Organ Acquistition cost

[Guest guest]

Hi,

Will Medicare cover the acquisition cost for a kidney transplant if the primary

insurance carrier excludes the acquisition of the organ costs? Medicare will

not become primary for this patient until 6/1/02 The plan covers all other

transplant related expenses except for the acquisition of the organ.

Mia Bolton-McKelvey

Kidney/Pancreas Program

Medical University of S.C.

[Guest guest]

It's my understanding that medicare would cover the acquisition with the a

copy of the EOB from the insurance.

Organ Acquistition cost

Hi,

Will Medicare cover the acquisition cost for a kidney transplant if

the primary insurance carrier excludes the acquisition of the organ costs?

Medicare will not become primary for this patient until 6/1/02 The plan

covers all other transplant related expenses except for the acquisition of

the organ.

Mia Bolton-McKelvey

Kidney/Pancreas Program

Medical University of S.C.

[Guest guest]

Are there any regulation or guidelines from Medicare you can direct me to. What

you and Rea have told me is my feelings too but the person who does our cost

report feels differently.

>>> mchaney@... 01/04 10:52 AM >>>

It's my understanding that medicare would cover the acquisition with the a

copy of the EOB from the insurance.

Organ Acquistition cost

Hi,

Will Medicare cover the acquisition cost for a kidney transplant if

the primary insurance carrier excludes the acquisition of the organ costs?

Medicare will not become primary for this patient until 6/1/02 The plan

covers all other transplant related expenses except for the acquisition of

the organ.

Mia Bolton-McKelvey

Kidney/Pancreas Program

Medical University of S.C.

[Guest guest]

Are there any regulation or guidelines from Medicare you can direct me to. What you and Rea have told me is my feelings too but the person who does our cost report feels differently.[(Aguiar, )] I'm confused, Mia-I thought you were asking whether you could balance bill Medicare for a charge denied by the primary commercial payer-how did the Cost Report get into the picture?

J. Aguiar

Beth Israel Deaconess, Boston >>> mchaney@... 01/04 10:52 AM >>>It's my understanding that medicare would cover the acquisition with the acopy of the EOB from the insurance. Organ Acquistition cost Hi, Will Medicare cover the acquisition cost for a kidney transplant ifthe primary insurance carrier excludes the acquisition of the organ costs?Medicare will not become primary for this patient until 6/1/02 The plancovers all other transplant related expenses except for the acquisition ofthe organ. Mia Bolton-McKelvey Kidney/Pancreas Program Medical University of S.C.

[Guest guest]

DRG stands for Diagnosis Related Groups. This is a grouping of diagnosis codes

that are similar, and Medicare allows a payment according to this grouping.

There are some other factors that can go into the actual reimbursement such as

outlier days, but you can get a good idea of what you will get according to this

payment schedule. (They have formulas in which they plug weighted values, etc,

but you have to really specialize in Medicare to get an exact amount to match

what they will actually pay.)

What you said about not getting reimbursed by Medicare for acquisition costs

applies whether they are the primary or secondary payor. The DRG payment is all

that will actually be reimbursed by Medicare as an " insurance carrier " for the

actual transplant bill that is submitted, even though the acquisition (SAC) is

included. They are not looking at the total charges, they are only concerned

with the DRG schedule. By the way, the DRG payment does not even cover the

hospital bill if you subtract out the acquisition charge.

Once a year though, we are able to file the Medicare cost report and include

such items as the kidney acquisition costs which were written off during the

year (because no actual payment was received from Medicare towards the

transplant bill for these services), and get those monies back. These monies go

back to our hospital's general ledger account, and not back to the specific

patient visit.

The commercial insurance for this patient will pay for the hospital and

professional fees as primary payor but will not cover any acquisition costs. My

issue remains that we want to file the acquisition portion of this patient's

transplant bill on the Medicare cost report like we would if Medicare was

primary. The cost report is very complex to file, and there is always

discussion about how and what can be included. I believe that there may be a

way around the normal procedure, or some special billing notations that need to

be included on the report, in order to recoup the lost acquisition. Please send

me names and numbers of the persons who do your cost report(s).

