Insurance says Home Hemo is experimental

[swramsay]

I have been planning to start training for Home hemo this Monday. The home hemo nurse called and said my insurance is being difficult refusing to cover home dialysis because is it 'experimental'. I got a letter from them a few weeks ago saying that they pay for supplies and even the training for home dialysis but daily home dialysis and nocturnal dialysis (quotidian?) are experimental and not covered.     When I called the company twice, no one had a clue what any of it was. I'm sure it's just a misinperpretation of something somewhere and we just need to talk to someone that knows what's going on. Hopefully, all will be straightened out in a few days. Davita has been great about working on this with the insurance company as well as with my new nephrologist. I didn't have a clue this was even going on. Usually, I am the one hopping on the phone to staighten every thing out. Odd not to be this time.

Has anyone ever heard of that reason from an insurance company before? It's Blue Cross/Boeing traditional. They have been incredible with all of my cancer treatments & surgeries paying for many things without question that other insurance companies don't. I have never had a problem with them at all before.

My fistual is ready to use. Because I don't want a bunch of different people doing needles on me, I was planning on using it for the first time with the home dialysis nurse. I will be doing my own needles at home. She suggested that I start using it here at the center but I don't know if I trust some of the techs here. I know they know more than me but I need to keep this fistula because I have very few options for veins I was told.
I think I'll wait.

[Razman]

My only guess is that they are not informed or they feel that they will loose control on costs.  If you go to a clinic you go 3 times a week. If you do it at home there is no control on how many times you do it and maybe the feel that it will cost more.  Just a guess.

[jbeany]

Once you start home training, Medicare becomes primary, no matter how long it's been since you started dialysis.  If you have to call, make sure to tell them it will save them money!

[petey]

Marvin has Medicare (primary) and Blue Cross/ Blue Shield (secondary, my state employees' policy and I carry him on it).  We haven't had any problems with BCBS for Marvin's home hemo (18 months now), but it is his secondary insurance.  I do know that DaVita charges MORE for a home hemo treatment than they do for an in-center treatment (on a treatment-per-treatment basis).  That, to me, really doesn't seem quite right.  I mean, here at home, I'm paying the overhead (lights, water, etc.), and I'm the "nurse/tech."  Why would one home hemo treatment be more than one in-center treatment?

I've never heard home hemo called "experimental."  That's interesting.

Stay after them.  There is research / data that shows that home hemo patients typically have fewer hospitalizations (hence, fewer claims, less they have to pay).  If I were you, I'll keep calling and calling someone higher up the chain each time.

[Rerun]

Once you start home training, Medicare becomes primary, no matter how long it's been since you started dialysis.  If you have to call, make sure to tell them it will save them money!

I'm not so sure on this.  I think if you have regular health care insurance Medicare makes them be primary for 30 months.  Now, if you start home training Medicare takes effect right away and there is not a 4 month wait.  But they are still secondary "if" you have another health care insurance.

Also, I have a friend who has been doing home hemo dialysis for 22 years and wanted to start home hemo "nocturnal" and her insurance is calling it experimental and won't pay for it.

[Adam_W]

I haven't had a single problem with insurance and home hemo. I have Medicare primary and Indiana Medicaid secondary. Now, getting them to pay for my medical bills from my motorscooter accident quite a while back....I'm still working on it.

Adam

[thegrammalady]

i know it's no help at all , but all i have to say is "bull pucky" insurance companies and i mean all of them are full of it.

[swramsay]

Whoa. This is the first I've heard of medicare becoming primary right away. Ugh. I'm not ready for that. I still have a major surgery ahead of me and need the 100% coverage of the insurance I have now. Plus, I need to figure out coverage with meds etc. Wow. Didn't expect this one. I need the insurance I have now to stay that way....or does medicare become primary only for the dialysis part allowing me to keep my current coverage for the cancer part?  I need to ask a lot of questions on Monday. Glad this came up the way it did.
I would hate to have found out I lost my insurance after the fact.

[Wenchie58]

You don't lose your insurance.  You carry both.  Medicare pays first, then your insurance picks up whats left ( or most of it)

[swramsay]

Here is a section copied from Home Dialysis Central (http://www.homedialysis.org/resources/medicarefaq/). They say my employer insurance should cover during the 30 months. I'll keep checking other sites. .

