New bundling rules

[vcarmody]

Does anyone out there know the new rules with Medicare bundling about giving Epogen injections at home.  I know I was told that in the new bundling it was approved to be given at home, but today my husband was informed that it is no longer approved with the new changes so as of Jan 1st he has to make trips back to the center weekly for his injections.  My husband is not even on Medicare not until 2012 but they say they have to follow these rules.  Please if anyone knows the rules (I'm pretty sure Bill has posted something on it before but for the life of me I can not find it now that I need it).  Thanks!!!

[MooseMom]

I have absolutely no idea, but I wanted to jump in and say that 2 years ago, I had to take Procrit for about 6 months for anemia caused by something other than CKD, but it was my neph who prescribed it.  My insurance company wouldn't pay for it to be administered anywhere BUT home!  I filled the prescription and was given the syringes but absolutely no instructions for how to use it.  My neph's nurse offered to give it to me, but I had to pay a fee.  So I don't understand why I was told to self-inject at home but your hubby is not told the same thing.  Is it just because he's on D and I was not?  That's just so stupid.  It seems so arbitrary, that these rules are made by people whose only reason to make such rules is because they CAN.

I'll be watching this thread.  Thanks for posting this.  D is hard enough without all of the rules.

[paul.karen]

It seems so arbitrary, that these rules are made by people whose only reason to make such rules is because they CAN.

Scary huh.  Probably have no experience in the health filed either??

[Bill Peckham]

Does anyone out there know the new rules with Medicare bundling about giving Epogen injections at home.  I know I was told that in the new bundling it was approved to be given at home, but today my husband was informed that it is no longer approved with the new changes so as of Jan 1st he has to make trips back to the center weekly for his injections.  My husband is not even on Medicare not until 2012 but they say they have to follow these rules.  Please if anyone knows the rules (I'm pretty sure Bill has posted something on it before but for the life of me I can not find it now that I need it).  Thanks!!!

What your unit is saying makes no sense to me. The new bundling rules include payment for erythropoietin stimulating agents (EPO and Arnesp are two brands for people using dialysis; Procrit is for people who are predialysis) in the payment for the treatment, the rules actually make it easier to supply meds at home. But if you're not Medicare primary yet then they should have no effect.  I don't know what they're talking about.

[vcarmody]

Bill, this is a problem I have been having with the center for a while.  When I first wanted to give him his injections at home they told me the insurance would not allow it.  So I contacted my husbands insurance company and they said they would cover it at home.  So I went to them and told them what my insurance said, then there excuse was if they gave it to us they needed a pharmaceutical license to distribute RX medications.   I counter that with well you give me heparin and that is RX so how can that be?  Then they said it was a Renal Ventures policy not to allow us to do injections at home.  So I sent and email to corporate telling them how making my husband travel weekly for an injection that could be given at home was defeating the purpose of doing home hemo dialysis. They then approved us to do it at home for the last month.  Today he goes and they tell him that with the new bundling it can no longer be done at home so starting Jan 1st he has to travel in center to get his injection.  I read the new bundling over and over and It only seems to address a change in giving it intravenously, which is not how it is given to him.   I'm at a loss, why it is including in the bundling for home dialysis but our center says the injection are only covered if he comes in center.  I think this is just a battle with the head person at the center, that person was the one denying us all along, low and behold she goes out on medical for a while and we get approved to do it at home.  Now she is back and the first time he sees her she says oh, no no this cant be done no more.  Frustrating yes, but I'm not about to accept this decision without a fight.  For once my husband is feeling good and I know it is because he is getting his injections when he is supposed and not when ever they remember to give it to him. 

[greg10]

Vcarmody, I am sorry Renal Ventures is putting you through this.  As you have gathered by now, it is either a gross ignorance of medicare rules on their part, or RV is getting paid a lot more for epoetin injections in-center vs at-home.  I can tell you from personal experience that at our center we have no problem getting heparin, zemplar, epoetin, epinephrine and diphenylhydramine made available for home injections.  There may be a few drugs that could be at more risk for home injections, usually those causing allergic reactions, but epoetin in not one of them.  If anything, you could monitor the patient's hemoglobin levels more closely when you do home epoetin injections.  There are home point-of-care Hgb testing kits that cost no more than $1 to $2 per test that could let you inject the optimum amount of epoetin for the optimal Hgb level (usually around 11 g/dL).

http://ihatedialysis.com/forum/index.php?topic=20798.msg350568#msg350568

[Rerun]

Maybe you could ask your Nephrologist for a prescription and go get it filled.  Screw the center.