*It is hard to believe that an insurance company would pay for the hospital

bill, but would not allow for the acquisition of the solid organ (SAC).

taylorkb@...

B.

Medical University of South Carolina

ton, South Carolina

>>> ldnsteve@... 01/12 12:10 PM >>>

- that actually sounds right to me - though again I barely

have a grasp on this. I will get you the number of our cost report guy

- he is very friendly and I am sure will be glad to talk to you. Also -

could you (or anyone) explain the meaning of DRG to me? I've heard it a

lot and know the general meaning - but am unclear about what it really

means. And - I guess what I was trying to say earlier is that when we

file the cost report we actually don't recoup any acquisition costs from

Medicare as a secondary payer. I have called and left a message for

Todd to call me and then I'll tell him about you so that he'll know

what's going on when you call him - okay? Thanks.

s

LDS Hospital

Salt Lake City, Utah

>>> taylorkb@... 01/10/01 05:06PM >>>

,

Do you have a person at your facility who handles your cost report that

we could contact directly? Maybe some of the rules and regulations

change from state to state, but we only get reimbursed for the

transplant admit by Medicare according to the DRG, and then we file the

cost report to (hopefully) recoup our acquisition costs yearly.

taylorkb@...

B.

Medical University of South Carolina

ton, South Carolina

>>> ldnsteve@... 01/05 12:48 PM >>>

Hi Mia - our center has actually had a lot of problems with this very

issue. Our local Blue Cross/Blue Shield has put a cap on how much

they

will pay for acquisition. Though I don't understand this fully, I do

know that you can " bill " Medicare as secondary for the acquisition

(which has to do with the cost report) but that your center will

probably not actuallly receive any money from secondary Medicare as

the

primary insurance almost always pays more (even without acquisition)

than Medicare would have anyway. Confusing.

So - in summary, the patient will not be left with the bill, and

Medicare will be billed for it through the cost report, but ultimately

the hospital does not get paid for the remainder billed to Medicare.

The person who does your cost report is thinking differently because

he/she sees, I think, that Medicare really does not " pay " for the

acquisition, nor anything as secondary usually. Again, I barely have

a

grasp on this, so I am not sure of all the details, just the

generalities.

Basically what it has come down to for us is whether or not the

hospital is willing to eat some of the acquisition charges in order to

receive the other payments.

Good luck

s

LDS Hospital

Salt Lake City, Utah

>>> mckelvem@... 01/04/01 08:00AM >>>

Hi,

Will Medicare cover the acquisition cost for a kidney transplant if

the

primary insurance carrier excludes the acquisition of the organ costs?

Medicare will not become primary for this patient until 6/1/02 The

plan

covers all other transplant related expenses except for the

acquisition of the organ.

Mia Bolton-McKelvey

Kidney/Pancreas Program

Medical University of S.C.

[Guest guest]

I agree that it is hard to believe that an insurance company will pay

for the hospital bill but not acquisition charges. Doesn't really make

sense at all.

I spoke with Todd in our accounting office (he's the Medicare

reimbursement specialist - the one who files the cost report). He

explained a lot of what you explained to me, as well, and said he would

be glad to talk with you. His number is . Tell him

s in his transplant deparment sent you

s

LDS Hospital

Salt Lake City, Utah

>>> taylorkb@... 01/15/01 05:47PM >>>

DRG stands for Diagnosis Related Groups. This is a grouping of

diagnosis codes that are similar, and Medicare allows a payment

according to this grouping. There are some other factors that can go

into the actual reimbursement such as outlier days, but you can get a

good idea of what you will get according to this payment schedule.

(They have formulas in which they plug weighted values, etc, but you

have to really specialize in Medicare to get an exact amount to match

what they will actually pay.)

