Medicare Basics for the New TFC

1. Medicare Basics for the New TFC

2. Why do we need Medicare Certification? • Reimbursement of costs via the Medicare Cost Report • Most commercial insurance carriers require their members to utilize Medicare certified transplant centers or no coverage is provided for the transplant. • All transplant Centers of Excellence Networks (Aetna, BCBS, etc) require member centers to be Medicare certified to participate. • Medicare will not cover a transplant performed in a non-Medicare certified transplant center. • Medicare recipients must have their transplants in a Medicare certified transplant center in order to qualify for coverage of immunosuppressives under Medicare Part B and to receive long-term protection for the living donor. (c) 2017 Transplant Solutions, LLC

3. Who ‘Owns’ the Transplant Program? • Transplantation is a hospital-based program, therefore, the hospital where the transplant program is located ‘owns’ the transplant program(s). • The hospital is fully-responsible for all activities that take place within the transplant program(s). (c) 2017 Transplant Solutions, LLC

4. The Transplant Program Workload Patient Populations Patients Evaluated Patients Re Evaluated Patients on the Waitlist Living Donors Evaluated Reimbursement Charged to Pre-Tx OACC: Reimbursement for these services is primarily via the Medicare Cost Report Referrals Build Waitlist Inpatient Transplant Reimbursement from the Recipient’s Insurance Transplants performed each year TX Post-Transplant and Post Donation Follow-Up Post-Tx Outpatient Clinic Reimbursement is from the recipient’s insurance Post-Tx Svcs (c) 2017 Transplant Solutions, LLC

5. Medicare Coverage for Transplant Services • Rooted 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 kidney transplants in the U.S. (c) 2017 Transplant Solutions, LLC

6. Evaluation or Treatment Evaluation is GENERALLY NOT a Billable Service: • Evaluation is a YES or NO decision making process and is not Patient Care • To Bill a Service Must be either Diagnosis or Treatment • To Bill for Technical Services, the Physician Service Must be Billable (c) 2017 Transplant Solutions, LLC

7. Medicare Patient – Non Renal • Under the Medicare program, a non-renal patient for registration and billing purposes is Medicare due to: • Age • Social Security Disability • IF the patient does NOT meet one of these definitions, then the patient is a NON Medicare Patient, and the fun begins. (c) 2017 Transplant Solutions, LLC

8. Medicare Patient – Non Renal The general rule is that a Non Renal patient either has Medicare or does not have Medicare. • If NON Medicare, bill the payer for the patient and or the patient based on the contract with the payer or patient (c) 2017 Transplant Solutions, LLC

9. Pre-Transplant Evaluation: Physician Services - Non Renal • If the patient is Medicare, physician evaluation is billed to the transplant center and paid at a negotiated percentage of the Medicare fee schedule, preferably 100% • If the patient is Non Medicare, the payer or patient is billed at the contracted amount (c) 2017 Transplant Solutions, LLC

10. Medicare Patient - Kidney • Under the ESRD program, a patient for registration and billing purposes has three phases: • Pre-entitlement • Entitlement • Medicare Patient (Medicare either primary or secondary) Please Note: If a patient is working or has a work history, they are probably going to be a Medicare Beneficiary. • IF the patient is NOT in one of these three phases, then the patient is a NON Medicare Patient. (Probably around 5% of the population.) (c) 2017 Transplant Solutions, LLC

11. Medicare Patient - Kidney • Pre-entitlement: This is the period when services are furnished after the patient has been determined to be eligible for Medicare under ESRD regulations, but prior to such patient’s actual Medicare entitlement (patient has not begun treatment for ESRD and/or has not applied for Medicare). • Entitlement: This is the period that begins when the patient actually begins treatment for ESRD and files an application for benefits (patient is assumed to qualify for Medicare and should be assumed to be Medicare). • Medicare Beneficiary: The patient is enrolled in the Medicare system (c) 2017 Transplant Solutions, LLC

12. Medicare Entitlement An individual under age 65 is entitled to Medicare hospital insurance benefits if all of the following conditions are met: • (1) he or she is medically determined to have ESRD; • (2) he or she is either (i) fully or currently insured under the social security program or would be fully or currently insured if his or her employment (after 1936) as defined under the Railroad Retirement Act were considered employment under the Social Security Act; (ii) entitled to monthly social security or Railroad Retirement benefits or (iii) the spouse or a dependent child of a person who meets the requirements of (i) and (ii) above; • (3) he or she has filed an application for Medicare Part A; and • (4) he or she has satisfied the waiting period. (c) 2017 Transplant Solutions, LLC

13. Dual ESRD Entitlement • If Medicare was the primary payer prior to the onset of End Stage Renal Disease, Medicare will continue to pay primary during the 30-month coordination period. • However, if Medicare was secondary prior to the onset of End Stage Renal Disease, it will continue to pay secondary until the 30-month coordination period has expired. • After the 30-month coordination period has expired, Medicare will pay primary regardless of the patient’s employment status. (c) 2017 Transplant Solutions, LLC

14. Trumps • If Medicare due to ESRD, prior to group insurance, Medicare remains primary-NO COB ESRD trumps Disability • if disabled, then ESRD; ESRD rules apply Disabled and group insurance coverage • if disabled, then ESRD; COB rules • if ESRD, then disabled; ESRD rules apply (c) 2017 Transplant Solutions, LLC

