Social Worker

What does a HHD clinic need to do in order to ensure coverage for the 4th, 5th, or 6th treatment? Is it necessary to contact/ establish a relationship with your state FI in order to do so? Are there any clinics having trouble getting payment beyond the 3rd treatment? Any further recommendations?

If you’re referring to receiving Medicare payment for more than three HD treatments routinely in a week, this requires medical justification for additional treatments. Medical justification must be sent to the FI with the dialysis claim. It might help if the patient’s MD or the facility medical director talks with the FI to be sure what information the FI needs to review the claim and process it for payment the first time.

The following are discussed in FAQs from NxStage.

  1. Provide patient-specific information (name, Medicare number, birthdate) in a letter that contains these things:
  2. State the purpose for writing the letter, i.e. to get Medicare reimbursement for x days of hemodialysis per week
  3. Describe the patient’s medical history including how long the MD has seen the doctor and what conditions more frequent dialysis could help
  4. State the reasons why the MD believes more dialysis is medically justified, i.e., what conditions could be improved and what else has ben attempted, if anything to improve those problems
  5. State what improvements the MD has observed since providing more frequent treatments, e.g. This patient has received x treatments a week for [length of time] and I’ve observed improvements in [specific symptoms, labs, hospitalizations, etc.]
  6. State what the patient believes more HD treatments a week will help, e.g., symptoms, labs (may help to provide RN assessment), appetite/nutritional status (may help to provide RD assessment), hospitalizations, psychosocial status work ability (if working state this) and QOL (may help to provide MSW assessment)
  7. Provide 1-2 prestigious journal article(s) of the benefits
  8. Provide contact informaiton to answer questions or provide more information if desired

Some health conditions that improve with additional HD treatments a week include:
– Fluid overload/LVH/heart failure (intradialytic weight gains, measures)
– Hypertension (# medications, average BP, presence of LVH, CHF or other CV disease)
– Metabolic bone disease (# and current PTH binders, vitamin D dose, PO4, any bone complicaions)
– Anemia control (EPO dose, current Hgb/Hct)
– Quality of life (hardship with current regimen and how more treatments could help the patient with work and home responsibilities and participate in other desired activities)

For young patients especially, you might want to add how providing more frequent dialysis treatments could help the patient live longer and more productively. If the patient is interested in transplant, you might add how more frequent HD can help the patient stay healthier for transplant.

Decisions about extra treatments are decided by FIs. Some are more lenient than others. If the FI denies the claim, you can appeal it through the reconsiderations and appeals process, then before an HHD administrative law judge, and finally to the District Court in that order following the procedure in the Explanation of Medicare Benefits.

Commercial payers may not have set a limit on the number of dialysis treatments a week. I’ve heard that clinics do not have trouble with commercial payers paying for the number of treatments provided.