Reimbursement Issues

Our Oupatient facility is currently looking at pursuing a Home Hemodialysis program.

Our manager is concerned that our intermediary may deny the fourth tx billed per week even with attached justification.

Questions: Any feedback on how any of your fiscal intermediaries are reimbursing? What is your patient criteria for home hemo?

We currently have a home hemodialysis program. Our criteria for patients are the following:

  1. A dependable support system.
  2. A patient and partner who is willing to learn the procedure and to assist regularly with the dialysis treatment.
  3. Social assessment, including competency, ability to learn and a stable social situation.
  4. A clean home enviroment that can be altered to meet the necessary plumbing, electrical and storage needs.
  5. Appropriate water supply.
  6. Commitment from the patient to attend monthly clinic visits.
  7. A fistula or graft for vascular access.

Is anyone routinely getting Medicare coverage for more than 3txs per week for patients not involved in a clinical trial? CMS has sent info to the intermediaries stating that 4th treatments will be allowed only for patients involved in the NIH trial.

Even if Medicare won’t pay for a 4th treatment, if patients are employed and have an employer group health plan, that plan may pay for a 4th (or even 5th or 6th payment)–or at the very least, may pay more than the Medicare composite rate. On average, EGHPs pay 3x the Medicare rate, so getting that 4th treatment paid for becomes less important…

In Massachusetts, there is no licensure required for providing staff-assisted home hemodialysis. Our success has been in negotiating extra-contractural agreements with the patient’s commercial insurer to reimburse us for the caregiver. Because we are also an approved Medicare DME provider we bill for our supplies under the Method II option for home hemodialysis. We have also entered into a support service agreement ( required by Medicare ) with a local outpatient clinic, who maintains records on all the patients, provides dietary and social service support, reports to the ESRD network, and provides some medications for which they bill.

Many units are not interested or equipped to launch their own home program, however there are those who support the concept and that may be willing to engage in an agreement with you so you can do it.

If I can be of further help you may email me at :

Elton Harding

1 Like