Some Medicare HMOs don't want home hemo

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.

Wow, what a nightmare. This would be extremely frustrating if I were in your shoes. I hope someone else on here has personal experience that will help. I think in California, Kaiser is offering daily in-center dialysis just because it makes good economic sense – let alone the moral imperative – your HMO’s actions are hard to fathom. I guess I don’t understand why your HMO would pay the charges if you were in-center but wont pay while you’re at home – the billing should be the same. Was your center just billing for three times a week? Or for every treatment? Or are you saying the HMO would act this way even if you were in-center?

From your center’s point of view would they be satisfied if you had straight Medicare? I understand what you wrote - that some HMOs do offer advantages to their clients - but yours sure doesn’t sound like one of them. What did you see previously (when you first joined) as the upside, personally, to be in this HMO?

Have you been getting things in writing – why they deny, their coverage rules, etc.? Any thought given to going through State bureaucracies? – here in WA State it’d be the State Insurance Commissioner.

I assume that your Medicare HMO gave you a copy of its grievance and appeal process and that you followed it step-by-step and were denied at evey level. What were the reasons the Medicare HMO denied coverage for your clinic and home dialysis? What state are you in?

I assume you may have already done this, but if not, have you contacted your state’s Quality Improvement Organization? These agencies are supposed to handle Medicare beneficiaries’ complaints, notices and appeals and address coverage denials. You can find the organization in your area from a link to QIO directory:

I’d suggest contacting the ESRD Network. I’ve worked with ESRD Networks on cases where they were able to advocate with HMOs to get patients home training and home dialysis. They may have contacts in these organizations that will get action faster. and click on your state

You might want to read this booklet and see if any of the situations in the rights and protections section apply to you and then look at the section on Medigap plans for peple under 65 and disabled or with ESRD.

Check to see what the insurance regulations are in your state by talking with the state insurance department.

Send your story to the newspaper, call your local consumer action news station, write your U.S. senators and representatives and your state senators and representatives. You can find any of these (media included) through our Legislative Action Center on this site. Be sure to mention that you feel locked into this plan that is denying benefits that patients in Original Medicare can get readily. Most companies don’t like bad publicity because it stirs up others and makes regulators take notice.

If worse comes to worse, are there other clinics in your area that are in-network providers of the Medicare HMO and do home hemodialysis too? Obviously, it appears that you trust your clinic so this would be a last resort rather than going in-center.

I’ve tried everything mentioned in the replies – and more–since I am talking directly to Medicare. Some of the agencies you mention don’t have any influence over HMOs. I have come to the realization that I will someday have to retain an attorney if I want to continue daily home hemo.

I didn’t post my experiences as an appeal for help (unless you know someone at Medicare who can force an HMO to do the right thing.) I posted my experiences for the benefit of those who are covered by a Medicare HMO.

People have a belief that all problems can be easily solved by making a phone call or asking an agency for help. This isn’t true. Sometimes problems are so severe they defy resolution.

The bottom line is that Medicare does not regulate its HMOs when it comes to daily home hemo.

That’s a good example about how flawed our system is…nobody cares, all they care is their money…

Remember Katrina?

Anyway, I guess you’d need to go further with an attorney and even expose them to the media…national news…

I know some people in the CMS central office in Baltimore. I also have a list of ESRD experts in all CMS regional offices. Who are you talking with and where (state)?

The Quality Improvement Organizations (QIOs) have in their statement of work (what they’re supposed to do) that they will help Medicare beneficiaries with Medicare Advantage (Medicare HMO) appeals. I haven’t had any real contact with QIOs so I can’t say how effective they are. Here’s a brief description of what they do and links to other documents:

I personally know of 2 people on opposite coasts (CA and MA) that called Medical Education Institute wanting home dialysis training that they were being denied by their HMO. In both instances, I contacted the ESRD Network and that organization advocated with the patient’s HMO in one case and with the indepedent practice group (referring MD) in another case so both patients were able to do home dialysis training and home dialysis with coverage through their HMO. I don’t know if all networks will help in this way.

The Medicare Advantage plan must think for some reason that clinic dialysis would save the MA plan money. On the contrary, home hemodialysis no more expensive than in-center hemodialysis for 3 days a week for the dialysis. Medicare doesn’t routinely cover more than 3 days a week dialysis and most clinics that have Medicare patients on more frequent dialysis realize that they may get reimbursed for 1 more treatment with medical justification, but that they will not get reimbursed for more than 4…from Medicare. I believe most clinics that offer home hemo more frequently than conventional figure they’ll make up added costs by patients missing fewer treatments due to hospitalizations, patients needing fewer drugs during dialysis and/or they’ll collect more from commercial payers to offset what Medicare allows/pays.

Does the Medicare Advantage plan have cost effectiveness data? Having this data helped in advocating for the two people I mentioned earlier.

[Beth writes:
quote] I believe most clinics that offer home hemo more frequently than conventional figure they’ll make up added costs by patients missing fewer treatments due to hospitalizations, patients needing fewer drugs during dialysis and/or they’ll collect more from commercial payers to offset what Medicare allows/pays. [/quote]

How does needing fewer drugs during dialysis profit the units?

