What is End-Stage Renal Disease (ESRD)?
End-Stage Renal Disease (ESRD) is a diagnosis given to patients when their kidneys no longer function. Without dialysis or a kidney transplant the patient will die from accumulated waste in the blood.
How do people get End-Stage Renal (ESRD) Disease?
The main causes of End-Stage Renal Disease (ESRD) are diabetes and high blood pressure. These two diseases left untreated may eventually destroy the kidneys ability to effectively filter waste from the blood.
How is End-Stage Renal Disease (ESRD) diagnosed?
End-Stage Renal Disease (ESRD) is diagnosed when a patient’s glomerural filtration rate falls below 15 mil/min. This calculation looks at your blood creatinine, age, weight, race and gender.
What type of doctor will I see for my End Stage Renal Disease (ESRD) diagnosis?
Nephrologists treat patients with End-Stage Renal Disease (ESRD).
What is the treatment for End-Stage Renal Disease (ESRD)?
The treatments for End-Stage Renal Disease (ESRD) are dialysis and kidney transplant.
What can I expect during a dialysis treatment?
You can expect to be in the facility between three and four hours resting comfortably in a chair. You will be in a large room with limited privacy in most cases.
How often are the treatments needed?
Most patients receive their hemodialysis treatments three (3) times a week at a free standing dialysis center. The other options are daily home hemodialysis six days a week or peritoneal dialysis seven days a week. Patients are encouraged to explore and discuss all treatment options with their doctor.
Will End-Stage Renal Disease (ESRD) go away or are treatments for life?
End-Stage Renal Disease (ESRD) is permanent. Without a kidney transplant, the patient will require dialysis for the rest of their life. Acute renal failure on the other hand is not permanent and the kidney function eventually returns.
Where is treatment for End-Stage Renal Disease (ESRD) provided?
End-Stage Renal Disease (ESRD) services can be received at the hospital, free-standing dialysis clinic or at the patient’s home.
Who provides End-Stage Renal Disease (ESRD) treatment?
End-Stage Renal Disease (ESRD) treatments are provided by large dialysis chains and smaller local facilities. The providers of care at the dialysis facilities include Nephrologists, Nephrology nurses, Patient Care Technicians and Social Workers.
Can I choose where I go for End-Stage Renal Disease (ESRD) treatments?
Patients have the right to choose where they receive their dialysis treatments. In some communities, they have numerous provider options to choose from while other areas only have one choice.
Can I do dialysis at home?
Home dialysis is a great option for some patients, but it may not be right for everyone. Ask your doctor if home dialysis is a viable option for you.
What are the advantages to home dialysis?
Home dialysis keeps the patient out of the dialysis facility and in the comfort of their own home. This allows the patient to be treated at their convenience; they are not bound by the schedule of a facility. It also keeps the patients away from a large population of sick patients which can prevent sicknesses and possible infections. The treatment schedule of six or seven treatments for home dialysis is also better for the patient because it mimics the body’s kidneys and does not allow waste to build up like it does for patients treating 3 times a week in the facility.
What is the difference between hemodialysis and peritoneal dialysis?
Hemodialysis removes the blood from the body and filters it through a dialyszer before returning clean blood back to the body. Peritoneal dialysis uses dialysate in the peritoneum to remove waste by osmosis from the abdominal wall.
Can I travel and still get my dialysis treatments?
Yes, many facilities treat traveling or so-called transient patients. It’s important to find a facility and make arrangements prior to your travel.
How long does each dialysis treatment last?
Dialysis treatments vary by modality. In center hemodialysis treatments typically last between three and four hours and daily home hemodialysis treatments typically last 2 hours. Peritoneal dialysis takes longer as it is a more passive modality.
Is there anything I can do to prevent getting End-Stage Renal Disease (ESRD)?
Some of the best ways to prevent End-Stage Renal Disease (ESRD) are to remain active, eat healthy, avoid smoking and have regularly scheduled physicals that include routine blood work. Patients that develop diseases like Diabetes and High Blood Pressure early can delay the onset of End-Stage Renal Diseasse (ESRD) and sometimes prevent kidney damage altogether.
Does insurance cover End-Stage Renal Disease (ESRD) treatment?
Insurance will typically cover dialysis treatments as the primary payer for the first 33 months of service, but since not all plans are created equal it’s best to speak directly with your insurance carrier or health plan administrator to confirm your benefits. After paying primary for 33 months, a commercial insurance payer (either a fully insured insurance carrier or self-funded health plan sponsor) becomes the secondary payer and Medicare becomes the primary payer.
Do dialysis treatments require prior authorization?
Maybe, that would depend on the design of the insurance policy or health plan. Patients are encouraged to consult their insurance carrier or health plan administrator before beginning dialysis treatments.
Does insurance cover all the costs of End-Stage Renal Disease (ESRD) treatment?
