Medicare might cover NxStage only 3 times/week

[caregivertech1]

 
 
 


Got this email today. Wow this could be a game changer. This is crazy. 
 
 



 
Customer Communication
November 13th, 2017   

 
Dear ,
At NxStage Medical, we’ve taken pride over the years in providing technology that is designed to help give dialysis patients their lives back, enabling them to feel better, be more active, spend more time with family and friends, live healthier – and hopefully, longer – lives.
 
We believe that insurance should pay for the therapy that is right for you, in consultation with your doctor(s).  Because of this belief, and our commitment to serving you, our patients, with dialysis education, advocacy and social responsibility, we want to make you aware of a proposed change to Medicare dialysis coverage that could restrict your access to more frequent home hemodialysis.

Here's what you should know:
•   Medicare has a long-standing policy of paying for more frequent hemodialysis treatment when medically necessary and included in a patient’s plan of care.
•   Medicare contracts with insurance companies (known as Medicare Administrative Contractors, or “MACs” for short) to manage your Medicare claims and they have the power to determine what qualifies for Medicare coverage and, as a result, what qualifies for Medicare payment.
•   Recently, these MACs announced that in most cases, they won’t authorize coverage for more than three hemodialysis sessions per week.  If this change happens, Medicare may no longer pay for more than three treatments per week, even if it’s what the doctor wants done.
This is important for all patients, but especially important for patients who need more frequent dialysis.  More frequent hemodialysis is most practically administered in the home, and the clinical benefits that can be achieved from more frequent therapy are what makes the additional effort of doing your own care worth it.  Peritoneal Dialysis is another home option for many, but not all people are medically suitable for PD. For those, home hemodialysis is their only available home option. If payment for more than three hemodialysis treatments per week for most patients goes away, patient access to and use of home dialysis will decrease overall.
 
All of us at NxStage are here to make a difference, and are working diligently – together with others in the kidney community – to ensure that decision makers in Washington understand how the proposed changes could affect you, but no one can tell your story…like you.  That is why we need your help to tell Medicare about the importance of more frequent dialysis and the benefits of this life-changing therapy.  Your experiences and opinions can make a difference with Medicare and your elected officials.

Here’s how you can help:
•   Let your voice be heard TODAY! The MAC that manages your Medicare claims, Medicare and your Members of Congress need to know how important more frequent hemodialysis is to you.  As you’ll see below, we’ve worked with the Alliance for Home Dialysis who has a Legislative Action Center where you can quickly and easily get your message to the people who will make the final decision on these proposals.
•   This is URGENT. Without an uprising from patients and the entire dialysis community, more frequent dialysis could be denied for thousands of patients as soon as the end of this year. These MACs will soon decide whether these proposed restrictions on more frequent dialysis will happen.  Your MAC, Medicare – and your representatives in Congress – need to hear from patients like you about the benefits you have experienced with more frequent hemodialysis. They need to see how this has improved your health and how it makes a difference in your life
 
•   Here’s how to get involved and have your voice heard: It’s easy for you to make a difference and to share your positive experiences with more frequent hemodialysis.  Just visit STOPtheMACs.com for more information about this issue. The website is preloaded with a sample message you can customize and share with your MAC, Medicare and your elected officials with just the click of a button.  We’ve even pre-loaded the site with sample messages for you to send on Twitter and Facebook. And please use the hashtag, #STOPtheMACs.
 
•   Help us spread the word to others who care. The MACs and Washington need to hear from people like you – current patients - but also from your friends and loved ones, transplanted patients, caregivers, neighbors, doctors and nurses … anyone who shares our belief that kidney patients should have  access to more frequent hemodialysis.

So after you send your message, please encourage others to visit STOPtheMACs.com.  And don’t forget to use your social media accounts, like Twitter and Facebook, to ask others to help protect patient access to more frequent dialysis. And post a picture or video with your message.  Information on how to do that can be found here. And with all of your social media posts, include the hashtag #StoptheMACs.
 
As you know, more frequent dialysis has significant health benefits, including improved cardiovascular health and blood pressure, reductions in medication requirements, lower overall health care costs, and improvements in post-dialysis recovery time, and quality-of-life.  Additional sessions may also increase the chance for transplantation and allow patients to live longer, more productive lives.
 
