a transplant potpourri: evaluation vs. treatment medicare ... · division of policy, analysis, and...

2015 Annual Workshop for

Transplant Financial Coordinators

(c) 2015 Transplant Solutions, LLC

1

A Transplant Potpourri:

Evaluation vs. Treatment

&

Medicare Advantage Plans: Is There Any

Advantage for Transplant Patients?

Where’s Bill???

(c) 2015 Transplant Solutions, LLC 2


See you next year!

Regulatory Food Chain

1. Law

2. Regulation

3. The Manual-The Provider Reimbursement

Manual is considered “interpretative

guidelines” for applicable Law and

Regulation.



• Evaluation asks whether the patient is appropriate for transplant, or living donation, right now today.

• Treatment is to ‘fix’ or correct a medical condition that is adversely impacting a patient.

These terms are not interchangeable.



• Evaluation-not billable to patient’s insurance as it lacks key components for reimbursement, diagnosis and/or treatment. Physician services are not billable if the technical component is not billable.

• Treatment-not allowable to the Organ Acquisition Cost Center(s). Remember-the OACC can’t be used to ‘fix’ a patient or living donor and make them appropriate for transplant.


January 2005 Regulatory Change

• CMS removed the word “Kidney” and inserted the word “Organ” in the Provider Reimbursement Manual. (PRM I, Section 2770 – 2775.4)

• Medicare regulations for evaluation services for recipients and living donors now apply to all Medicare beneficiaries regardless of organ type.


Evaluation vs. Treatment-Kidney Recipient

• Regardless of who the recipient’s primary payer is, the evaluation service must be logged for inclusion on the Medicare Cost Report.

• If the potential recipient has Medicare primary, neither Medicare or the patient is to be billed for any evaluation service.

• If the potential recipient has a primary payer other than Medicare, the transplant center may opt to bill the payer for hospital & ancillary services based on the Contract with the payer (subject to look-back, offset, and Social Security 1881).

• We know of nothing in regulation that allows the physician component to be billed to any payer; these are the financial responsibility of the transplant center.


Evaluation vs. Treatment-

Extra Renal Recipient • Regardless of who the recipient’s primary payer is, the

evaluation service must be logged for inclusion on the Medicare Cost Report.

• If the potential recipient has Medicare primary, neither Medicare or the patient is to be billed for any evaluation service, including deductible/copay/coins.

• If the potential recipient has a primary payer other than Medicare, the transplant center should bill the payer for hospital, ancillary, and physician services based on the Contract with the payer.

• Patient is responsible for deductible/copay/coins as required by the non-Medicare health plan.


Living Donor Evaluation Services

• The potential living donor for a Medicare Entitled

or Eligible recipient is never to be billed for pre-

transplant evaluation services.

NEVER, NEVER, NEVER!!

• If you must contact the Donor’s Insurance carrier

to obtain a denial because of recipient’s

insurance requirements, do not do so without

written permission of the donor. If the donor says

no, the donor should then need to be deemed not

appropriate for donation.


Don’t forget! • We will not really know the kidney recipient’s

Medicare Status until the time of Transplant. If

the Transplant is the entitling event, the

recipient then has a year to apply for

Medicare.

• Even if Medicare is secondary, or the patient

is in the ESRD pre-entitlement phase, the

patient is still a Medicare beneficiary. S/he is

not a ‘non-Medicare’ patient.


Where did MA Plans Come From?

• Originated with the Balanced Budget Act of 1997

• Originally known as ‘Medicare+Choice’ or Medicare ‘Part C’

• Rebranded to ‘Medicare Advantage’ Plans in 2003 as part of the Medicare Modernization Act

• MA Plans are typically PPO’s or HMO’s

• MA Plan may be capitated


Medicare Advantage

Plan Specifics

• A Medicare beneficiary who chooses to enroll in a MA plan gives up the right to have Medicare A and/or B pay for his/her services. The beneficiary must abide by all MA plan provisions as long as she/he is enrolled.

• MA plans are generally not available to beneficiaries who’s only entitlement to Medicare is ESRD.


Medicare Advantage Plan Specifics

• Beneficiary must be enrolled in Medicare Part A & Part B.

• Beneficiary must continue to pay Medicare Part B premiums.

• Beneficiary may have additional monthly premiums for the MA plan.

• MA plans generally provide coverage for prescription drugs.


Medicare Advantage Plan Specifics

• Members enrolled in a MA plan are not eligible to buy a Medicare Supplement plan to cover MA plan out of pocket expenses.