I've not done this I'm just saying.......

[looneytunes]

VC...we go through a Fresenius clinic and they are bundling our treatment.  We do our epo injections here at home.  You might want to go the corporate route again on this with maybe your neph's support.  Also, might be worth a shot....call Medicare to see if there is anything they can do to help you in this.   

[cookie2008]

Vicky, they called me and told me I wont be able to take my vitamin d as a prescription at home because of the new bundling, are they going to make me do that in center, I need to talk to doc about it next week.  My private insurance pays for it not medicare I dont have part d.

[Bill Peckham]

Vicky, they called me and told me I wont be able to take my vitamin d as a prescription at home because of the new bundling, are they going to make me do that in center, I need to talk to doc about it next week.  My private insurance pays for it not medicare I dont have part d.

This one makes a little more sense. Meds with oral equivalents - ie meds available in pill and injection form - are now in the bundle.  This is probably the biggest change that dialyzors will notice post bundle. Vitamin D analogs will be provided by units post 1/1/11 (with exceptions possible for the few units that are not going all in and people who are not Medicare primary).

For people who are Medicare primary it does not matter where you are getting your vitamin D today - Part D or EPGH - post 1/1/11 it will be the provider's responsibility to give it to you. What I can't say for sure is how units will fulfill this obligation. For incenter dialyzors there won't be much of an apparent difference, you'll get it IV during your run. For people using PD or HHD I would expect most will be given the ability to give it themselves at home, maybe via pill form for those using PD and injectable for people on HHD with blood access or maybe pill form for anyone at home. Going incenter to have it injected doesn't make sense.

The issue that may complicate this is that states have their own rules about who can dispense drugs and where and how, some of this isn't really known yet so it is possible that this is a state issue. If it was a state issue I'd probably want to go to the oral version.

[vcarmody]

Yes, Cookie they want you to go in center now for the medication, Chris takes, Zemplar and 2000 units of over the counter vitamin D.  They said that the new rule for that does not effect him, but they said it affects you. How do you get your vitamin D is it in pill form or inject able?   What is the sense of doing home hemo if we have to travel to the center weekly for medication? I have read the new bundling over and over and to me it seems that EPO is still approved by medicare to be given in the bundled supplies to home hemo patients.  They also gave Chris paperwork that says everyone is now responsible for 20% cost of there blood work.  Not that I am worried about that because we have 3 insurance companies, but I feel really bad for the people who only have Medicare and are struggling now just to get by. 

[cookie2008]

I found out today that the center will be giving me my vitamin d and I will take it at home, about the blood work no one said it was going to cost us 20% I will make another phone call tomorrow.

[vcarmody]

They will be supply oral medication to us now that is related to ESRD through a DaVita pharmacy. Inject able medication you have to go in center for.  Medicare will now only pay 80% of lab testing so if.you have no other insurance you are responsible for the other 20% you and Chris are lucky you have secondary insurance so the 20% will be covered.. but not everyone has a secondary insurance and that's sad, dialysis parents have enough stress and enough stuff to worry about.

[Bill Peckham]

Previously labs were paid 100% by Medicare. Where as Medicare typically pays 80% of charges labs were billed to Medicare directly by the laboratory doing the tests, the unit just sent the blood and got the result (with the exception of your normal monthly labs which were and are part of the core composite rate (I do wish I could write an unqualified statement about this bundle)).


CMS acknowledged when they proposed the bundle that changing how they paid for labs would mean that 20% of the cost would be shifted to the patient but the authorizing law MIPPA that Congress passed clearly imagines that labs would be in the bundle. It would take legislation to change it now.


