Home Dialysis Home Dialysis Reimbursement & Reimbursement & Financial Financial ConsiderationsConsiderations

Anthony MessanaAnthony MessanaNephrology Consulting & Nephrology Consulting &

Management Services, LLCManagement Services, LLC

Home Dialysis and MSPHome Dialysis and MSP

• Medicare Secondary Payer Status – Medicare Secondary Payer Status – Home DialysisHome Dialysis Initial 90 day period before qualifying for Initial 90 day period before qualifying for

Medicare is waivedMedicare is waived Medicare is secondary to commercial plans forMedicare is secondary to commercial plans for

the first 30 months of dialysis therapies the first 30 months of dialysis therapies Medicare becomes primary on the 1Medicare becomes primary on the 1stst day of day of

the 31the 31stst month after starting dialysis month after starting dialysis

Initial Method Selection – Initial Method Selection – Beneficiary Selection Form CMS-382Beneficiary Selection Form CMS-382

Method IMethod I• Patient’s Patient’s FacilityFacility provides: provides:

All equipment, suppliesAll equipment, supplies All support servicesAll support services

• Medicare pays the facility Medicare pays the facility directly for all these directly for all these supplies through an all supplies through an all inclusive daily rateinclusive daily rate

Method IIMethod II• Patient’s Patient’s SupplierSupplier provides: provides:

All equipment, suppliesAll equipment, supplies

• Medicare pays Medicare pays SupplierSupplier CCPD $1974.45 capCCPD $1974.45 cap CAPD $1490.85 capCAPD $1490.85 cap

• Patient’s Patient’s FacilityFacility provides provides All support servicesAll support services

• Medicare pays Medicare pays FacilityFacility $121.15 for support services$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 2~4 weeks before January 1.

Support Services – Method ISupport Services – Method I

• Provide periodic monitoring of Provide periodic monitoring of patient’s home adaptationpatient’s home adaptation

• Emergency visits by facility Emergency visits by facility personnelpersonnel

• Providing for and arranging Providing for and arranging suppliessupplies

• Installation and maintenance of Installation and maintenance of the dialysis equipmentthe dialysis equipment

• ESRD related routine lab testsESRD related routine lab tests• Testing and appropriate water Testing and appropriate water

treatmenttreatment• Monitoring of the functionality Monitoring of the functionality

of the dialysis equipmentof the dialysis equipment

• For CAPD & CCPD the For CAPD & CCPD the following is added:following is added:

• Changing the tubingChanging the tubing• Watching the patient perform Watching the patient perform

PD and assuring that it is done PD and assuring that it is done correctlycorrectly

• Documentation of peritonitisDocumentation of peritonitis• Inspection and monitoring of Inspection and monitoring of

patient’s catheter sitepatient’s catheter site

Separately Billable ItemsSeparately Billable Items

• Routine tests and medications are reimbursed Routine tests and medications are reimbursed the same as an incenter hemodialysis patientthe same as an incenter hemodialysis patient Antibiotics for treating peritonitis are only Antibiotics for treating peritonitis are only

reimbursed when they are administered in the unit. reimbursed when they are administered in the unit. Facilities must provide injectable antibiotics for treating Facilities must provide injectable antibiotics for treating

peritonitis and exit site infections for patients to self peritonitis and exit site infections for patients to self administer at homeadminister at home

Home Peritoneal Dialysis TrainingHome Peritoneal Dialysis Training

Home Home HemodialysisHemodialysis

• Hemodialysis Machine• Water Treatment

Cultures & Water Analysis

• Supplies• Initiation & Termination

of Treatment• Preparation for

Emergencies • Self Administration of

EPOGEN

CAPD TrainingCAPD Training

• Medicare allows 15 training treatments Medicare allows 15 training treatments per patientper patient Additional training treatments are allowed Additional training treatments are allowed

if documentation exists for the need for more if documentation exists for the need for more treatments to achieve a successful training sessiontreatments to achieve a successful training session