Dialysis patients, both now and for years to come, could lose access to more than three treatments per week if the proposed changes are allowed to go into effect.     
 
Now is the time to stand up and make your voice heard, before it’s too late. Please take action today. These MACs will make the decision soon, make certain they’ve heard your voice.  If you would like to discuss this issue directly, please contact Linda Upchurch, NxStage Director of Public Policy, at lupchurch@nxstage.com . 

     
In Health,

Joseph E. Turk, Jr.
President
NxStage Medical
 
 
   

[Simon Dog]

I believe that the current billing practice is to normalize the NxStage treatments to traditional.  For example, I am on 5x/wk NxStage which I believe means my clinic bills 3/5 the cost of a treatment per NxStage treatment.

The real issue is that MDs have the ability to prescribe 4x/wk for patients they feel need it (excessive fluid gain; cramping, etc.).

While uprising is a good protective measure, I don't think the current CMS action has NxStage frequent home hemo in its sights.

[caregivertech1]

I checked several medicare billings along with my UHC supplemental payments. Fresenius bills $4951 per treatment or around $80,000 per month. Medicare only pays around $1900 total and UNH around $300 leaving me with around $100. Looks like it's all bundled regardless of how many treatments are billed. Medicare doesn't pay much. We were on Aetna only a few years ago and they actually paid $2600 per treatment. So back to this email. I don't see how CMS has much room  to reduce Medicare coverage..........but I still don't trust them!

[Simon Dog]

Looks like it's all bundled regardless of how many treatments are billed.

I believe there is extra billing for more than a standard number of in-center treatments.

[Maggie and Jeff]

Double post

[Maggie and Jeff]

Maggie does 6x per week. 

The clinic is saying they will eat the cost difference for Maggie because 6x is working for her 11+ years.

We signed the petition and got others to sign as well.

Medicare stopped paying for more than 3x at the beginning of 2017.

[Simon Dog]

Medicare stopped paying for more than 3x at the beginning of 2017.

I believe clinics typically bill for a total of 3 at the in-center rate, and that this has been standard practice for some time.

[Maggie and Jeff]

Here in Tennessee they paid for 6x for the last 10 years for Maggie.

For the first 7-8 years they paid 50,000 to 120,000 monthly.

Last few years it has been as low as 1,500 up to 5,000 monthly.

Of course the lower amounts are the most recent.

I found this template on the web.
We should all be writing letters like this.

DATE
MAC NAME
C/O FIRST LAST
TITLE
ADDRESS
CITY, STATE ZIP

RE: Frequency of Hemodialysis Local Coverage Determination
Dear FIRST LAST:
<Introductory paragraph about you, what is important to you, your personal experience with more frequent dialysis. EXAMPLE: my name is Jane and I am 31 years old.  I was born with a heart problem and lost my kidney function 4 years ago after problems during pregnancy.  Fortunately, I was able to receive more frequent dialysis while I was pregnant and my son was born healthy.  Unfortunately, my kidney function did not return.  I was not a candidate for PD, so I started dialysis incenter.  There, I was seemed to get sicker instead of better.  The three times per week dialysis was just not enough for my body. My heart function declined.  To be able to do dialysis more frequently, my doctor suggested I should go on home dialysis.  The training was hard, but once we adjusted and I got the treatment I needed to stabilize my heart, I felt so much better.  Now, I do dialysis 4 nights per week, 9 hours per night.  It is not fun, but it is part of my routine and worth it to feel healthier and be able to be a mom, a wife and employed part time at my son’s school.>
I write to respectfully request that <MAC NAME> reconsider its draft Local Coverage Determination (LCD) on frequency of hemodialysis. As I understand your policy, it essentially says that payment is limited to temporary conditions, and can never be used over the long term. Your definition would include my situation. As a result, it is possible that I may not have access to the treatment my nephrologist has ordered to meet my medical needs.

I can attest that I benefit from my current dialysis schedule. <INSERT SPECIFICS AS YOU ARE ABLE> I worked with my nephrologist to determine a plan of care that was best for my particular set of health conditions, including ESRD, and my health has improved significantly with more frequent dialysis. Changing my treatment regimen may impact my health.

