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Donor and Recipient Billing Issues

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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 – PowerPoint PPT presentation

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Title: Donor and Recipient Billing Issues


1
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

2
The January 2005 Regulatory Change
  • What does it mean to your center?
  • What does it mean to the industry?

3
What Changed?
  • CMS removed the word Kidney and inserted the
    word Organ in the Provider Reimbursement
    Manual. (PRM I, Section 2770 2775.4)

4
Regulatory Food Chain
  • Law
  • Regulation
  • Manual
  • The Provider Reimbursement Manual is considered
    interpretative guidelines for applicable Law
    and Regulation.

5
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.

6
Potential Living Donor Billing
  • Evaluation
  • vs.
  • Patient Care

7
Patient Billing Non-Renal Solid Organ
8
Pre-Transplant EvaluationESRD Rules
  • Two primary areas of concern
  • Potential Living Donor Billing
  • Potential Recipient Billing

9
Patient Billing Renal Organ
10
Current Billing Recommendations for external
Pairs/Chains
11
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.

12
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!!!

13
NEVER TO BE BILLED
  • If you must contact the Donors Insurance Company
    to obtain a denial because of Recipients
    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.

14
Recipient Status!
  • Please remember, we will not know the recipients
    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.

15
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.

16
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.

17
Potential Recipient Billing
  • Pre-transplant evaluation
  • vs.
  • Patient Care

18
Recipient Pre-Transplant Evaluation
  • A Medicare Entitled ESRD patient is NOT to be
    billed for pre-transplant evaluation services!!!

19
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.

20
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 Beneficiarys 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.

21
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.

22
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!)

23
Transplant
  • Bill the appropriate payer at the time of
    Transplant Admission.

24
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.

25
Post-Transplant Care
  • The post-transplant care of the Recipient is to
    be billed to the patients appropriate primary
    payer.

26
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.

27
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.

28
Pancreas
  • Pancreas evaluation rules follows Kidney
    evaluation rules.

29
NON Renal Transplant Other Than Pancreas
  • Medicare Beneficiary
  • Other Third Party Payers or Self Pay

30
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

31
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.

32
Non Renal Transplant
  • At the time of transplant, the appropriate
    primary payer should be billed.

33
Post-Transplant Care
  • Post-Transplant Care is billed to the appropriate
    payer.

34
QUESTIONS PLEASE
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