Third Party Reimbursement

1. Third Party Reimbursement Conference on Ethical and Policy Issues Related to Solid Organ Transplantation in People with HIV July, 2001 Cheryl Janov, RN, UPMC

2. The Pittsburgh Experience • 28 patients cleared by third-party payers for solid organ transplantation • 20 different insurers approved transplant • 2 patients denied access • 6 patients died while waiting an organ donor • 11 transplants occurred • 4 kidney • 7 liver

3. Pittsburgh Experience • Insurers include: • Medicare via the Hospital Notice of Noncoverage process • Medical Assistance of Kentucky • Aetna US Healthcare • Blue Cross of Alabama • Guardian • Empire Blue Cross • Blue Cross of Texas • Medical Assistance of California • Trigon Health Keeper as secondary insurer to Medicare

4. Pittsburgh experience • Insurers cont’d • Blue Cross of Utica • Blue Cross of Michigan • Blue Cross of California • United Health Care • Blue Cross of Maryland • Federal Blue Cross • Medical Assistance of New York • US Life • Coresource • Blue Cross of New Jersey • CHAMPUS under special care funds

5. Medicare Rules • Federal Register, Medicare Manuals, Local Medical Policy • No rule specifically precludes transplant for HIV positive people • When the rules are silent the local intermediaries have discretionary authority

6. Medicare Strategies • Issue individual HNN- “Medicare has no guidelines” • PRO review at 2 levels • Last appeal is to Administrative Law Judge • Request local coverage policy • Request national coverage decision • “At risk”

7. Investigational/Experimental • General acceptance as effective and proven • Safe and effective: • Mortality • How often performed, where performed, success or failure of the procedure • Reputation of centers and MD who are performing and their record in related areas • Long term prognosis and lessons derived from related procedures • Extent that the procedure and related areas in medicine have developed rapidly

8. Advocacy: Essential Elements • Support • safe and effective • Not systemic infection/disease based upon lack of opportunistic infection, projected survival with triple therapy, stable CD4 and viral loads • Enclose articles from refereed journals and protocol of the center

9. Advocacy: Essential Elements • Provide specific patient details that emphasize transplant is only viable therapy • Physician letter of advocacy or physician signature • Obtain written copy of appeal process • Be Persistent!!!

10. Advocacy: Access to Care • The battle will either be fought at the referral stage or following evaluation • Provide center advocacy early in the referral process • Inability or difficulty obtaining insurance authorization for evaluation resulted in delays of care of 1 year or more • 6 deaths while waiting

11. Suggestions • Maintain and update list of insurers approving transplant among the centers • Regular exchange of reimbursement information among centers • Consider reimbursement packet which contains bibliography, sample letters and strategies