The effect of bundling is not the same for everyone. The bundle amount is based on averages, thus the 20% not covered by Medicare is 20% of the average. If you used more than the average amount of EPO, the 20% not covered by Medicare was more than average. Now, it is possible that you'll be getting more than the average dose while being responsible for the average 20%. Or you could be like me and not use EPO and still have responsibility for 20% of the average per treatment EPO dose.


Anyway FYI labs I believe amount to about $8 of the new per treatment rate, so you can say on average your 20% is ~$1.60 more but MIPPA also directed CMS to cut the program by 2%. The average authorized per treatment rate is $250, so they cut about $5, which makes the 20% go down $1, meaning the net effect of the bundle, on the average 20% not covered, is about +$.60

[Bill Peckham]

They will be supply oral medication to us now that is related to ESRD through a DaVita pharmacy. Inject able medication you have to go in center for.  Medicare will now only pay 80% of lab testing so if.you have no other insurance you are responsible for the other 20% you and Chris are lucky you have secondary insurance so the 20% will be covered.. but not everyone has a secondary insurance and that's sad, dialysis parents have enough stress and enough stuff to worry about.

I'm still not understanding why you can't continue to give your injectables at home.

[cookie2008]

Bill, I go to the same center as Vicky husband we are the only 2 so far on Nxstage, they tell us the same thing but since being on nxstage almost 2 years I have not needed epo injections just iv iron which I prefer to do incenter because I reacted to it.

[noahvale]

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[vcarmody]

Bill, I'm not understanding why we can't continue them at home either. He went to the center to get supplies. He was told as of Jan 1 we could not do it at home anymore. He question why and she spent 20 minutes looking for an email she said that explained why. He had another appointment and had to leave but she took his email address and said.she would email the explanation to him. As he was walking out she said she found the paperwork and it was on the way to his inbox. When it didn't arrive I called and left a voice mail telling her we never received the email so can she resend it. I told her I was not sure if this is a Renal Ventures policy or a Medicare bundling issue but I would like to be informed either way. I still have not received that email or a call back, but when I do receive there response I let you all know what they say.

[cookie2008]

There is a number you could call medicare and ask about the injections with the new bundling and ask them to send you the information so you have it to show (T). couldnt hurt to try, explain to them your are not even on medicare yet that you have private insurance.

[tyefly]

  I do my Epo at home....  always have......  cant understand why this (your) clinic is telling you this.....    keep fighting and calling....   they are wrong..  but they hold the power....   

   I am still dealing with my clinic on a heparin pump..... I have been dealing with this for 8 months....   I am persistant

[vcarmody]

Thank you noahvale I made that call and the person I spoke to was very helpful. There is nothing in the new bundling that says Epo has to be given in center so she asked permission to contact the director on our behalf to find out why they are changing there policy. I'll let you know the outcome.

[The Lone IT from HM]

I want to make sure that I understand one thing in your situation.  Medicare is not in the picture until 2012.  If that is true, then the bundle has no affect on your situation.

Here is a wonderful wedsite: http://www.medicare.gov/Dialysis/Include/DataSection/Questions/SearchCriteria.asp?version=default&browser=IE%7C8%7CWindows+7&language=English&pagelist=Home%7CResults&dest=NAV|Home|Search|SearchCriteria&Type=NewSearch#tabtop

It is the Medicare website where you can find Dialisis Clinics. Once you have all the clinics in your area, you can look at the services they provide, and compare their quality of service.

Maybe you can find someplace that remembers they are providing you a service.  I would also go with the suggestion about going directly to your Doctor and asking for a Prescription for any of your needs.  I will ask around about different ways to get all your supplies.

[noahvale]

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[vcarmody]

We got the call today from the director of our clinic and we have been approved to continue doing his EPO at home.   Thanks again noahvale,  if you didn't give me that information I don't think we would have been continuing it at home.  On Wednesday they sent the director in to meet with us and she said she understood why we were upset but corporate said NO and that wasn't going to change but she would "work on it" from her end.  Today I got a call from the advocate from the ESRD network saying she spoke to the director today and the director spoke to corporate and my husband will be allowed to continue his EPO at home and if I have any problems with it in the future to contact her.  My husband is so happy he don't have to make that trip weekly in the cold and snow just to get the shot.   

[noahvale]

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