Third Party Reimbursement

Conference on Ethical and Policy Issues Related to Solid Organ Transplantation in People with HIV

July, 2001 Cheryl Janov, RN, UPMC

The Pittsburgh Experience

28 patients cleared by third-party payers for solid organ transplantation

20 different insurers approved transplant 2 patients denied access 6 patients died while waiting an organ

donor 11 transplants occurred

– 4 kidney– 7 liver

Pittsburgh Experience Insurers include:

– Medicare via the Hospital Notice of Noncoverage process– Medical Assistance of Kentucky– Aetna US Healthcare– Blue Cross of Alabama– Guardian– Empire Blue Cross– Blue Cross of Texas– Medical Assistance of California– Trigon Health Keeper as secondary insurer to

Medicare

Pittsburgh experience Insurers cont’d

– Blue Cross of Utica– Blue Cross of Michigan– Blue Cross of California– United Health Care– Blue Cross of Maryland– Federal Blue Cross– Medical Assistance of New York– US Life– Coresource– Blue Cross of New Jersey– CHAMPUS under special care funds

Medicare Rules

Federal Register, Medicare Manuals, Local Medical Policy

No rule specifically precludes transplant for HIV positive people

When the rules are silent the local intermediaries have discretionary authority

Medicare Strategies

Issue individual HNN- “Medicare has no guidelines”– PRO review at 2 levels– Last appeal is to Administrative Law Judge

Request local coverage policy Request national coverage decision “At risk”

Investigational/Experimental General acceptance as effective and proven Safe and effective:

– Mortality– How often performed, where performed, success or

failure of the procedure– Reputation of centers and MD who are performing and

their record in related areas– Long term prognosis and lessons derived from related

procedures– Extent that the procedure and related areas in medicine

have developed rapidly

Advocacy: Essential Elements

Support– safe and effective– Not systemic infection/disease based upon lack

of opportunistic infection, projected survival with triple therapy, stable CD4 and viral loads

Enclose articles from refereed journals and protocol of the center

Advocacy: Essential Elements

Provide specific patient details that emphasize transplant is only viable therapy

Physician letter of advocacy or physician signature

Obtain written copy of appeal process Be Persistent!!!

Advocacy: Access to Care

The battle will either be fought at the referral stage or following evaluation

Provide center advocacy early in the referral process

Inability or difficulty obtaining insurance authorization for evaluation resulted in delays of care of 1 year or more

6 deaths while waiting

Suggestions

Maintain and update list of insurers approving transplant among the centers

Regular exchange of reimbursement information among centers

Consider reimbursement packet which contains bibliography, sample letters and strategies