• Members who enroll in an MA plan and already have a Medicare Supplement plan cannot use that plan to cover MA out of pocket expenses.


Medicare Advantage

Plan Coverage Specifics

In general, MA plans cannot, by law,

provide less coverage than Original

Medicare.

However, the MA plans can choose to

provide that coverage in a different

manner than Original Medicare and in a

way that may actually increase the out of

pocket expense to the member.


Medicare Coverage of Immunos-

Part B vs. Part D

Part B Coverage of immunos requires:

• Patient has a Medicare covered transplant

• Performed in a Medicare certified transplant center

• Medicare Part A at the time of transplant

• Medicare Part B at the time the prescription is filled.

• Immunos paid under Part B will be paid at 80% as a medical claim


Medicare Coverage of Immunos-

Part B vs. Part D

• Part D Coverage of Immunos, which includes MA plans, are subject to all Part D plan provisions which may include:

• Prior authorizations

• Formulary limitations

• Plan provisions including deductible/copay/co-insurance

• The Donut Hole (closing by 2020)

• Annual maximum


MA Coverage of

Immunosuppressives

• Plans are increasingly limiting coverage amount of immunosuppressives to 80%, which comparable to Medicare Part B coverage.

• Patient is then responsible for the remaining 20%.

• Plan provisions should be checked carefully!


The Dis-Advantage of MA Plans for

Transplant Centers

• Patients who are enrolled in a MA plan at the time of transplant are not considered ‘Medicare’ for Cost Reporting purposes.

• Hospital contracting must ensure there is language in the MA contract specific to the payment of organ acquisition costs (preferably as defined on the hospital’s D-4).


Can the transplant hospital claim

MSPR with an MA Plan?

• Yes-if the hospital has a contract with the MA plan for transplant services, there is no ‘paid in full language’ in the contract, & there is MSPR language in the contract.

And…


Can the transplant hospital claim

MSPR with an MA Plan?

• No-The Medicare Advantage statute requires Medicare Advantage organizations to pay, and for providers that do not have contracts with a Medicare Advantage organization, to accept as payment in full, the amount that would have been paid under the original Medicare program to a non-contracting provider had it provided services to an original fee-for-service Medicare enrollee.


CMS Clarification 2014-Coverage of

Living Donor Complications by MA Plans

‘Regulations at 42 CFR §422.101 stipulate that each Medicare Advantage plan must meet the requirement to “provide coverage of, by furnishing, arranging for, or making payment for all, services that are covered by Part A and Part B of Medicare…”. Further, Chapter 4 of the Medicare Managed Care Manual specifically states in Section 30.2 page 30, under “Prohibition of Benefits for Non-enrollees”, that an “MAO may not offer as a benefit services furnished to a person other than the enrollee (unless Original Medicare specifically allows such services e.g. Original Medicare coverage of a living donor for medical complications arising from a

kidney transplant)”.


Susan S. Radke, Centers for Medicare & Medicaid Services

Division of Policy, Analysis, and Planning MCAG/CPC

September 17, 2014



“Moreover, Original Medicare Benefit Policy Manual Chapter 11 Section 140.5 states, “Instead, during the donor’s inpatient stay for the excision surgery and during any subsequent donor inpatient stays resulting from a direct complication of the organ donation, physician services are billed under Part B. They are billed in the normal manner but on the account of the recipient at 100 percent of the fee schedule. Note that services furnished to kidney donors are covered under the account of the recipient.”



September 17, 2014




“Therefore, the MA plan must provide payment of the Original Medicare service to the organ donor and in this case, the MA plan is required to pay for the care of the complications and follow up from the donation of the organ.”



September 17, 2014




We then asked what happened if…

• Recipient has changed MA plans

• Recipient has gone back to original Medicare

• MA Plan that paid for the transplant is no longer in business

• Recipient has died




“If any of these scenarios that you identify actually occur, please contact us so that we can address those specific situations. Generally, the MA plan that was covering the recipient at time of the organ donation and kidney transplant is responsible for payment, even if the recipient has gone back to original Medicare or changed plans. But, we really would need to know the specifics I each situation to make this determination.”



September 18, 2014


So, is there any Advantage in a Medicare

Advantage Plan for a Transplant Patient

or Transplant Program?



Questions?

Laura J. Aguiar, Principal/Managing Partner

Transplant Solutions, LLC

[email protected]

623-302-3136

www.TransplantSolutionsLLC.Com

mailto:[email protected]

a transplant potpourri: evaluation vs. treatment medicare ... · division of policy, analysis, and...

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