With my home program, I am required to attend monthly clinic. If ever I can not attend does Medicare allow me to do so or must it be made up somehow? Can the doctor still get paid if he does not see me in person?
The ESRD regulations require patient “consultation” with members of the interdisciplinary team (physician, nurse, dietitian and social worker) as needed. The physician is not required to see home patients at all to get paid by Medicare. However, the ESRD regulations require that physicians see their in-center patients monthly at least. To provide the same level of care to home patients, the regulations require dialysis clinics to have a policy that explains how the physician is going to provide monthly evaluation of each home patient like he/she must do for in-center. One way the physician can evaluate how well the patient is doing at home is by seeing the patient at his/her office. The regulations allow this as long as the records of that visit are shared with the dialysis clinic.
Speaking of records…Home dialysis patients are supposed to document each home PD or hemo treatment. Some clinics have patients send dialysis records every treatment by fax or computer and other clinics ask patients to bring printed or electronic records to clinic visits. The clinic needs these records to monitor how you’re doing and to bill Medicare or other insurance correctly so you don’t have to pay any more than necessary.
There may be times that it’s impossible for you to come to a scheduled clinic visit. It’s always a good idea to alert the person at your clinic who is your liaison (usually the home training nurse) to the home program before you miss a clinic appointment to keep clinic staff from worrying about you. Your home training nurse may be able to schedule another time that you can come in and still meet with the dietitian, social worker and him/her. Everyone on the team wants to have a chance to talk with the you to be sure that you’re doing well and, if not, to identify and resolve any problems you may have before they get worse. Remember, you can always call your physician, nurse, dietitian or social worker when you want/need them when you’re at home.
Jane, Here is an excerpt from the CMS Guidelines… Unless a service is rendered, they cannot bill you or your insurance for that is fraud. Im sure beth will be able to give you more info.
From CMS Website
CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE FACILITIES
TAGV560 Page 220
At a minimum, monthly medical progress notes should document that a physician or that a non-physician practitioner (i.e., advanced practice registered nurse or physician assistant) who functions in lieu of the physician, has seen each patient and addressed the status and plan for that patient’s renal and active comorbid problems.
This requirement applies equally to home patients, who are expected to receive equivalent care to in-center patients. A monthly visit is required for each home patient by either a physician, an advanced practice registered nurse, or a physician assistant. This visit may be conducted in the dialysis facility, at the physician’s office, or in the patient’s home.
Any patient may choose not to be seen by a physician every month. However, if there is a pattern of a patient consistently missing physician visits, the IDT should determine whether or not the patient is unstable according to these regulations, and should address the lack of medical oversight with the patient in the plan of care.
Hope this helps…
///MM
The facility charge (composite rate) for a home dialysis patient is what Medicare calls a “prospective payment.” The Medicare allowed charge is supposed to pay for the equipment (if required), home dialysis supplies for 3 HD treatments a week, and support services (monitoring) during the month by the nurse, dietitian, and social worker. Support services can be provided in many ways, including in-person visits, phone calls, emails, etc. Usually dialysis clinics schedule clinic appointments with all home patients on a monthly basis. Some patients come in other times to get IV medications or to get blood drawn, while patients choose not to come every month. Reasons why a patient may not come to clinic could be due to transportation, scheduling conflicts with work or home responsibilities, being out of town on vacation, or just not seeing the need to come to talk with the nurse, dietitian or social worker (a patient elsehwere on this board complained vehemently about having to go to clinic appointments). To accommodate patients who may be working or may not be able to make an appointment at the dialysis clinic, the ESRD regulations offer the option for the patient to see the physician in his/her office. It is not Medicare or insurance fraud if a patient does not come to a clinic visit and the clinic bills the composite rate for dialysis.
Thanks very much for all this helpful info. All this time, I mistakenly thought that my neph would not get paid if I missed a monthly visit. Sometimes I am amazed that I have never missed a visit. It is hard on my caregiver I depend on for transportation as he never gets a break. If I understand you both correctly, Medicare does not require monthly visits if the patient opts out when necessary. Can the unit have a regulation that overrides the Medicare regs when it comes to missed appointments? Sometimes, I find monthly appointments a waste of time as absolutely nothing new is discussed. When I want to discuss something and know there is a chance of learning something from my team, that is when I want to go. But if I know they don’t have any ideas on a subject, I feel it is a waste of time. I was interested to learn that Dr. Agar’s nocturnal home patients are only seen every 2-3 mo. as they are stable and don’t need to be seen more often than that.
When I was first on dialysis in-center, the neph rounded weekly. I liked it that way then as I always had questions. But I wouldn’t of had so many questions if the neph and team would of made education a priority. Even now, being in a home program, education is not a priority. It’s still if I can think of the questions to ask, I might get answers, but too often my team does not know the answers to my questions re nocturnal. So, that is why I say that I would prefer not going to clinic visits monthly. Every other month or less would be good enough. My nurse does a decent job of handling most concerns on the phone and if she doesn’t know an answer, she asks the regional nurse. But no one knows much about nocturnal yet as it is new to them, thus some visits are for nothing.