I understand that other MACs recently released virtually identical policies, and I am also concerned about others like me who will be forced to return to a three-times-a-week schedule, which may result in their previous health issues returning. I believe that Medicare has a responsibility to let kidney doctors like mine decide what is best to manage my complex medical issues. The LCD you propose does exactly the opposite.

I can assure you that no patient enjoys doing dialysis.  It is hard and it is not convenient.  So, doing more treatments simply would not happen for any patient who did not feel life-changing medical improvements.  That is why this is so important to me.  I just want to feel as healthy as I can and be able to live my life as fully as possible with kidney disease. 

Please reconsider this decision and allow patients like me, and those who come after me, to benefit from a more frequent dialysis treatment regimen when it is medically appropriate.

Thank you for the chance to provide a comment.
Respectfully, 


 

[Simon Dog]

For the first 7-8 years they paid 50,000 to 120,000 monthly.

There is no way Medicare paid "50,000 to $120,000 monthly" for dialysis.  That may have been the "asking price", but certainly not the "Medicare paid rate".  Both are generally listed on the bill.

At a Medicare rate of $300 per (approx), a 3 day /wk is about 21 treatments per month of $2900.    Add to that MD fees and other extras.

[Charlie B53]

I've always said that Insurance Companies are not in business to pay out claims.  Their business is to SELL insurance and collect premiums so upper management can recieve huge salaries.

Ins Co have huge buildings full of attorney's all working to find ways to limit payments on claims.  Any doubt about this read the book 'Rainmaker'.  There are a number of books written on the Class Action business.

Seeing this huge divide in treatment between the DAILY method of PD and now seeing those on Hemo having IN-CLINIC limits of only 3 treatments a week, I can fully understand how many patients fail to get sufficient Hemo Dialysis while in-clinic. 

Now insurance companies attempting to limit in-home hemo dialysis to that same 3 times a week limit, causing patient sickness, and eventual premature death, I foresee potential Federal Class Action lawsuits as these insurance companies are in effect creating this 'Class' of in-home dialysis patients.

The insurance companies are not stupid, they KNOW they will lose this suit but they will drag it out as long as possible, extending the time before they actually make any pay-out.  The only ones to win anything will be the attorneys as the Court will award Plaintiff Attorney's massive fees.

[Simon Dog]

I can fully understand how many patients fail to get sufficient Hemo Dialysis while in-clinic. 

Now insurance companies attempting to limit in-home hemo dialysis to that same 3 times a week limit

Remember, the goal is "adequate treatment", not "best possible treatment".  I think that one thing holding home back is MDs reluctance to tell patients how much of a quality compromise 3x/week really is.  My doc said "It is wasn't good we wouldn't do it".  I guess that all depends what your definition of "good" is.

I think the 3x limit home may be a red herring, since home patients (even 5 or 6x/wk NxStage) are billed the equivalent of 3 in center treatments.  That being said, one must be wary of unintended consequences in the wording of any new regulation.

The insurance companies are not stupid, they KNOW they will lose this suit but they will drag it out as long as possible, extending the time before they actually make any pay-out.  The only ones to win anything will be the attorneys as the Court will award Plaintiff Attorney's massive fees.

Also unfortunate is the provision under ERISA that limits the claim to anyone denied coverage under an employer provided plan to the cost of the denied claim.   Employee insurance customers cannot sue for the medical damage done by the lack of treatment.

[Charlie B53]

Employee insurance customers cannot sue for the medical damage done by the lack of treatment.

A decent class action suit should be able to reverse this ruling as Insurance Companies have been held liable for deaths caused by the insurance companies failure to cover necessary treatment.  That lack of timely treatment caused the death.

Unfortunately it will require a number of deaths first.   Who is willing to sign up for this one?

[Simon Dog]

A decent class action suit should be able to reverse this ruling as Insurance Companies have been held liable for deaths caused by the insurance companies failure to cover necessary treatment.  That lack of timely treatment caused the death.

It is not a "ruling", but a "provision of law".   Big difference.

I suggest you read the entire text of ERISA (Employee Retirement Income Security Act of 1974).   If the plan is employer sponsored, the insurance company is immune from liability beyond the cost of the denied claim.