Billing Challenges for Living Donation Services Pre-Transplant Thru Post-Transplant 2016 Annual Workshop for Transplant Financial Coordinators
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1 Billing Challenges for Living Donation Services Pre-Transplant Thru Post-Transplant 2016 Annual Workshop for Transplant Financial Coordinators (c) 2016 Transplant Solutions, LLC 1
2 1. Law 2. Regulation Regulatory Food Chain 3. The Manual-The Provider Reimbursement Manual is considered interpretative guidelines for applicable Law and Regulation. (c) 2016 Transplant Solutions, LLC 2
3 Medicare Coverage for Transplant Services Based in the ESRD Act of 1972 Currently provides coverage for kidney, pancreas, liver, heart, lung, & small bowel transplants. Beneficiaries can qualify for Medicare via: ESRD Social Security Disability Age Pays for the majority of transplants in the U.S. (c) 2016 Transplant Solutions, LLC 3
4 January 2005 Regulatory Change CMS removed the word Kidney and inserted the word Organ in the Provider Reimbursement Manual. (PRM I, Section ) Medicare regulations for evaluation services for recipients and living donors now apply to all Medicare beneficiaries regardless of organ type. (c) 2016 Transplant Solutions, LLC 4
5 Section 1881 (d) of the Social Security Act (d) Notwithstanding any provision to the contrary in section 226, any individual who donates a kidney for transplant surgery shall be entitled to benefits under parts A and B of this title with respect to such donation. Reimbursement for the reasonable expenses incurred by such an individual with respect to a kidney donation shall be made (without regard to the deductible, premium, and coinsurance provisions of this title), in such manner as may be prescribed by the Secretary in regulations, for all reasonable preparatory, operation, and postoperation recovery expenses associated with such donation, including but not limited to the expenses for which payment could be made if he were an eligible individual for purposes of parts A and B of this title without regard to this subsection. Payments for postoperation recovery expenses shall be limited to the actual period of recovery. (c) 2016 Transplant Solutions, LLC 5
6 Section 1881 (d) of the Social Security Act Nowhere does this stipulate that: The recipient must be a Medicare Beneficiary. That commercial health insurance contract requirements supersede this Section. Who would you rather be out of compliance with? (c) 2016 Transplant Solutions, LLC 6
7 Which means There is no provision in Regulation for a Live Donor to be billed for any donation-related service such as: Evaluation (including routine testing) The inpatient stay for the donation, Post donation follow-up Complications due to the donation (c) 2016 Transplant Solutions, LLC 7
8 Evaluation vs. Treatment 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. (c) 2016 Transplant Solutions, LLC 8
9 Evaluation vs. Treatment 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. (c) 2016 Transplant Solutions, LLC 9
10 2011 CMS Revision-Billing for Donation-Related Complications CMS issued two notices in 2011 with regards to billing for live donor post-kidney complications. Medicare Benefit Policy Manual (100-02) : This relates to the specific policy changes. BP.pdf Medicare Claims Processing Manual (100-04): This relates to the specific billing requirements. 4CP.pdf (c) 2016 Transplant Solutions, LLC 10
11 2011 CMS Revision-Billing for Donation-Related Complications In 2011 CMS issued clarification regarding the billing of post donor complications. Specifically, the language is modified in the Medicare Benefit Policy Manual (100-02), Chapter 11, Section One item of note is the treatment of post discharge donor complications. The revised language states: Complications that arise after the date of the donor's discharge will be billed under the recipient's health insurance claim number. This is true of both facility cost and physician services. Billings for donor complications will be reviewed. In the past, transplant facilities have included the facility charges for post discharge donor complications within organ acquisition on the cost report. Effective November 28, 2011, these should be billed under the recipient's Medicare number and no longer claimed as organ acquisition. (c) 2016 Transplant Solutions, LLC 11
12 2011 CMS Revision-Billing for Donation-Related Complications When submitting claims for donation-related complications be sure to: Bill the recipient s insurance directly Use relationship code 39/11-Organ Donor Use Occurrence Code 36 on Medicare claims to process without deductible or co-insurance Use Modifier Q3 (c) 2016 Transplant Solutions, LLC 12
13 CMS Clarification- Living Donor Complications It is the policy folks interpretation and understanding that a recipient would have both Medicare part A and B at the time of transplant for Medicare to cover Part A and B related services. The donor complication would be covered even if the recipient is no longer covered by Medicare part A or B; meaning after the 36 month of successful transplant, or if the recipient is deceased. David Santana Health Insurance Specialist Centers for Medicare & Medicaid Services May 1, 2013 (c) 2016 Transplant Solutions, LLC 13
