When I began my adventure in renal billing, I was looking for an opportunity to make a meaningful contribution to society. I did not yet understand the dialysis industry and the challenges small dialysis programs and their patients faced each day, but I quickly learned. I felt that the one small thing I could do to ease their burden was to make sure patient claims for dialysis services were paid correctly and benefit issues were handled smoothly.
Over the years, I began to learn about the advantages that the large dialysis organizations (LDOs) have over the small, independent programs that I was used to working with. Due to their size, LDOs can negotiate better purchase rates for medications and supplies, are able to obtain significantly better rates with commercial insurance companies, and, in some instances, prevent independent programs from getting contracts with a payer.
I was fortunate enough to learn from dialysis facility staff about the challenges they face in treating their patient populations. My company has worked with dialysis programs that help patients with limited resources get set up with food, housing, and transportation services. This knowledge really drove home the understanding that the small, independent programs I worked with were the underdogs and their patient populations were counting on them to provide the treatment they needed to stay alive.
On the other end of the spectrum are large insurance companies—which, just like dialysis programs and nephrologists, play an integral role in a patient’s healthcare. When a patient enrolls with an insurance plan, they agree to follow a set of guidelines and make their premium payments each month and the insurance company agrees to reimburse the medical providers that render medical services covered by the insurance policy. What happens if the patients and dialysis program follow the insurance company’s guidelines, but the insurance company refuses to pay?
The dialysis program has an obligation to continue treating the patient because patients with ESRD need dialysis or a transplant to sustain life. Depending on the renal network they are in, it may be difficult to transfer the patient to a different dialysis program. A reader of this column wrote to me recently to ask for guidance on how to resolve a specific situation in the dialysis program where they work. The reader’s dialysis facility is in the same building as a well-established nursing home that shares common ownership and is contracted with all area insurance companies. The facility has been Medicare certified for quite some time but has been out of network with some of the large commercial payers that administer Medicare Advantage plans in their area. While working to get contracted with these large commercial payers, the facility has been careful to only admit patients to the dialysis unit that have out-of-network benefits. When the facility began submitting claims to the commercial payer that insured the largest portion of the dialysis program’s Medicare Advantage patients, they received denials requesting copies of documentation the insurance needed to load the dialysis facility into their system. After submitting the requested documentation, the dialysis program expected that their claims would be reimbursed. Instead, the insurance company denied the claims a second time and requested different documentation.
These denials continued for months but eventually the facility was successful in escalating their problem to a supervisor at the insurance company. Much to the surprise of the dialysis facility, the supervisor claimed that their hands were tied, and they were unable to process any of the dialysis facility’s claims due to a system issue outside of their control. When the dialysis facility asked the claims supervisor what could be done, the supervisor told them that the system issue needed to be resolved yet offered no further guidance. This situation has left the dialysis facility without reimbursement from the insurance company for nearly two years.
Unfortunately, situations like this happen to small independent dialysis programs and nephrologists more often than they should. If you are a small dialysis program or small provider and are struggling with a difficult reimbursement situation, know the requirements the insurance company has for disputing denied claims and follow them, document your actions in resolving the denied claims and continue to escalate the issue until it receives the attention of someone who can resolve the problem. If you are an insurance company in receipt of claims from a small dialysis program, do the right thing and pay the claims if they meet your guidelines for coverage.
Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome, and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.