Guest guest Posted April 29, 2002 Report Share Posted April 29, 2002 One issue we are just now encountering is that even if the patient has Medicare at the time of transplant with a grp policy paying prime, Medicare is indicating that if they did not PAY for the transplant they will not cover the immunosuppressive drugs. It was my understanding that the only requirement for drug coverage for Medicare was that you have it at the time of transplant not that they would pay for the organ transplant. Medicare is also resistent to sending information in writing when requested. They indicate it will be approved at the time the service is rendered. This is not acceptable for patients to blindly have to undergo expensive procedures with no information regarding coverage by Medicare. Thanks for your help. Bev Larson, Norfolk, VA . >>> LAguiar@... 04/26/02 09:56AM >>> Hi everyone, As some of you probably know, the NKF, AST, ASTS, & DOT sponsored a meeting in May in Philadelphia to " Analyze the Wait List for Kidney Transplantation " & in their Executive Report from this conference Access to the Waitlist (or lack thereof would probably be a better wait to put it) was discussed. Among the specifics mentioned was the issue of COE's & insurers who mandate their members utilize these centers, even if there are non-COE ctrs more local to the pt & more easily accessible. It was felt that these mandates can actually be a deterrant to some pts who would otherwise proceed with transplantation. Plans are in the works for a follow-up conference in NY in June focusing on Access issues & I've been asked to provide a list of additional issues, similar to the one I just mentioned, that might impact or deter a pt from proceeding with tx as a sort of jumping off point for the conference. I'd like some input from this group as I know there may be regional issues which you deal with regularly that I'm unaware of, but that should also be included. A couple of other issues that I came up with off the top of my head include the VERY limited Rx coverage most of the Medicare HMO's now offer, unrealistic caps on organ acquisition charges, lengthy review process' by insurers & lack of tx knowledge by some of the reviewers. Thanks everyone, J. Aguiar Beth Israel Deaconess, Boston Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 29, 2002 Report Share Posted April 29, 2002 Wonder who she's talking to. Re: Access to Tx One issue we are just now encountering is that even if the patient has Medicare at the time of transplant with a grp policy paying prime, Medicare is indicating that if they did not PAY for the transplant they will not cover the immunosuppressive drugs. It was my understanding that the only requirement for drug coverage for Medicare was that you have it at the time of transplant not that they would pay for the organ transplant. Medicare is also resistent to sending information in writing when requested. They indicate it will be approved at the time the service is rendered. This is not acceptable for patients to blindly have to undergo expensive procedures with no information regarding coverage by Medicare. Thanks for your help. Bev Larson, Norfolk, VA . >>> LAguiar@... 04/26/02 09:56AM >>> Hi everyone, As some of you probably know, the NKF, AST, ASTS, & DOT sponsored a meeting in May in Philadelphia to " Analyze the Wait List for Kidney Transplantation " & in their Executive Report from this conference Access to the Waitlist (or lack thereof would probably be a better wait to put it) was discussed. Among the specifics mentioned was the issue of COE's & insurers who mandate their members utilize these centers, even if there are non-COE ctrs more local to the pt & more easily accessible. It was felt that these mandates can actually be a deterrant to some pts who would otherwise proceed with transplantation. Plans are in the works for a follow-up conference in NY in June focusing on Access issues & I've been asked to provide a list of additional issues, similar to the one I just mentioned, that might impact or deter a pt from proceeding with tx as a sort of jumping off point for the conference. I'd like some input from this group as I know there may be regional issues which you deal with regularly that I'm unaware of, but that should also be included. A couple of other issues that I came up with off the top of my head include the VERY limited Rx coverage most of the Medicare HMO's now offer, unrealistic caps on organ acquisition charges, lengthy review process' by insurers & lack of tx knowledge by some of the reviewers. Thanks everyone, J. Aguiar Beth Israel Deaconess, Boston Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 30, 2002 Report Share Posted April 30, 2002 I don't believe we have ever come across this issue of Mcare not paying for immunos if EGHP prime at time of transplant. When we were researching Therapeutic Apheresis coverage for high PRA patients I had some contact with Medicare B. They had told me to fax my question to a Tully, Educational Outreach . I was suprised to hear back from her within a few days. I guess it's worth a shot. Sherri Sbalbi Transplant Division Baystate Medical Center Springfield, MA ---------- From: BEVERLY A. LARSON To: TxFinancialCoordinators Subject: Re: Access to Tx Date: Monday, April 29, 2002 1:53PM One issue we are just now encountering is that even if the patient has Medicare at the time of transplant with a grp policy paying prime, Medicare is indicating that if they did not PAY for the transplant they will not cover the immunosuppressive drugs. It was my understanding that the only requirement for drug coverage for Medicare was that you have it at the time of transplant not that they would pay for the organ transplant. Medicare is also resistent to sending information in writing when requested. They indicate it will be approved at the time the service is rendered. This is not acceptable for patients to blindly have to undergo expensive procedures with no information regarding coverage by Medicare. Thanks for your help. Bev Larson, Norfolk, VA . >>> LAguiar@... 