14 CMS Clarification-Routine Living Donor Follow-Up Services The UNOS required 6 month, 1 year and 2 year visits, although required by UNOS, are not considered routine donor follow-up care, pursuant to the Medicare Benefit Policy Manual, Chapter 11, section As such the UNOS required follow-up visits would not be allowable nor be reported as organ acquisition costs on the Medicare Cost Report and should not be billed to the recipients health insurance number. The UNOS Living Donation document states Transplant centers must send follow-up data to UNOS on living donors for two years after the donation surgery. It is important to ask your transplant team about payment for follow-up care. The center and the recipient s insurance may not cover these costs. (c) 2016 Transplant Solutions, LLC 14
15 CMS Clarification- Routine Living Donor Follow-Up The hospital may include the costs as cost of doing business. The services they render may be classified as normal ancillary services and included in their appropriate cost centers on the cost report; however, they are not reimbursable as organ acquisition costs, and they may not be billed to Medicare. The cost to the transplant center is costs they incur as a participant in transplantation and as required by UNOS. Deanna Rhodes Deputy Division Director Division of Cost Reporting Centers for Medicare and Medicaid Services 8/16/13 (c) 2016 Transplant Solutions, LLC 15
16 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. (c) 2016 Transplant Solutions, LLC 16
17 CMS Clarification 2014-Coverage of Living Donor Complications by MA Plans Regulations at 42 CFR 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). (c) 2016 Transplant Solutions, LLC 17
18 CMS Clarification 2014-Coverage of Living Donor Complications by MA Plans Moreover, Original Medicare Benefit Policy Manual Chapter 11 Section 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. Susan S. Radke, Centers for Medicare & Medicaid Services Division of Policy, Analysis, and Planning MCAG/CPC September 17, 2014 (c) 2016 Transplant Solutions, LLC 18
19 CMS Clarification 2014-Coverage of Living Donor Complications by MA Plans 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. Susan S. Radke, Centers for Medicare & Medicaid Services Division of Policy, Analysis, and Planning MCAG/CPC September 17, 2014 (c) 2016 Transplant Solutions, LLC 19
20 CMS Clarification 2014-Coverage of Living Donor Complications by MA Plans 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 (c) 2016 Transplant Solutions, LLC 20
21 CMS Clarification 2014-Coverage of Living Donor Complications by MA Plans 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. Susan S. Radke, Centers for Medicare & Medicaid Services Division of Policy, Analysis, and Planning MCAG/CPC September 18, 2014 (c) 2016 Transplant Solutions, LLC 21
22 Medicare Cost Report-Allowable Costs for the Living Donor Tissue Typing/HLA Costs Living Donor Evaluation Costs-Hospital and Professional OPTN New Patient Registration Fees Inpatient stay for the donation surgery (c) 2016 Transplant Solutions, LLC 22
23 Costs Not Allowed Medical interventions for the donor during evaluation (i.e., polyp removal during a colonoscopy) Professional fees associated with the donation surgery (surgeon, anesthesia, etc) Travel and housing for the living donor Routine post-transplant care of the living donor Costs for donation-related complications Registration fees for paired-exchange programs such as NKR or APD. (c) 2016 Transplant Solutions, LLC 23
24 Living Donor Services-Who Gets Billed? Live Donor Transplant Services Hospital Facility Services Inpatient and Outpatient Ancillary EVAL Pre-TX Medical Mgt. TX Episode Post TX Donor OACC* Insurance OACC Recipient's Insurance** Physician Services EVAL Pre-TX Medical Mgt TX Episode Post TX Recipient's Insurance Donor OACC* Insurance *OACC=Organ Acquisition Cost Center **Donation-related complications only with supporting documentation in the medical record. Recipient's Insurance** Live Donor Transplant Services - Non Renal Organs Hospital Facility Services Inpatient and Outpatient Ancillary EVAL Pre-TX Medical Mgt. TX Episode Post TX Donor OACC* Insurance OACC OACC** Physician Services EVAL Pre-TX Medical Mgt TX Episode Post TX Recipient's Insurance Donor OACC* Insurance Recipient's Insurance** (c) 2016 Transplant Solutions, LLC 24
25 Remember If you must contact the donor s insurance carrier to obtain a denial, because of the recipient s insurance requirements, please 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 and the evaluation ended. (c) 2016 Transplant Solutions, LLC 25
26 Never forget the Golden Rules Neither the donor, nor the donor s own insurance is ever billed for any donation-related services. Never. Never. Never. And A donor is a donor is a donor (c) 2016 Transplant Solutions, LLC 26
27 Questions? Laura J. Aguiar, Principal/Managing Partner Transplant Solutions, LLC (c) 2016 Transplant Solutions, LLC 27
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