Although low in occurrence, patients experiencing dialysis treatments can incur annual medical expenses that approach $1 million per year.  These expenses can have a crippling effect on a self insured employer group health plan and cause significant increases in stop-loss premiums as well.

Relevant Healthcare Cost Containment’s (RHCC) Dialysis Claims Settlement Program saves an average of up to 90% off billed charges and often as much as 75% off standard PPO rates.  Billed charges can and do vary by a large margin.  However, our program normally saves $300,000 to $750,000 each year.

RHCC utilizes a unique approach to saving money including negotiated settlements, Dialysis Pre-Authorization or Carve-Out programs, and U&C adjustment recommendations.

  • Our first option is to attempt a negotiated settlement with the provider.
  • Our second option is our Dialysis Pre-Authorization program which has the provider contact the payer prior to the first treatment.  At that time, Relevant Healthcare is contacted and an agreement is attempted and structured.
  • The third option is the review of the entire Summary Plan Document (SPD) to determine if the plan’s provisions contain a usual customary and reasonable (UCR) limitation or provision. If the SPD contains a UCR provision that is compatible with our database methodologies, we would suggest an adjustment recommendation based on UCR.
  • Our fourth option is to create a Dialysis Carve-Out Program whereas dialysis remains a covered benefit and reimbursement methodologies defined, but outside of the primary PPO that is being utilized by the Plan.

Our average turnaround time for settlements is only 2 days. Should you need a case rushed, just ask and we’ll do our best to accommodate.

Average time for U&C adjustment recommendations is also 2 days. As with settlements, we accept special requests for expedited repricing.

Average savings history:

  • In-network claims using a signed release/settlement:   33%
  • Out-of-network claims using a signed release/settlement: 71%
  • Using an adjustment recommendation based on UCR: 90%
  • Implementing a dialysis carve-out program:   *91%+

*varies based on the multiple of Medicare utilized

Appeals happen. No program exists without appeals. And, when an appeal is received, we are here to help. We will review the provider’s appeal and provide you with a prompt response that can be used to formulate your own response.

FAQ

What are dialysis treatments?

Dialysis treatments remove waste and toxins from the blood of a patient suffering from renal failure, allowing them to live without the natural ability to clean their own blood.  Patients can be treated with Hemodialysis, which removes blood from the body and filters it through a machine and returns the cleaned blood back to the body, or Peritoneal Dialysis, which uses the peritoneum and a neutral solution called dialysate within the patient’s peritoneum to remove the waste by osmosis.

What is “ESRD”? How long does this illness typically last?

End Stage Renal Disease (ESRD) is the point when the kidneys stop working and can no longer adequately remove waste toxins from the blood.   ESRD is often the result of untreated diabetes and/or high blood pressure.  ESRD is permanent so the only way to reverse the condition is through a kidney transplant.

Why is dialysis so expensive? Why do charges range from $40K to $100k per month?

The biggest factor in the price rise of dialysis is the consolidation of the industry.  There are two major providers that make up two thirds of all dialysis facilities in the country.   Both are publicly traded companies that need to please their stock holders as well as their patients.  Another reason dialysis is so expensive is due to the patient mix.  For the average dialysis facility, approximately 85% of their patients are primarily covered under Medicare/Medicaid and the remaining 15% of the patients have commercial insurance as their primary coverage.  The providers often shift costs to the commercial payers to make up for the lower reimbursement rates paid under the aforementioned government programs.

How does Medicare apply to dialysis?

Medicare maintains a separate category for ESRD patients.  Patients become eligible to apply for Medicare on their first date of dialysis.  The majority of dialysis patients have Medicare part B as their primary payer.

How long should we wait before we send you our dialysis claims for discounts?

The earlier we receive notification from the payer the better the chance of our success.  Please review the codes below which can be used to identify impending dialysis cases as well as existing cases.

We recommend looking for the following codes that could indicate a dialysis patient is on the way:

  • ICD-9-CM: 585.1 to 585.6,  585.9 and 586
  • ICD-10-CM: N18.1 to N18.6,  N18.9 and N19
  • CPT Codes: 36800, 36810, 36815, 36011 and 36147
  • The following codes indicate that a patient has started treatment already:
  • HCPCS/CPT:  J0882, J0886, J1270, J1756, J2501, J2916, Q4081, 90935, 90937, 90940, 90945, 90947, 90989, 90993, and 90999

Can becoming trained in home dialysis affect the Medicare waiting period? 

Yes.   When a patient completes home training, the three-month waiting period for ESRD Medicare is waived and the 30-month coordination period begins.

Can transplant patients have more than one Medicare ESRD Coordination Period?

Yes, if the patient’s kidney transplant fails after the 37th month, there is an additional 30month coordination period with Medicare as the secondary payer, although there is no three-month waiting period in the second coordination period.

Can we pay the first three months of dialysis differently than the remaining 30 months?

No, payers should pay the claims with the same methodology in the first three months as they pay the claims for the remaining 30 months of the coordination period.

Why can’t I just buy a dialysis machine?

Only a doctor can purchase a dialysis machine and a patient needs a prescription from a doctor to start dialysis.

What is a dialysis pre-authorization program?

It is a cost-saving program where group health plans add a dialysis pre-authorization phone number to their benefit card requiring dialysis providers to call Relevant Healthcare before patients begin treatment. This first point of contact with the provider is when allowable charges are first discussed and we work to negotiate the best possible rate.

What is a good example of plan verbiage?

Good plan verbiage provides group health plans the means to prudently manage their assets by clearly defining covered, non-covered, excluded and allowable charges.

Click here to view a savings report for ONE patient over the course of only 10 months of dialysis treatment.