04/26/02 09:56AM >>> Hi everyone, As some of you probably know, the NKF, AST, ASTS, & DOT sponsored a meeting in May in Philadelphia to " Analyze the Wait List for Kidney Transplantation " & in their Executive Report from this conference Access to the Waitlist (or lack thereof would probably be a better wait to put it) was discussed. Among the specifics mentioned was the issue of COE's & insurers who mandate their members utilize these centers, even if there are non-COE ctrs more local to the pt & more easily accessible. It was felt that these mandates can actually be a deterrant to some pts who would otherwise proceed with transplantation. Plans are in the works for a follow-up conference in NY in June focusing on Access issues & I've been asked to provide a list of additional issues, similar to the one I just mentioned, that might impact or deter a pt from proceeding with tx as a sort of jumping off point for the conference. I'd like some input from this group as I know there may be regional issues which you deal with regularly that I'm unaware of, but that should also be included. A couple of other issues that I came up with off the top of my head include the VERY limited Rx coverage most of the Medicare HMO's now offer, unrealistic caps on organ acquisition charges, lengthy review process' by insurers & lack of tx knowledge by some of the reviewers. Thanks everyone, J. Aguiar Beth Israel Deaconess, Boston Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 30, 2002 Report Share Posted April 30, 2002 What about the HIPAA ruling that states no patient should be sent outside a 75 mile radius for services that is available within a 75 mile radius of their residence? We have had problems with most HMO's & contacted the Department of Insurance in our state (TX). We were told at that time that because the way in which the HMO's contract for transplants only, the patients could be sent outside the 75 mile radius. However, for all other plans, the ruling stands. Patients seem to be their own best advocate so I would always recommend patients involvement in this as they are better able to persuade the insurance company, usually with the help of the employer. n, Austin, Tx >>> McIlvaineJ@... 04/26/02 11:54AM >>> Hi all - We just submitted an RFP to Aetna. Apparently they now contract with 170 transplant centers across the country and want to reduce this number substantially. We have been told that they will direct all transplant business (HMO, PPO, etc) to Centers of Excellence with no coverage for patients who want to go elsewhere. Our Managed Care Dept. believes that BC is going to follow this same model. This would have major implications for centers not included in these networks. Has anybody heard more? Jan Re: Access to Tx , With regards to Cigna and your facility as not being part of the LifeSource Network, " negotiations " is an option. My advise is to have the patient or insured go to Human Resources and to make a statement or a threat that insured will sue if transplant is not approved. In most cases and with my personal experience, I believe that the case managers makes the final determination without consulting with the medical director. With the medical director involved, chances are the transplant will be approved. Will just have to come to terms as far as negotiations. I just finalized a case this AM, negotiations were NOT an option because Cigna's case manager was adamant about the patient's strict HMO with no o-o-n benefits. To make the long story short, recipient and donor (Living-related) contacted medical director and TXP was approved at an Out-of-Network facility. , specially with your situation, no LifeSource network w/in your area, you have a good chance getting txp approved. It's worth a try. Good Luck ! Sioson NY Presbyterian Hospital Renal TFC wrote: > > This is a subject which I deal with on a daily basis. I have been dealing with > CiGNA and they now have the Life Source network for transplant. There is not > a facility in this part of the PA which is in this network. A patient from the Pittsburgh area would need to go to Philadelphia area for a network transplant facility. They do not even offer lodging or transportation , how ever if pt does not go to facility they would have a $2250. out of pocket. Our contracting department is looking into this issue since we participate with Cigna and also InterCore, but are not in the LifeSource network for transplants. > Another issue we have is one Medicare HMO from this area does not have a facility in Penna which a patient can go for a heart transplant, they must > be referred to Ohio, this seems unfair to pts when there are two facility's in this area that do heart transplants but patients must be referred to Ohio, > > There is also one HMO in this area Health Plan of the Upper Ohio Valley > which can have a $3000 per year cap on prescriptions. Case managers will > assist patients with pharmacy assistance programs. Many patients are not > aware of the limited coverage they have until we tell them on the eval day. > > There is also a problem with getting verification of coverage that is reliable. > Many insurance companies will not put in writing what benefits they quote > you, I have had occasions where incorrect information was given by the > insurance company, in one case they authorized pt to be transplanted her because they had on tape me asking the ins company if we were in network for a transplant and told yes, when a center of excellence applied which we were not part of. > > Another issue we have with the state of PA they will only issue PER numbers of two month, so you are constantly calling the state to renew an > PER number. > > These are some of the daily issue's that are faced here in the Pittsburgh area. > Good luck with this issue, let me know if I can help. > > M1@... > > ********************************************************************** > This email and any files transmitted with it are confidential and > intended solely for the use of the individual or entity to whom they > are addressed. If you have received this email in error please notify > the West Penn Allegheny Health System at and contact the > > Information Security Department at telephone ext.1746. > > This footnote also confirms that this email message has been swept by > MIMEsweeper for the presence of computer viruses. > > www.mimesweeper.com > ********************************************************************** > > > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.