[Most insurance pays for home dialysis and training. Some managed care organizations may require "prior authorization." If your insurance won't approve home dialysis or training, ask your doctor, dialysis clinic, or ESRD Network to go to bat for you. Once your insurance knows that people who choose home dialysis do as well or better than those on in-center dialysis, and that home dialysis may be cheaper, it will probably cover these services.

If you have an employer group health plan (EGHP), it will pay first and Medicare will pay second for 30 months from when you could have Medicare (the "coordination of benefits" period). When you start home training and home dialysis during this 30 month period, your EGHP pays first and Medicare pays second. So, if your EGHP does not pay the whole charge, your clinic can bill Medicare for the balance. After 30 months, Medicare will pay first and your EGHP will pay second.

[jbeany]

Hmm - guess I should have said Medicare CAN become primary.  I lost my regular BC insurance, and because I was already on home dialysis, Medicare immediately became primary, even though I hadn't been on dialysis for 30 months yet.  Without that option, I would have been SOL!

[qwerty]

Here is a section copied from Home Dialysis Central (http://www.homedialysis.org/resources/medicarefaq/). They say my employer insurance should cover during the 30 months. I'll keep checking other sites. .

[Most insurance pays for home dialysis and training. Some managed care organizations may require "prior authorization." If your insurance won't approve home dialysis or training, ask your doctor, dialysis clinic, or ESRD Network to go to bat for you. Once your insurance knows that people who choose home dialysis do as well or better than those on in-center dialysis, and that home dialysis may be cheaper, it will probably cover these services.

If you have an employer group health plan (EGHP), it will pay first and Medicare will pay second for 30 months from when you could have Medicare (the "coordination of benefits" period). When you start home training and home dialysis during this 30 month period, your EGHP pays first and Medicare pays second. So, if your EGHP does not pay the whole charge, your clinic can bill Medicare for the balance. After 30 months, Medicare will pay first and your EGHP will pay second.

This is the correct information. After you have been on for 30 months then medicare should become the primary with your secondary picking it up. If they are questioning the claim you can appeal it and have your doc provide them with the correct information regarding the "Experimental issue" and why it is better for you.

[Rerun]

Did NO ONE read my post??  Just skip what RERUN has to say??

                                           

[swramsay]

 
Yes, Rerun. I did read your post which gave me a little hope. It was your post that I was trying to back up with some research. 

[lola]

We were told also that the day Otto started Home-hemo training medicare becomes secondary. But because of "surprise surprise" paper work being done wrong I just got everything done on Tuesday so we should be getting our letter next week and we just got part A since he already has ins through work. Do you have a "case" worker with your ins. company? Otto's has helped us so much, and that's who I'd go to about Home-hemo being "experimental"  Good luck

[nursewratchet]

We have LOTS of people on Home, with BCBS, with Medicare.  Its' not a problem, someone at BCBS is mixed up.  The social Worker at the clinic will fix this.  Good Luck with your fistula...

[Wallyz]

Are you training through Da Vita, or Northwest Kidney centers?  Also is this with Premera Blue Cross?  Becasue that's what I have, and they have been great about paying.

[swramsay]

I am at Davita (as I speak) and have Regence Blue Shield Boeing Traditional. The Davita Insurance coordinator (Valerie) just stopped by. She's going to contact the insurance company and Boeing with research and statistics and will also have my nephrologist write a letter. Valerie gave me several links for me to get some info ans stats from to include in my conversations with them this week. I have several people trying to help. We'll see what happens.

[Wallyz]

Keep it up. There are lots of people in Washington doing home hemo.  Ask for help from the NKC folks, and I iwll be glrad to get  a letter form PSKC.

[MandaMe1986]

Good luck I hope it all works out.  Insurance can be such a pain in the butt sometimes.  But where would we be without it?

[swramsay]

Keep it up. There are lots of people in Washington doing home hemo. Ask for help from the NKC folks, and I iwll be glrad to get a letter form PSKC.

Excuse my ignorance but what is PSKC?
Puget Sound Kidney Care? Pretty Sweet Kidney Company? Poor Sap Kidney Crap? 

[Wallyz]

Puget Sound Kidney Centers

North Sound Non Profit (Everett, Smokey Point, Mountlake Terrace, Oak HArbor).

[swramsay]

I was close.
That would be wonderful if you could get some sort of letter! Everything would help. Boeing Regence is a big insurance company. Thankyou very much!!
My email is swramsay@comcast.net. My fax is 1-888-527-1105. Or just let me know if you want more info.

Wendy