Living Donation from a Financial Per$pective

Transcription

1 Living Donation from a Financial Per$pective Andrea Tietjen, CPA, MBA Objective Why is financial clearance important to the process of living donation? How are donor costs handled? 1

2 Financial Coordination Basics Conflicting Objectives Transplant Volume Appropriateness of candidates both long and short term Transplant Outcomes 2

3 Critical Elements to Donation MD SW RN IDLA FC The Financial Coordinator Financial Coordinator Verifies Insurance, Dialysis Start Date, Employment, COB, etc. Contacts Insurance Case Management Refers Case to Contracting Communicates with Patient Updates Insurance Carrier 3

4 Critical Elements to Donation The donor gives Critical Elements to Donation The living donor team assesses the donor and gives care throughout the continuum. 4

5 Laying the foundation SW MD RN IDLA FC Importance of a foundation FC 5

6 Welcome to... Scoreboard X O Click Here if X Wins Click Here if O Wins 6

7 1 How much does a living donor transplant cost? Question 1 1 It s a formula. Answer 1 7

8 Formula for Transplant Cost Pre-Transplant Costs of Recipient & Donor In-Patient Costs of Recipient & Donor Post-Transplant Care for Managed Care Contracts Can include donor complications KPD Cost of Transplantation Pre-transplant donor costs Registry fees Inpatient costs- both facility and provider for donor nephrectomy Transportation of donor organ Donor post management Donor complications 8

9 2 Who pays for what and why? Question 2 2 Recipient s Insurance pays for costs of donor evaluation and donation. Follows Medicare guidelines Most payors follow this as well Answer 2 9

10 However, some commercial payors do try to require donor insurance assumes responsibility. transplant center needs to assess and address before case can proceed. 3 How does the billing work for the donor? Question 3 10

11 Billing for Living Donation Who Pays for What? What is covered? Tests to determine suitability for donation Treatment is not covered Pre-donation work-up is not a blank check Education of Process Donors Providers Internal External Billing for Living Donation Billing for donor workup How will bills be paid? How and when is the facility reimbursed? How are the providers reimbursed? Does your facility use a billing letter/agreement? 11

12 4 And what about donor complications? Question 4 4 Centers need to know in advance: Who pays? When coverage ends? How is claim submitted? Answer 4 12

13 5 What should be assessed by the transplant center and when? Question Does recipient have coverage for both recipient and donor charges? 2. If not, can recipient afford costs? Answer 5 13

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15 Multi-disciplinary A Coordinated team must Process periodically review throughout the phases of transplant/donation: Candidate suitability Medical Psychosocial Insurance coverage Contract inclusions/exclusions Technical & professional claims billing Outcomes Complications Issues 15

16 6 What else should centers know about living donation finances? Question 6 Negotiated Case Rates Fee for Service Global Rate Contractual Agreements Donor Travel Follow-up/Complications Reimbursement Reconciliation Timely and accurate payment Provider reimbursement Answer 6 16

17 7 What is different for paired exchange? Question 7 7 Donor costs should follow the matched recipient Answer 7 17

18 Complexities of KPD Finances Your recipient Facility charges for donor Donor provider charges Your donor giving to another center OPO Recipi ent at Does your recipient have coverage for a donor from another center? Is your donor and your providers covered by a recipient from another center? Transport Donors o Recipients Not only requires clinical but also insurance coordination between multiple centers DA KM KI DM JC BM DS MM A AB o o B A AB FM MI CM CC PM BG JW o A AB o o B A 54 Type 2 DM predialysis Cr:4.3,Cardiac cleared. Defib in place EF 59% 59 HPT, 1 vessel CABG 10/10, Cardiac cleared HD, ASA/Plavix 51 2 nd tsp, predialysis, Cr 4.4, Type 2 DM, 2 coronary stents, Cardiac cleared, Insulin pump, Sleep apnea 38, SLE, Not hypercoagulable, HD Twice a Week. 58, Type 2 DM, 5 vessel CABG, Gastric bypass, NST 10/10 wnl, Cardiac cleared, recent line sepsis treated with Vanco 3.5 gms 47, HPT nephrosclerosis, Hep C+, Hep B Ag+ HD dependent 62, Type 2 DM, Oral meds, Asthma, Hx of Sleep apnea, NST 8/10 nl, TEE OK AB Waitlist Recipient 53, Type 2 DM, PD, CAD Stent 5/10, Cardiac cleared, Hx colon cancer. 18

19 Complexities of KPD Finances 8 Are there other considerations with Paired Exchange? Question 8 19

20 8 Yes Answer 8 Absence of formal/clear guidelines and regulations Regional differences in OPO participation Center differences in donor policies Some access donor insurance Cases can become financially complex Could impose financial liability on: Recipient Donor Provider Transplant center KPD extremely time consuming Are centers capturing true cost? Medicare Cost Report Implications KPD and the Medicare Cost Report 20

21 KPD and the Medicare Cost Report KPD and the Medicare Cost Report 21

22 9 What can happen if centers do not properly confirm insurance? Question 9 9 Financial Liability Recipient Donor costs Facility Providers Legal Liability Medicare compliance Billing practices Program Reputation Could trigger.. Loss of accreditation; fines, sanctions, legal fees, etc. Answer 9 22

23 Paired Exchange Case Review Pair A Recipient NJ Donor VA Recipient Insurance Medicare NJ Medicaid Recipient has no secondary coverage for Out of State Donor providers. Pair B Recipient - East Coast Donor West Coast Recipient Insurance Blue Cross Blue Shield Aetna Pre-cert needed for provider charges. What happens if donor providers are not in network? Payor involvement required True Cost of Living Donation Recipient Work-up = $$$ Donor Work-up = $$ Cost of successful transplant with happy and satisfied recipients and donors Priceless 23

24 Questions? Me Andrea Tietjen Barnabas Health Renal & Pancreas Transplant Director of Transplant Finance and Data