What you said about not getting reimbursed by Medicare for acquisition

costs applies whether they are the primary or secondary payor. The DRG

payment is all that will actually be reimbursed by Medicare as an

" insurance carrier " for the actual transplant bill that is submitted,

even though the acquisition (SAC) is included. They are not looking at

the total charges, they are only concerned with the DRG schedule. By

the way, the DRG payment does not even cover the hospital bill if you

subtract out the acquisition charge.

Once a year though, we are able to file the Medicare cost report and

include such items as the kidney acquisition costs which were written

off during the year (because no actual payment was received from

Medicare towards the transplant bill for these services), and get those

monies back. These monies go back to our hospital's general ledger

account, and not back to the specific patient visit.

The commercial insurance for this patient will pay for the hospital and

professional fees as primary payor but will not cover any acquisition

costs. My issue remains that we want to file the acquisition portion of

this patient's transplant bill on the Medicare cost report like we would

if Medicare was primary. The cost report is very complex to file, and

there is always discussion about how and what can be included. I

believe that there may be a way around the normal procedure, or some

special billing notations that need to be included on the report, in

order to recoup the lost acquisition. Please send me names and numbers

of the persons who do your cost report(s).

*It is hard to believe that an insurance company would pay for the

hospital bill, but would not allow for the acquisition of the solid

organ (SAC).

taylorkb@...

B.

Medical University of South Carolina

ton, South Carolina

>>> ldnsteve@... 01/12 12:10 PM >>>

- that actually sounds right to me - though again I barely

have a grasp on this. I will get you the number of our cost report

guy

- he is very friendly and I am sure will be glad to talk to you. Also

-

could you (or anyone) explain the meaning of DRG to me? I've heard it

a

lot and know the general meaning - but am unclear about what it really

means. And - I guess what I was trying to say earlier is that when we

file the cost report we actually don't recoup any acquisition costs

from

Medicare as a secondary payer. I have called and left a message for

Todd to call me and then I'll tell him about you so that he'll know

what's going on when you call him - okay? Thanks.

s

LDS Hospital

Salt Lake City, Utah

>>> taylorkb@... 01/10/01 05:06PM >>>

,

Do you have a person at your facility who handles your cost report

that

we could contact directly? Maybe some of the rules and regulations

change from state to state, but we only get reimbursed for the

transplant admit by Medicare according to the DRG, and then we file

the

cost report to (hopefully) recoup our acquisition costs yearly.

taylorkb@...

B.

Medical University of South Carolina

ton, South Carolina

>>> ldnsteve@... 01/05 12:48 PM >>>

Hi Mia - our center has actually had a lot of problems with this very

issue. Our local Blue Cross/Blue Shield has put a cap on how much

they

will pay for acquisition. Though I don't understand this fully, I do

know that you can " bill " Medicare as secondary for the acquisition

(which has to do with the cost report) but that your center will

probably not actuallly receive any money from secondary Medicare as

the

primary insurance almost always pays more (even without acquisition)

than Medicare would have anyway. Confusing.

So - in summary, the patient will not be left with the bill, and

Medicare will be billed for it through the cost report, but ultimately

the hospital does not get paid for the remainder billed to Medicare.

The person who does your cost report is thinking differently because

he/she sees, I think, that Medicare really does not " pay " for the

acquisition, nor anything as secondary usually. Again, I barely have

a

grasp on this, so I am not sure of all the details, just the

generalities.

Basically what it has come down to for us is whether or not the

hospital is willing to eat some of the acquisition charges in order to

receive the other payments.

Good luck

s

LDS Hospital

Salt Lake City, Utah

>>> mckelvem@... 01/04/01 08:00AM >>>

Hi,

Will Medicare cover the acquisition cost for a kidney transplant if

the

primary insurance carrier excludes the acquisition of the organ costs?

Medicare will not become primary for this patient until 6/1/02 The

plan

covers all other transplant related expenses except for the

acquisition of the organ.

Mia Bolton-McKelvey

Kidney/Pancreas Program

Medical University of S.C.