Financial Coordinators Should Know About Organ Transplantation

Financial Coordinators Should Know About Organ Transplantation
Top Ten Things Financial Coordinators Should Know About Organ Transplantation Andrea L. Tietjen, CPA, MBA Director of Transplant Finance and Data

I have no financial relationships to disclose.
Disclosure I have no financial relationships to disclose.

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TFCA’s Top 10 List 2017: Things Financial Coordinators Should Know About Organ Transplantation

Top Ten Things Financial Coordinators Should Know About Organ Transplant
10 – Financial Coordinators are a critical member of the disciplinary team

Map out your multi-disciplinary flow…

Know what happens and when All team members need to know this too Look for triggers or weaknesses in your flow

Define who does what For example…

Financial Coordinator:
Top Ten Things Financial Coordinators Should Know About Organ Transplant Financial Coordinator: To provide accurate financial information to our patients and their families in a compassionate and tactful manner. Function as a liaison between transplant center, insurance carriers and government (CMS, Medicare, Medicaid). Works cooperatively with other members of the transplant team to establish the most beneficial financial outcome for our patients.

Social Workers and Financial Coordinator work closely together.
Top Ten Things Financial Coordinators Should Know About Organ Transplant Social Workers and Financial Coordinator work closely together. Financial issues only a portion of Social Worker responsibility as a resource and advocate. Financial Coordinator deals with insurance companies, admitting and billing.

Why Financial Coordinators and Social Works need to work together: Patient states he has Medicare A & B and secondary Insurance is verified and coverage is adequate But – patient’s dialysis unit is paying for the Part B and the secondary… and patient has financial stressors and cannot afford the Part B premiums or the secondary insurance post transplant

Lay the foundation for your team
SW MD RN IDLA FC

Why the foundation of your team is so important…
IDLA FC RN SW MD

9 – Timing is everything

Financial Clearance for your recipient must occur at multiple time points

At time of referral At time of evaluation At time of listing Prior to scheduling of Living Donor Transplant At time of re-evaluation (per your policy…1 month, 6 months, 1 year, etc.)

For Kidney Paired Exchange: Prior to consideration for exchange At time of registry/exchange entry At time of match Prior to scheduling of transplant

Remind your team and your patients how important it is to notify the finance team of any insurance changes

8 – Know your recipient and donor policies

Know in advance so you can be confident in your communication and educate the patients, and their care givers, correctly.

Does your center: Accept out of state Medicaid patients? Require recipients to have Medicare? Require donors to have insurance? Pay for donor complications? Have contractual agreements with payors? If so, what are they? How do they impact the facility and the patient?

Does your center: Access donor insurance? Have employed or private providers? What resources are available? How are patients educated?

If your patients know what to expect, they will not be disappointed. Establish process and use tools to assist….

7 – Communication is key

It is not only what we say to the patient, but how we say it. Explain the “why” behind the sensitive questions you are asking

Critical Elements to Donation
The donor gives

The living donor team assesses the donor and gives care throughout the continuum.

MD SW IDLA RN FC

Communication between team members is vital Helps to provide key information about the patient to determine suitability – both medically and psycho-socially Adherence Support Financial stressors

Communicate what the transplant patient’s responsibility will be:
Provide accurate insurance information to the transplant center. Notify the transplant financial coordinator or social worker of financial concerns. Report insurance changes in a timely manner.

Why is communication so important?
Patients change coverage At least annually Patients are educated at multiple time points throughout evaluation, at listing, and at time of transplant, but often do not realize coverage until they are paying.

Many plans and programs have strict guidelines and timelines. Patients can easily lose coverage either temporarily or permanently if they do not pay attention to notices.

Insurance is complicated Patients, and their support, can be overwhelmed by the details, despite assistance available to them. Patients also do not always admit that they do not understand or are concerned about insurance until an issue arises.