15. Medicare Patient - Kidney Medicare Patient • In 30 month Coordination of Benefits Period, bill the insurance company • Do NOT bill the patient for deductibles or co insurance Non Medicare Patient • Bill the insurance company or the patient based on contract with patient (c) 2017 Transplant Solutions, LLC

16. Retroactivity The patient has 1 year from the ESRD “Entitling” event to apply for Benefits. The benefits are retroactive to the first of the month of the Entitling event. (c) 2017 Transplant Solutions, LLC

17. Pre-Transplant Evaluation and Re-Evaluation, Patient is Medicare Primary • No payer is billed, the bill is dropped, “logged” for the Cost Report and written off • THIS IS FOR ALL ORGANS (c) 2017 Transplant Solutions, LLC

18. Pre-Transplant Evaluation and Re-Evaluation, Physician Services - Renal • If the patient is considered Medicare (see the three phases defined in slide # 12), physician evaluation is billed to the transplant center and paid at a negotiated percentage of the Medicare fee schedule, preferably 100% • If the patient is NON Medicare, bill the payer or patient based on contracted rate (c) 2017 Transplant Solutions, LLC

19. Paired Donation Process The Hospital process is basically the same as if the donor were being utilized locally. Generally, the donor bill is logged as before, then donor bill is reduced to cost utilizing an agreed upon formula and billed to the transplant center for payment. The Physicians billing is the same unless the recipients insurance is a Global, then the Transplant Center is billed for payment. (c) 2017 Transplant Solutions, LLC

20. The Transplant Event The Hospital Bills the appropriate Primary Payer for the patient and bills the patient based on their contract with their payer. The Physician Transplant team bills the Primary Payer or the Hospital and bills the patient based on their contract with the payer. (c) 2017 Transplant Solutions, LLC

21. Post - Transplant The Hospital and Physicians and other providers bill the payer and the patient based on their contract with their payer. (c) 2017 Transplant Solutions, LLC

22. Recipient & Living Donor Billing Issues • Patient & Living Donor Identification & Registration • Evaluation Services Review & Approval • Reimbursement Rate for Evaluation Services-Physician and Other Outside Providers • Billing for the Transplant Admission-Recipients vs. Living Donors • Billing for Recipient Post-Transplant Services • Billing for Donation-Related Living Donor Complications & ‘Well Baby’ Visits (c) 2017 Transplant Solutions, LLC

23. Medicare Advantage Plans and Transplant Services • A patient with a MA plan as primary does not count as a Medicare transplant for Cost Reporting purposes • MA plans are required to pay for organ acquisition-may need specific language in the MA contract, though (c) 2017 Transplant Solutions, LLC

24. The Medicare Cost Report: The Financial Lifeline of the Transplant Center • Helps establish the Standard Acquisition Charge (SAC) • Reimburses the Hospital for Medicare’s share of pre-transplant costs including: recipient & living donor evaluation services, staff salaries, overhead, & benefits, and space utilization • And the inpatient admission for the living donor nephrectomy surgery • And facilitates the Medicare Secondary Payer Review (c) 2017 Transplant Solutions, LLC

25. The Medicare Cost Report: Allowable Costs • Tissue Typing/HLA Costs • Recipient and Living Donor Evaluation Costs • Salary & Benefits for Pre-Transplant Staff Hours • Professional meetings & memberships • OPO Organ Acquisition Costs • OPTN New Patient Registration Fees • Square footage for pre-transplant space • Medical & Surgical Administrative Directorship Costs • Some Consultant fees (c) 2017 Transplant Solutions, LLC

26. Costs Not Allowed • Medical interventions for the donor or recipient during evaluation (i.e., polyp removal during a colonoscopy) • Travel & housing for the living donor • Post-transplant care of the recipient • Routine post-transplant care of the living donor • Salary & benefits for post-transplant staff hours • Fees associated with kidney paired-donation registries such as NKR or APD (c) 2017 Transplant Solutions, LLC

27. Medicare Secondary Payer Review “A provider must submit a bill to Medicare when payment from the primary payer is insufficient to cover the entire cost of a transplant including both the DRG and organ acquisition costs.” Clarification of MSP Policy for Organ Transplants Torris Smith, Associate Regional Administrator Division of Medicare Financial Management & FFSO June 29, 2008 (c) 2017 Transplant Solutions, LLC

28. Medicare Coverage of Immunos-Part B vs. Part D • Part B Coverage 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 (c) 2017 Transplant Solutions, LLC

29. Medicare Coverage of Immunos-Part B vs. Part D Part D Coverage of Immunos are subject to all Part D plan provisions including: • Prior authorizations • Formulary limitations • Annual maximum • The Donut Hole • Plan provisions including deductible/copay/co-insurance (c) 2017 Transplant Solutions, LLC

30. 10 Iron Rules of Medicare* • Just because it has a code, that doesn’t mean it’s covered. • Just because it’s covered, that doesn’t mean you can bill for it. • Just because you can bill for it, that doesn’t mean you’ll get paid for it. • Just because you’ve been paid for it, that doesn’t mean you can keep the money. • Just because you’ve been paid once, that doesn’t mean you’ll get paid again. • Just because you got paid in one state doesn’t mean you’ll get paid in another state. • You’ll never know all the rules. • Not knowing the rules can land you in the slammer. • There’s always some schlemiel who doesn’t get the message. • There’s always some schmendrik (jerk) who gets the message and ignores it. *Larry Oday, JD Vince & Elkins Modern Healthcare, June 19, 2000 (c) 2017 Transplant Solutions, LLC

31. Questions? (c) 2017 Transplant Solutions, LLC