• Medicare reimbursement rateMedicare reimbursement rate Local Composite Rate plus $15.00 per sessionLocal Composite Rate plus $15.00 per session

CCPD Training SessionsCCPD Training Sessions

• Medicare allows 15 training sessions per Medicare allows 15 training sessions per patientpatient Additional training sessions are allowed if Additional training sessions are allowed if

documentation exists for the need for more documentation exists for the need for more sessions to achieve a successful training sessionsessions to achieve a successful training session

• Medicare reimbursement rateMedicare reimbursement rate Local Composite Rate plus $20.00 per sessionLocal Composite Rate plus $20.00 per session

Home HemodialysisHome Hemodialysis Training Rate Training Rate

• Medicare allows 25 training treatments per Medicare allows 25 training treatments per patientpatient Additional training treatments are allowed if Additional training treatments are allowed if

documentation exists for the need for more documentation exists for the need for more treatments to achieve a successful training sessiontreatments to achieve a successful training session

• Medicare reimbursement rateMedicare reimbursement rate Local Composite Rate plus $20.00 per sessionLocal Composite Rate plus $20.00 per session

Training Reimbursement ExampleTraining Reimbursement Example

Patient A Home Hemodialysis Candidate

Composite Rate: $133.57 per treatmentTraining 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

Patient B CAPD Candidate

Composite Rate:$133.57 per treatment

Training Rate:$148.57 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

Self Administration of EPOGEN Self Administration of EPOGEN

• Congressionally legislated exception to Medicare Congressionally legislated exception to Medicare BenefitsBenefits Allows units to train patients to self administer EPOGEN Allows units to train patients to self administer EPOGEN Allows units to bill for EPOGEN sent home to patientsAllows units to bill for EPOGEN sent home to patients

Bill the amount given to the patient not the based on specific dose 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 amount – patient can maintain up to a 2 month supply of EPOGEN for self administrationfor self administration

Medicare Payment Exception RequestsMedicare Payment Exception Requests

• Accelerated Home TrainingAccelerated Home Training Average number of training sessions is less than Average number of training sessions is less than

Medicare allowsMedicare allows Cost of training exceeds Medicare paymentCost of training exceeds Medicare payment Documentation supports the exception requestDocumentation supports the exception request

• Isolated Essential FacilityIsolated Essential Facility• Atypical Patient MixAtypical Patient Mix

It is too bad the Medicare and Congress closed this It is too bad the Medicare and Congress closed this opportunity except for pediatric programs who did opportunity except for pediatric programs who did not have an exception as of October 2002not have an exception as of October 2002

Exception RequestsException Requests

• Process for applying eliminated by CMSProcess for applying eliminated by CMS• Exceptions granted prior to July 2001 are Exceptions granted prior to July 2001 are

grandfathered in and will remain in effect until the grandfathered in and will remain in effect until the exception rate is below the Medicare composite rate, exception rate is below the Medicare composite rate, at which time the payment will revert to the higher at which time the payment will revert to the higher of the twoof the two

• Cost reports and record keeping are important should Cost reports and record keeping are important should the exception window open at some future datethe exception window open at some future date

Documentation – Key Factor in Documentation – Key Factor in Successful ReimbursementSuccessful Reimbursement

For all services provided documentation should exist in For all services provided documentation should exist in the patients chart that:the patients chart that:

1.1. Provides clinical tracking of a patients progressProvides clinical tracking of a patients progress

2.2. Provides clinical rationale for the selected modalityProvides clinical rationale for the selected modality

3.3. Justifies the therapies provided – Justifies the therapies provided – a. Dialysis treatment – why was this modality chosen, how does a. Dialysis treatment – why was this modality chosen, how does

it benefit the patient’s clinical outcome, how is it it benefit the patient’s clinical outcome, how is it monitoredmonitored

b. Medications – supported and monitored, protocols b. Medications – supported and monitored, protocols

c. Laboratory services – reviewed and supports therapiesc. Laboratory services – reviewed and supports therapies