And don’ forget about the case manager (if applicable) Case managers can assist with: Patient communication Benefits information and insurance updates Claims payment Travel

6 -It’s all about the recipient’s insurance…

Rule of thumb – the donor costs are billed to and covered by the recipient’s insurance. However, some centers do access donor insurance. Don’t forget...you need to know your centers policies*

Assess your patients Consider financial language in your consent/education For both recipients and donors The team collectively should include all psycho-social/financial aspects such as: Ability to maintain health insurance Ability to pay premiums/copays Family/social support Other financial stressors Past/present social history

Sample education for a recipient

Sample education for a donor

Is there a global agreement? If so, how does it work? What is the plan for coverage for donor complications? Are there limits? 30 days, 90 days, etc. Co-pays, deductibles, etc.

5 – Medicare … it’s complicated

In addition to the rules and regulations, understand the enrollment considerations for patients – on disability, on dialysis and at the time of transplant

Enrollment Considerations
Medicare during 30-month coordination period Patients may not need Medicare Medicare could help pay deductibles and coinsurance There will be a higher premium if patient delays enrollment in Part B As we mentioned earlier, if you are covered by GHP, you may want to delay applying for Medicare. If you have GHP coverage, consider the following: If your plan will pay all of your health care costs with no deductible or coinsurance, you may want to delay enrolling in Medicare until the 30-month coordination period is over. However, if you must pay a deductible or coinsurance under your GHP, enrolling in Medicare Parts A and B could pay those costs. If you enroll in Part A but delay enrolling in Part B, you will not have to pay the Part B premium during this time. However, as we mentioned earlier, you will have to wait until the next General Enrollment Period to enroll in Part B (with coverage effective July 1), and your Part B premium may be higher. If you enroll in Part A but delay enrolling in Part D, you will not have to pay a Part D premium during this time. However, similar to Part B, you may have to wait until the next Annual Coordinated Election Period (with coverage effective January 1) to enroll in Part D. Your Part D premium may be higher, unless you have creditable drug coverage. If you will soon be receiving a kidney transplant, one important consideration is that immunosuppressive drug therapy is covered by Medicare Part B only under certain conditions, shown on the next slide. (Also consider that doctors’ services are covered by Part B, and services for a living kidney donor may not be covered by your GHP.)

Enrollment Considerations
Also, possible higher premium if patient delays enrollment in Part D Not having Medicare in place at time of transplant can effect coverage for immunosuppressive drugs Offer Living Donor coverage (life long) Even if recipient expires or recipient loses the Medicare As we mentioned earlier, if you are covered by GHP, you may want to delay applying for Medicare. If you have GHP coverage, consider the following: If your plan will pay all of your health care costs with no deductible or coinsurance, you may want to delay enrolling in Medicare until the 30-month coordination period is over. However, if you must pay a deductible or coinsurance under your GHP, enrolling in Medicare Parts A and B could pay those costs. If you enroll in Part A but delay enrolling in Part B, you will not have to pay the Part B premium during this time. However, as we mentioned earlier, you will have to wait until the next General Enrollment Period to enroll in Part B (with coverage effective July 1), and your Part B premium may be higher. If you enroll in Part A but delay enrolling in Part D, you will not have to pay a Part D premium during this time. However, similar to Part B, you may have to wait until the next Annual Coordinated Election Period (with coverage effective January 1) to enroll in Part D. Your Part D premium may be higher, unless you have creditable drug coverage. If you will soon be receiving a kidney transplant, one important consideration is that immunosuppressive drug therapy is covered by Medicare Part B only under certain conditions, shown on the next slide. (Also consider that doctors’ services are covered by Part B, and services for a living kidney donor may not be covered by your GHP.)

For Patients Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

For Dialysis Units Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

large out of pocket costs that they cannot afford.
Medicare provides special coverage for a kidney transplant, including coverage for their donor and for their medications– which is not provided by any other commercial plan. Patients often defer their Medicare while on dialysis if they are enrolled in a commercial insurance plan. While these commercial plans may provide good coverage for dialysis, these same plans do not provide adequate coverage for a transplant and transplant medications, and can leave the patient with large out of pocket costs that they cannot afford. Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

