006, increases yearly) before SSDI cash benefits cease. If you haven’t tried to work on disability before, you have a 9-month “trial work period” that lets you keep your SSDI check plus any earnings from work for 9 months. You don’t use a month of your trial work period unless you earn $620 in a month after impairment related work expenses are deducted from your earnings. The goal would be to find a job with health insurance and a decent wage. There are resources to help people do that.
Bottom line…don’t give up doing hemo at home and look at all the ways possible to do longer and/or more frequent treatments. It could make the difference between merely surviving and living a fuller, happier life.
In the meantime, please keep in mind that the best reported outcomes in the world have come from Tassin, France, where Dr. Bernard Charra’s center does nocturnal home hemo three times a week. Medicare pays for 3 treatments per week, so it’s no problem to get this covered.