All insurance plans are different and not all are created equal. The amount of the claim that is covered by the insurance company is dictated by the insurance policy or Summary Plan Description (SPD) or Plan Document. Most End-Stage Renal Disease (ESRD) patients are eligible for Medicare the fourth month after they begin dialysis and this coverage picks up any balances not covered by their primary insurance. Medicare is the secondary payer for dialysis patients for thirty (30) months and then Medicare becomes the primary payer and the commercial insurance becomes secondary.
How much does End-Stage Renal Disease (ESRD) treatments cost?
The range in cost for dialysis can vary greatly depending on numerous factors. The average cost for a Medicare patient is roughly $3,500 per month. The average cost to commercial insurance plans varies from patient to patient and facility to facility, some pay $3,500 and others pay over $100,000 for a month. Patients are encouraged to get pricing information from their dialysis providers before they begin treatment.
Are there programs for uninsured End-Stage Renal Disease (ESRD) patients?
Most dialysis centers have some sort of free care program depending on the patient’s income and expenses. There are also programs through the American Kidney Foundation and National Kidney Foundation that can assist patients with payment for their insurance premiums.
How does Medicare help End-Stage Renal Disease patients?
End-Stage Renal Disease (ESRD) is a unique disease because it entitles patients to Medicare coverage. This coverage can be primary if the patient has no current insurance coverage or it helps patients with balances that are not paid by their primary insurance.
Do I have to buy Medicare if I have End-Stage Renal Disease?
No you do not. Patients can defer their Medicare enrollment or they can enroll in only Medicare Part A and defer their enrollment into Part B.
How much does Medicare cost End-Stage Renal Disease patients?
Medicare Part A does not have a premium. Medicare Part B costs $96.40 or $110.50 for patients already enrolled and having their premium withheld from their social security benefit. For all others, the monthly premium is $115.40.
If I stop working and go on COBRA, will my health plan still pay for End-Stage Renal Disease treatments?
If you go on COBRA, someone will pay for your End-Stage Renal Disease (ESRD) services. The key issue for End-Stage Renal Disease (ESRD) patients that go on COBRA is when they obtain their COBRA coverage and when they become entitled to Medicare part B. Health plans have the right to drop coverage for COBRA covered members of the plan when the patient becomes eligible for any other insurance. Because End-Stage Renal Disease (ESRD) patients are entitled to Medicare after a three month waiting period they could be at risk for losing their COBRA coverage. The best way for patients to be sure they won’t lose their COBRA coverage is to wait until after they have Medicare for End-Stage Renal Disease (ESRD) before they stop working or they could simply defer enrollment for Medicare part B and they could keep their COBRA coverage.
What is the medical coding associated with End-Stage Renal Disease diagnose and treatment?
The ICD-9 Diagnosis code of 585.6 is the most telling sign. CPT codes associated with End-Stage Renal Disease (ESRD) are: 90935, 90999, 90945, Q4081, J1756 and J2501.
How can insurance claim professionals impact dialysis treatment costs?
Identifying patients before they begin their dialysis treatments is the first step to having an impact. The next step is to work with someone that can use this information to find a reasonably priced facility with a good fee schedule.
What’s a good discount on dialysis claims?
A good discount will vary based on the amount the provider charges for services. The final cost for a month of service is the most important issue.
Can I pay at the PPO rate for the first three months and then UCR for all other months of dialysis?
This is not permissible as it is differentiating benefits between Medicare and non Medicare beneficiaries.
What is differentiation of benefits between those with Medicare secondary coverage and those without Medicare secondary coverage?
Differentiation is paying claims one way before a patient has secondary coverage through Medicare and then paying differently when they have Medicare.
What is Medicare secondary coverage?
It is secondary coverage that patients can obtain to augment their commercial insurance coverage and it prevents providers from balance billing the patient for services that are not covered in full. This is a good value for patients as it prevents balance billing for services not covered by their primary insurance.
Can you always use UCR to pay for dialysis treatments?
If it is supported by the insurance policy, Summary Plan Description (SPD) or Plan Document you can pay for dialysis treatments using UCR.
Where do I get UCR data to properly adjudicate dialysis claims?
Only a select number of firms offer UCR data for adjudicating dialysis claims. When searching for a firm to provider dialysis UCR, please be sure to ask them: (1) about the experience of the individuals who prepared the UCR database; (2) ask them how long them have been in business; (3) ask them about legal challenges to the UCR data; (4) ask them about turnaround time for repricing claims; and, (5) ask them what are their rates for providing you with dialysis UCR. Armed with this information you should be able to select a dialysis UCR vendor.
What I can do to reduce an increased specific deductible (“laser”) on renewal?
One method is to look at the insurance policy, Summary Plan Description (SPD) or Plan Document to determine how the plan language can be strengthened so UCR can be used as an option for paying claims since UCR generally will provide the maximum savings.