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

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The January 2005 Regulatory Change

• What does it mean to your center?
• What does it mean to the industry?

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What Changed?

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

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Regulatory Food Chain

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

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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.

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Potential Living Donor Billing

• Evaluation
• vs.
• Patient Care

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Patient Billing Non-Renal Solid Organ
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Pre-Transplant EvaluationESRD Rules

• Two primary areas of concern
• Potential Living Donor Billing
• Potential Recipient Billing

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

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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!!!

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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.

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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.

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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.

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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.

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Potential Recipient Billing

• Pre-transplant evaluation
• vs.
• Patient Care

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Recipient Pre-Transplant Evaluation

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

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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.

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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.

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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.

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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!)

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Transplant

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

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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.

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Post-Transplant Care

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

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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.

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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.

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Pancreas

• Pancreas evaluation rules follows Kidney
  evaluation rules.

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NON Renal Transplant Other Than Pancreas

• Medicare Beneficiary
• Other Third Party Payers or Self Pay

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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

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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.

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Non Renal Transplant

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

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Post-Transplant Care

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

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QUESTIONS PLEASE