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Donor and Recipient Billing Issues. Who Gets Billed For What When William P. Vaughan, Principal Health Systems Concepts, Inc. And Rebecca Dugan, Financial Coordinator Integris Baptist Medical Center TFCA Workshop October 21 st - 23 rd , 2009. The January 2005 Regulatory Change.

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donor and recipient billing issues

Donor and Recipient Billing Issues

Who Gets Billed For What When

William P. Vaughan, Principal

Health Systems Concepts, Inc.

And

Rebecca Dugan, Financial Coordinator

Integris Baptist Medical Center

TFCA Workshop

October 21st - 23rd , 2009

the january 2005 regulatory change
The January 2005 Regulatory Change

What does it mean to your center?

What does it mean to the industry?

what changed
What Changed?

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

regulatory food chain
Regulatory Food Chain
  • Law
  • Regulation
  • Manual

The Provider Reimbursement Manual is considered “interpretative guidelines” for applicable Law and Regulation.

pre transplant evaluation non renal rules
Pre Transplant EvaluationNon Renal Rules
  • Regardless of who the payer is, when an evaluation service is billed it MUST be logged for inclusion on the Cost Report.
  • If the Potential Recipient Has Medicare Primary, NEITHER Medicare or the Patient is to be billed for the evaluation service.
  • If the Potential Recipient has a Primary Payer other than Medicare, bill the Payer based on the Contract with the payer.
potential living donor billing
Potential Living Donor Billing

Evaluation

vs.

Patient Care

pre transplant evaluation esrd rules
Pre-Transplant EvaluationESRD Rules

Two primary areas of concern:

  • Potential Living Donor Billing
  • Potential Recipient Billing
what does the law say
What Does the Law Say?
  • 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 post operation 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 post operation recovery expenses shall be limited to the actual period of recovery.
potential living donor evaluation
Potential Living Donor Evaluation

The potential Living Donor for a Medicare Entitled ESRD recipient is NEVER to be billed for pre-transplant evaluation services.

NEVER!!!

never to be billed
NEVER TO BE BILLED

If you must contact the Donor’s Insurance Company to obtain a denial because of Recipient’s insurance requirements, do not do it without written permission of the Donor. The Donor may not want their insurance to know. If the Donor says no, the Donor would then need to be deemed not appropriate.

recipient status
Recipient Status!

Please remember, we will not know the recipient’s Medicare Status or Entitlement Status until the time of Transplant. And then to complicate matters, if the Transplant is the Entitling event, the recipient has a year to apply for Medicare.

potential living donor patient care
Potential Living Donor Patient Care

If a Medical Condition is discovered that needs to be taken care of during the Donor Evaluation process, taking care of the condition is the responsibility of the Donor.

billing for physician evaluation services
Billing for Physician Evaluation Services

Physician pre-transplant/donation evaluation services for potential recipients that are Medicare Entitled and their potential Living Donors are to be billed to the Transplant Center regardless of who is primary at the time of evaluation .

We find NO exceptions in the Regulations.

potential recipient billing
Potential Recipient Billing

Pre-transplant evaluation

vs.

Patient Care

recipient pre transplant evaluation
Recipient Pre-Transplant Evaluation

A Medicare Entitled ESRD patient is NOT to be billed for pre-transplant evaluation services!!!

easy way to bill for esrd recipient pre transplant evaluation services
Easy Way to Bill for ESRD Recipient Pre-Transplant Evaluation Services

Make the transplant center the guarantor or insurance company. Write off accounts receivable to a Medicare Contractual Allowance.

Ensure that neither the potential recipient nor the payer for the potential recipient is billed for pre-transplant evaluation services.

hard way to bill for esrd recipient pre transplant evaluation services
Hard Way to Bill for ESRD Recipient Pre-Transplant Evaluation Services

When an ESRD potential recipient is in the Coordination of Benefits period, it is permissible to bill the Beneficiary’s primary payer for evaluation services.

It is not permissible to bill the patient for deductibles and/or coinsurance.

The amounts collected must be accounted for because, if Medicare pays for the Kidney transplant, the amounts collected for evaluation services must be offset on Worksheet D-6, Part III, Line 58.

potential recipient patient care
Potential Recipient Patient Care

If a Medical Condition is discovered that needs to be taken care of during the Recipient Evaluation process, taking care of the condition is the responsibility of the Recipient and not the Transplant Center.

remember
REMEMBER!

PATIENT THAT HAS EMPLOYER

GROUP INSURANCE AND IS MEDICARE

ENTITLED AND/OR HAS THEIR MEDICARE

CARD IS STILL A MEDICARE BENEFICIARY!!!

THEY ARE NOT A “NON-MEDICARE” PATIENT!

(AND YES, I AM SHOUTING!)

transplant
Transplant

Bill the appropriate payer at the time of Transplant Admission.

living donor kidney donation
Living Donor Kidney Donation

The Transplant Center is financially responsible for the Inpatient stay of the Living Donor.

The bill for the inpatient stay is NOT to be billed to any payer (Donor or Recipient).

The transplant center should be the guarantor or the “insurance company” and the accounts receivable should be written off to a Medicare Contractual Allowance.

post transplant care
Post-Transplant Care

The post-transplant care of the Recipient is to be billed to the patient’s appropriate primary payer.

post donation complications
Post-Donation Complications

The Transplant Center is financially responsible for hospital services related to donation-related complications of the Living Donor.

The bill(s) for related in or outpatient services is NOT to be billed to any payer (Donor or Recipient). Physician Services are to be billed to the Recipients Payer.

The transplant center should be the guarantor or the “insurance company” and the accounts receivable should be written off to a Medicare Contractual Allowance.

unos post donation requirement
UNOS Post-Donation Requirement

A transplant center is only financially responsible for complications as a result of donation.

A transplant center cannot require a Living Donor to see a physician or have testing done to meet UNOS requirements.

If a center wishes to pay for those services it may. However doing so may have Compliance implications, so please check with your legal counsel.

pancreas
Pancreas

Pancreas evaluation rules follows Kidney evaluation rules.

non renal transplant other than pancreas
NON Renal Transplant Other Than Pancreas

Medicare Beneficiary

Other Third Party Payers or Self Pay

evaluation services
Evaluation Services

Medicare Primary –

Hospital Services – The Transplant Center is financially responsible.

Physician Services – Bill Transplant Center

Other Third Party Payers or Self Pay – Bill the patient or the payer for the patient for Transplant Center services and bill the Transplant Center for Physician Services

side issue
Side Issue

The Medicare Cost Reporting instructions indicate that we must account for ALL pre-transplant evaluation services for ALL potential recipients or live donors.

This is true even if the patients payer is billed for transplant center services.

non renal transplant
Non Renal Transplant

At the time of transplant, the appropriate primary payer should be billed.

post transplant care33
Post-Transplant Care

Post-Transplant Care is billed to the appropriate payer.