If a patient is receiving commercial insurance premium assistance at their dialysis center from the American Kidney Foundation (AKF), and is then transplanted, AKF will stop paying the premium and the patient loses the commercial plan coverage. Patient will have to enroll in another secondary plan while waiting for the Medicare to be active. Medicare enrollment can take 6-8 weeks and the patient cannot enroll in a Medigap plan until the month after their Medicare Parts A and B are active. Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

4 – Keep on top of the regulations

Healthcare Reform ACA plans Managed Care

ACA plans and transplantation
Medicare provides necessary benefits to transplant patients that ACA plans cannot provide, such as: Long term coverage for live kidney donor complications and Long term coverage for rejection medications. Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

If a patient is enrolled in an ACA plan, and needs to enroll in Medicare at the time of transplant for the benefits above, Medicare will backdate to primary at the time of transplant but the ACA plan will not pay as secondary. This leaves patients with large balances after Medicare Part A deductible and 20% for Part B services. Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

Also, if a patient is eligible for Medicare, they are not eligible for any ACA discounts/credits.
A Medicare eligible patient can enroll in an ACA plan and defer their Medicare benefits but they are then not eligible for the ACA premium discount. Without the ACA discount, the patient can continue the ACA plan, but at a much higher premium. Immunosuppressive drug therapy is only covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant, and the transplant was performed at a Medicare-approved facility, and Medicare made payment for the transplant, OR If Medicare made no payment, Medicare was secondary payer. That means if you delay enrolling in Medicare and have a transplant under your GHP, your immunosuppressive drugs will not be covered by Medicare Part B. We’ll discuss this subject in more detail when we talk about Medicare coverage for transplant patients. (IMPORTANT NOTE: If you apply for Medicare based on ESRD within 12 months of a kidney transplant, you can get Part A retroactive to the month of the transplant. You can choose to either delay Part B or take Part B. If you enroll in Part B, you can choose coverage retroactive to the Part A entitlement date or it may be effective the month the application is filed. If you decline to enroll in Part B, you must wait until a General Enrollment Period to enroll later.) If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by enrolling in Part D. But remember, Medicare entitlement ends 36 months after the month of a successful kidney transplant if ESRD is the only reason you have Medicare, i.e., you are not age 65 or over and you have not received Social Security disability payments for 24 months or longer. At the end of the 36 months, you will lose your coverage under all parts of Medicare, including Part D.

3 – If your center performs Kidney Paired Exchange – establish a process

First, when the offer is presented, does your recipient have coverage for donor providers from another center/state ? Is your donor fully covered by another recipient?

Check insurance contracts for coverage for exchange costs

Sample contracting language:

If matched pair is out of network, can an agreement be made? Coverage gaps? NDLAC assistance NKR solutions for: Patients with Medicaid Patients not eligible for Medicare

Ensure your center’s Administration & Finance staff have discussed: Internal process for billing for donors How to post receipts for donor invoices How this will affect the Medicare Cost Report

New CMS KPD guidelines published April 2016
Top Ten Things Financial Coordinators Should Know About Organ Transplant New CMS KPD guidelines published April 2016 the living donor is your center’s until the donor is accepted for a match with another recipient once the donor is matched with a recipient, any additional tests requested by the recipient’s center… are billed at cost to the recipient’s center

Have your center set up a system to blind all donor bills to avoid any breaches in confidentiality

Create a worksheet for tracking: Did you bill for your donor? Did you receive payment for your donor? Did you receive an invoice for your recipient’s donor? Did you pay the invoice for your recipient’s donor? Contact Chain Etc…

2 – Use tools that can help you accomplish what is needed and what has been completed

1- You make a difference!

(improve the process and strive to do more transplants)
Top Ten Things Financial Coordinators Should Know About Organ Transplant Learn from each other (improve the process and strive to do more transplants)

Don’t neglect your policy and procedure. Follow your flow. Perform a post-mortem after difficult cases Doesn’t have to be a long or formal meeting, but reviewing helps to determine best practice. Track your experience Spreadsheet and/or database Easier to track as it occurs rather than going back and trying to capture Improve your process Eliminate obstacles and barriers

It takes a village…

But delivers the gift of life!

Financial Coordinators Should Know About Organ Transplantation

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