Would all of the units that are offering daily txs be doing it if they were taking a loss? I doubt it. A machine rep told me they make about the same on daily txs as they do on incenter as there is no overhead. And there is a chart at the Geelong Experience website that shows the costs are close to the same for both modalites. So, it doesn’t appear that profit rate is the hang up. Seems the companies and doctors have taken the path of leaste resistance rather than put patients’ health at the pinnacle of care. It is easier to foster dependence than to put together a program that involves the patient and promotes patient independence.

If patients need fewer drugs during dialysis, clinics need to buy and stock fewer drugs for which they must wait to be reimbursed until they give a drug. Also, Medicare recently cut back on how it pays for drugs. Reportedly there isn’t any profit margin on Medicare reimbursement for drugs.

Training costs for home hemo are very expensive and are more expensive the longer it takes to train someone. Medicare only reimburses training at the normal hemo composite rate plus $20 per day. [Note: PD training is reimbursed at a lower rate.] Some clinics pay for or help their patients pay for home modifications (plumbing and electrical) that’s required to use a dialysis machine at home. This work can cost $1,000-$1,500 or more, depending on what needs to be done.

I’ve heard that a good home dialysis program needs to have a certain number of patients to be profitable – some have estimated 15-20 patients per nurse. Some programs offer PD and home hemo and nurses know and training and follow people on both. It takes a while to build a program to this point and clinics need to decide at what point to dedicate a nurse to a home program. This will probably be before the nurse has 15-20 patients so for a while the nurse won’t be fully utilized.

Once training has been completed and the patient is dialyzing at home, the costs for conventional home hemo are less than for in-center home hemo because of the reduced overhead. I’ve heard from those that know the economics of home dialysis that it takes 1-2 years of having a patient at home doing home hemo to make up the training and start-up costs. I assume this is for a patient doing conventional home hemo. I suspect any profit margin is less for daily or nocturnal because Medicare only reimburses for 3 treatment routinely.

Clinics hope that when a patient chooses to do home dialysis he/she will stick with it at least 1-2 years so the start up costs will be made up. I have to say that I’m not sure whether these estimates assume that the clinic buys or rents the home hemo machine.

If clinics have a mix of patients on Medicare and patients with commercial insurance they do better. I heard from one of the home dialysis machine reps this week something that made sense – no hemo program could stay afloat if all it had was Medicare patients. Medicare reimbursement today is about half what it would be if the dialysis composite rate had kept up with inflation. That’s why clinics charge as much as they do to commercial payers.

Beth writes:

Once training has been completed and the patient is dialyzing at home, the costs for conventional home hemo are less than for in-center home hemo because of the reduced overhead. I’ve heard from those that know the economics of home dialysis that it takes 1-2 years of having a patient at home doing home hemo to make up the training and start-up costs.

It may take some time to get their start up costs back, but they will as patients should be flourishing at home with the improved tx., and we hear that once patients gain their independence and better health, they say it is unthinkable to return in-center. And in many areas the patients’ in-center chairs will be filled by more patients=more profit. Also, the training period for the newer machines designed for home hemo is relatively short.

If patients were properly educated like they are in other countries, they wouldn’t be so ill due to in-center txs that are insufficient or improperly delivered. And, they wouldn’t become so dependent on others for their care. Education and independence are the strongest keys to improved health.

I totally agree that patient education is important and the earlier the better. From data I’ve seen only a little over 40% of patients are referred to a nephrologist a year prior to starting dialysis and some patients are not referred at all but show up in the hospital deathly ill. The renal community has been working to inform other doctors of the importance of early referral and of doing the testing that is needed to identify people at risk for kidney failure so kidney failure can be prevented or postponed.

In the meantime, those patients that are referred need more education than many of them are getting. In addition to working with Medical Education Institute, I coordinate classes for people with Stage 4 kidney disease (GFR <30) for the Missouri Kidney Program. You can’t imagine how frustrating it is to beg for referrals from doctors and other healthcare professionals and then to get referrals and have maybe 10% of those referred attend.

My frustration is compounded because I know that people who attend rave about what they’ve learned and how good the classes are. Scores on the pre-tests/post-tests that we give them shows significant knowledge gained and I suspect because they know more, these patients are more likely to cope better when their kidneys do fail and they’ll be better prepared to choose a treatment. Patients who attend our classes learn about ALL options for treatment – all kinds of home hemo and PD as well as in-center dialysis and transplant – from professionals and patients that are doing them. Patients who attend are much more interested in home dialysis – PD or home hemo – than reflected in the numbers of patients on home treatments today.

We’re not alone in doing education programs. Others doing them include NKF affiliates, dialysis corporations, AAKP chapters, and more. In spite of the fact that all of these classes are FREE, I bet if we as a community are lucky, we get referrals on maybe 5-10% of patients that start dialysis and as I said before only 5-10% of them attend. Maybe we should be doing something we’re not doing to promote the classes. Maybe doctors and other healthcare professionals could refer more patients. However, when they’re referred and know classes exist, I really do wish that more patients would choose to participate in them. The roadblock seems to be how to inform everyone with kidney disease that classes are available and then once they know about the classes, how to overcome the denial that many people have when kidneys are failing. Ideas?

Debby what happened?