Home Dialysis DocumentationHome Dialysis Documentation

• Patient modality selection supportedPatient modality selection supported LTCP – patient input and signatureLTCP – patient input and signature

• If more frequent care is required then this is If more frequent care is required then this is supported by medical conditions which may include:supported by medical conditions which may include: Cardiac conditionsCardiac conditions Rehabilitation – return or maintenance of workRehabilitation – return or maintenance of work Improved clinical outcomes – including but not limited to Improved clinical outcomes – including but not limited to

adequacy of dialysis, improved blood pressure control, adequacy of dialysis, improved blood pressure control, better anemia managementbetter anemia management

It is up to the physician to medically justify the It is up to the physician to medically justify the course of care for the patient course of care for the patient

Medicare Payment Changes for 2005Medicare Payment Changes for 2005

• Composite Rate will increase 1.6%Composite Rate will increase 1.6%

• Medications will be reimbursed at cost – possibly Medications will be reimbursed at cost – possibly 85% of AWP or some other determined costs85% of AWP or some other determined costs

• OIG & Medicare will determine an add-on amount to OIG & Medicare will determine an add-on amount to the composite rate for the average margin from the composite rate for the average margin from medications based on the following:medications based on the following: 2004 utilization of medications per treatment2004 utilization of medications per treatment Cost of Medications – sources pharmaceutical companies Cost of Medications – sources pharmaceutical companies

and audit submission by providersand audit submission by providers Amount of margin for these medications based on average Amount of margin for these medications based on average

utilizationutilization

Medicare Changes in Reimbursement Medicare Changes in Reimbursement starting in 2005 Support Home Dialysis starting in 2005 Support Home Dialysis TherapiesTherapies

• Home dialysis patients – utilize fewer medications Home dialysis patients – utilize fewer medications and under the current reimbursement scheme receive and under the current reimbursement scheme receive less margin from the medicationsless margin from the medications MedPAC reports show that the composite rate without the MedPAC reports show that the composite rate without the

average amount of medications administered looses moneyaverage amount of medications administered looses money

• Under the new reimbursement rate the home patient Under the new reimbursement rate the home patient will receive the add on to the composite rate for the will receive the add on to the composite rate for the average margin per treatment based on the average average margin per treatment based on the average amount of drug administeredamount of drug administered

Social Security Disability Social Security Disability Opportunities for PatientsOpportunities for Patients

• Trial Work PeriodsTrial Work Periods Disabled Beneficiaries are able to work 9 “trial” months Disabled Beneficiaries are able to work 9 “trial” months

every 5 years – these months are only used when the every 5 years – these months are only used when the income exceeds $580income exceeds $580

• Impairment related work expenses (IRWE), include Impairment related work expenses (IRWE), include the costs to have aides for home dialysis, will be the costs to have aides for home dialysis, will be deducted from the patient’s income when calculating deducted from the patient’s income when calculating incomeincome After IRWE deductions patients can earn up to $810 per After IRWE deductions patients can earn up to $810 per

month in 2004 ($1350 if legally blind) before disability month in 2004 ($1350 if legally blind) before disability payments will ceasepayments will cease

Medicaid Buy-InMedicaid Buy-In

• ““Ticket to Work” & “Work Incentives Ticket to Work” & “Work Incentives Improvement Act” Improvement Act” Allows people with disabilities to have more Allows people with disabilities to have more

income than non-working disabled individuals and income than non-working disabled individuals and still qualify for Medicaid benefits. still qualify for Medicaid benefits.

Aides with Commercial InsuranceAides with Commercial Insurance

• During the coordination period some During the coordination period some commercial insurance companies may pay commercial insurance companies may pay for an aide to assist the patient. for an aide to assist the patient.

• Have the patient check with their insurance Have the patient check with their insurance provider provider

QuestionsQuestions

The End The End