I haven’t posted in a while, but felt it was necessary to pass along information about my Medicare HMO in my state.
Medicare HMOs are required to provide, at minimum, all benefits of Medicare – they almost always provide more benefits. Sometimes, these HMOs are valuable because they offer drug coverage and many other free services not covered by traditional Medicare.
The problem is that the HMOs really are not well regulated by Medicare’s Policy and Inquiry Branch in Atlanta. The HMOs can deny coverages and engage in all sorts of financial wrongdoing and it takes months of red tape before the Center for Medicare Services steps in and corrects the transgressions. Sometimes the HMOs get their way.
Hemo patients in clinics rarely have these problems because Medicare has very specific rules about coverages and reimbursement. Although Medicare officials have publicly expressed support for home hemo, Medicare has failed to provide the needed regulations which allow home hemo to proliferate and prosper. Indeed, because Medicare has ignored home hemo, many patients are living in nightmarish situations.
My Medicare HMO was bought and sold several times before being acquired by one of the nation’s largest health-care providers. ESRD patients are stuck with these HMOs, especially if they were previously disabled and uninsurable. The only way you can move out of an HMO, if you are ESRD, is if the HMO goes out of business or leaves your geographic area. Your only options are to stay with the HMO, go back to regular Medicare and lose benefits, or become self-insured (rarely an option for the disabled). HMOs have exclusions which allow them to deny acceptance to applicants with ESRD.
The last time my HMO was purchased, the new company took over and immediately denied payments to my clinic, which is providing me with home hemo equipment and services. The HMO claimed it had not agreed to home hemo, even though my clinic has a signed contract. The HMO figures it can drag it out in court. The HMO then cut off my clinic’s reimbursements for my EPOGEN, claiming I wasn’t anemic. This decision was made by the HMO, not my nephrologist, and cost the clinic thousands of dollars. My clinic had no choice but to file lawsuits against the HMO.
Then the HMO tried to wrestle blood tests away from my clinic and force me to use its lab. The HMO refused to reimburse my clinic for annual and quarterly blood tests. This required me to use all new equipment, decant and freeze blood serum, and deliver the samples to another city. This was not possible since I no longer can drive a car. The HMO does not provide a courier service.
These types of problems may force me back into a clinic, not because home hemo isn’t effective, but because my husband and I cannot tolerate the emotional trauma caused by the HMO. I obviously cannot afford to pay for these services out of my own pocket. My health will suffer if I am forced to return to the three-times-a-week sessions at the clinic.
We have filed grievances against the HMO. Medicare is supposed to come to our rescue. But the Medicare system is overburdened and really doesn’t work to police the profit-hungry HMOs. Medicare says the HMOs have 60 days to reply to grievances, but they often ignore the filings or take twice that long to reply.
I am posting this information in hopes that potential home hemo patients will thoroughly investigate their insurers prior to starting home hemo. But even if you do, your insurer may change ownership and you may end up screwed. Don’t trust your clinic to check out reimbursement. You need to get involved or ask for help.
The only long-term solution is for Medicare to offer a complete set of service and reimbursement regulations for daily home hemo, including performance by HMOs.