Home Dialysis Reimbursement

1
Home Dialysis Reimbursement Financial
Considerations

• Anthony Messana
• Nephrology Consulting Management Services, LLC

2
Home Dialysis and MSP

• Medicare Secondary Payer Status Home Dialysis
• Initial 90 day period before qualifying for
  Medicare is waived
• Medicare is secondary to commercial plans for
  the first 30 months of dialysis therapies
• Medicare becomes primary on the 1st day of the
  31st month after starting dialysis

3
(No Transcript)
4
Initial Method Selection Beneficiary Selection
Form CMS-382

• Method I
• Patients Facility provides
• All equipment, supplies
• All support services
• Medicare pays the facility directly for all these
  supplies through an all inclusive daily rate

• Method II
• Patients Supplier provides
• All equipment, supplies
• Medicare pays Supplier
• CCPD 1974.45 cap
• CAPD 1490.85 cap
• Patients Facility provides
• All support services
• Medicare pays Facility
• 121.15 for support services

Beneficiary selection forms can be changed
annually but must be submitted prior to January 1
to take effect. Send them certified to the FI 24
weeks before January 1.
5
Support Services Method I

• Provide periodic monitoring of patients home
  adaptation
• Emergency visits by facility personnel
• Providing for and arranging supplies
• Installation and maintenance of the dialysis
  equipment
• ESRD related routine lab tests
• Testing and appropriate water treatment
• Monitoring of the functionality of the dialysis
  equipment

• For CAPD CCPD the following is added
• Changing the tubing
• Watching the patient perform PD and assuring that
  it is done correctly
• Documentation of peritonitis
• Inspection and monitoring of patients catheter
  site

6
Separately Billable Items

• Routine tests and medications are reimbursed the
  same as an incenter hemodialysis patient
• Antibiotics for treating peritonitis are only
  reimbursed when they are administered in the
  unit.
• Facilities must provide injectable antibiotics
  for treating peritonitis and exit site infections
  for patients to self administer at home

7
Home Peritoneal Dialysis Training
8
Home Hemodialysis

• Hemodialysis Machine
• Water Treatment
• Cultures Water Analysis
• Supplies
• Initiation Termination of Treatment
• Preparation for Emergencies
• Self Administration of EPOGEN

9
CAPD Training

• Medicare allows 15 training treatments per
  patient
• Additional training treatments are allowed if
  documentation exists for the need for more
  treatments to achieve a successful training
  session
• Medicare reimbursement rate
• Local Composite Rate plus 15.00 per session

10
CCPD Training Sessions

• Medicare allows 15 training sessions per patient
• Additional training sessions are allowed if
  documentation exists for the need for more
  sessions to achieve a successful training session
• Medicare reimbursement rate
• Local Composite Rate plus 20.00 per session

11
Home Hemodialysis Training Rate

• Medicare allows 25 training treatments per
  patient
• Additional training treatments are allowed if
  documentation exists for the need for more
  treatments to achieve a successful training
  session
• Medicare reimbursement rate
• Local Composite Rate plus 20.00 per session

12
Training Reimbursement Example

• Patient B CAPD Candidate
• Composite Rate133.57 per treatment
• Training Rate148.57 per training session
  (133.57 15.00 training add on)
• Patient B required 7 sessions to complete
  training
• Each Session would be billed at 148.57
• Total Reimbursement 7 x 148.57 1039.99

• Patient A Home Hemodialysis Candidate
• Composite Rate 133.57 per treatment
• Training Rate 153.57 per training session
  (133.57 20.00 training add on)
• Patient A required 21 sessions to complete
  training
• Each Session would be billed at 153.57
• Total Reimbursement 21 x 153.57 3224.97

13
Self Administration of EPOGEN

• Congressionally legislated exception to Medicare
  Benefits
• Allows units to train patients to self administer
  EPOGEN
• Allows units to bill for EPOGEN sent home to
  patients
• Bill the amount given to the patient not the
  based on specific dose amount patient can
  maintain up to a 2 month supply of EPOGEN for
  self administration

14
Medicare Payment Exception Requests

• Accelerated Home Training
• Average number of training sessions is less than
  Medicare allows
• Cost of training exceeds Medicare payment
• Documentation supports the exception request
• Isolated Essential Facility
• Atypical Patient Mix
• It is too bad the Medicare and Congress
  closed this opportunity except for pediatric
  programs who did not have an exception as of
  October 2002

15
Exception Requests

• Process for applying eliminated by CMS
• Exceptions granted prior to July 2001 are
  grandfathered in and will remain in effect until
  the exception rate is below the Medicare
  composite rate, at which time the payment will
  revert to the higher of the two
• Cost reports and record keeping are important
  should the exception window open at some future
  date

16
Documentation Key Factor in Successful
Reimbursement

• For all services provided documentation should
  exist in the patients chart that
• Provides clinical tracking of a patients progress
• Provides clinical rationale for the selected
  modality
• Justifies the therapies provided
• a. Dialysis treatment why was this modality
  chosen, how does it benefit the patients
  clinical outcome, how is it monitored
• b. Medications supported and monitored,
  protocols
• c. Laboratory services reviewed and supports
  therapies

17
Home Dialysis Documentation

• Patient modality selection supported
• LTCP patient input and signature
• If more frequent care is required then this is
  supported by medical conditions which may
  include
• Cardiac conditions
• Rehabilitation return or maintenance of work
• Improved clinical outcomes including but not
  limited to adequacy of dialysis, improved blood
  pressure control, better anemia management
• It is up to the physician to medically
  justify the course of care for the patient

18
Medicare Payment Changes for 2005

• Composite Rate will increase 1.6
• Medications will be reimbursed at cost possibly
  85 of AWP or some other determined costs
• OIG Medicare will determine an add-on amount to
  the composite rate for the average margin from
  medications based on the following
• 2004 utilization of medications per treatment
• Cost of Medications sources pharmaceutical
  companies and audit submission by providers
• Amount of margin for these medications based on
  average utilization

19
Medicare Changes in Reimbursement starting in
2005 Support Home Dialysis Therapies

• Home dialysis patients utilize fewer
  medications and under the current reimbursement
  scheme receive less margin from the medications
• MedPAC reports show that the composite rate
  without the average amount of medications
  administered looses money
• Under the new reimbursement rate the home patient
  will receive the add on to the composite rate for
  the average margin per treatment based on the
  average amount of drug administered

20
Social Security Disability Opportunities for
Patients

• Trial Work Periods
• Disabled Beneficiaries are able to work 9 trial
  months every 5 years these months are only used
  when the income exceeds 580
• Impairment related work expenses (IRWE), include
  the costs to have aides for home dialysis, will
  be deducted from the patients income when
  calculating income
• After IRWE deductions patients can earn up to
  810 per month in 2004 (1350 if legally blind)
  before disability payments will cease

21
Medicaid Buy-In

• Ticket to Work Work Incentives
  Improvement Act
• Allows people with disabilities to have more
  income than non-working disabled individuals and
  still qualify for Medicaid benefits.

22
Aides with Commercial Insurance

• During the coordination period some commercial
  insurance companies may pay for an aide to
  assist the patient.
• Have the patient check with their insurance
  provider

23
Questions
24
The End