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ESRD Dialysis Treatment Claims | Payers Reduce Costs Up To 90%

February 23, 2022 ESRD Dialysis

As a health insurance payer, you know the underlying complexities of End Stage Renal Disease claims management. With frequent treatments, provider charges can quickly add up to hundreds of thousands, and even millions, of dollars per patient.

When that happens, payers can start to feel like they're behind the eight ball. At H.H.C. Group, our advice is simple—don't let that happen.

H.H.C. Group has payer-tested, purpose-built solutions to significantly reduce your claims amounts and streamline the claims management process.

The nexus between the group health plan, CMS patient eligibility, and provider charges can easily become blurred with ESRD patients. Patients face decision support timelines related to CMS guidance and policies regarding applying for Medicare Part B coverage.. Missing these timelines can quickly cost payers hundreds of thousands of dollars.

We apply a combination of technology, experience, and bulldog tenacity to maximize claims reductions. We have purpose-built solutions for health insurance payers managing costly, complex ESRD claims. Interested in hearing more? Get in touch with one of our experts today.

In this blog, we're going to drill down into three critical areas of ESRD claims management:

  • Why Are ESRD Treatment Claims So Complex And Expensive?
  • What Are The Important Claims Metrics And Decision Points?
  • Are Cost-Effective, Strategic Solutions Available?

Why Are ESRD Claims So Complex And Expensive?

CMS offers some initial guidance:

(ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. Beneficiaries may become entitled to Medicare based on their ESRD. Benefits on the basis of ESRD are for all covered services, not only those related to the kidney failure condition.

Medicare is the secondary payer to group health plans (GHPs) for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the number of employees and whether the coverage is based on current employment status.

We're going to drill down into the roles of the group health plan vs. Medicare, as well as the timelines involved.

But first, we're going to look at the costs involved in ESRD treatments.

There are three common types of dialysis treatments defined by the National Kidney Foundation. Hemodialysis requires the patient to visit a dialysis center, where they are physically connected to a dialysis machine called a hemodialyzer.
Peritoneal dialysis, sometimes called ambulatory dialysis, can be done in the patient's home. This type of dialysis allows the patient freedom of mobility. The two types of peritoneal dialysis, CAPD and APD, differ in the mechanism for delivering and draining the fluid to and from the patient's belly.

With CAPD, filling and draining the fluid is done manually by the patient. With APD, the process is automated using a machine called a cycler, often while the patient is sleeping.

Dialysis centers typically charge upwards of $5,000 to $7,000 per treatment.

At three treatments per week, hemodialysis costs can quickly explode up to $750,000 - $1,000,000 or more—per patient, per year.

Annual costs for peritoneal dialysis treatments are similar.

GHPs are looking for claims reduction solutions that are payer-tested and proven to work. So what are their options?

Let's Look At The Important Claims Metrics And Decision Points.

ESRD Decision Points

First, we need to dig a little deeper into the CMS guidance. There are several timelines that payers need to be aware of:

  1. The time it takes for CMS to determine if the patient is eligible for Medicare Part B after applying—90-120 days
  2. The time (Coordination Period)during which the GHP is the primary insurer/payer and Medicare is the secondary insurer—30 months after Plan B eligibility approval
  3. The time after the initial 30 months— Medicare becomes the primary insurer and remains the insurer as long as the patient maintains ESRD based eligibility.

It's important to note that the Plan is the primary insurer/payer during the second timeline, and Medicare is the secondary.

So what does this all mean for the self-insured payer?

Cost-Effective, Strategic Solutions Are Available For ESRD Patients.

ESRD Cost Effectiveness

Here's how the reduced claims management process works:

  • H.H.C. Group charges a percentage of savings during the qualification period—the period of 90 to 120 days after applying for the Medicare ESRD benefit
  • H.H.C. Group charges a flat fee per treatment for the next 30 months until the patient goes on Medicare

Sound simple? It is when you have a team of experts working for you.

We have helped our payer clients save up to 90% on ESRD treatments. That can translate into upwards of $750,000 per year, per patient in some cases.

Using our proprietary process, our team of experts negotiates a flat fee for ESRD treatments based on Medicare rates.

It's important to note that some will charge a percentage of the group's savings throughout the 30 month period after Medicare accepts the patient. That tactic strips savings away from the GHP. At H.H.C., we charge a simple, easy-to-manage flat fee and pass on the savings to our clients for the entire 30 month period.

Our business model ensures that your net savings are significantly higher during the 30 month period after Medicare acceptance. If needed, HHC Group can also provide plan document modification assistance.

H.H.C. Group is your go-to strategic partner for ESRD claims management.

ESRD Expensive Claims

Would you like to reduce your expensive ESRD claims by up to 90 percent? Let our team of claims professionals walk you through some real-life case studies where we accomplished that. We've saved our payer clients upwards of $750,000 per year, per patient, in some cases.

We've structured our strategic flat-fee model to pass the savings through to our payer clients. Let H.H.C. do the heavy lifting for you. We'll design the right ESRD claims negotiation strategy to fit your group's needs.

Using bulldog tenacity to reduce medical claims!

Why do health insurance payer organizations partner with H.H.C. Group for claims management?

At H.H.C., we are a group of legal and clinical experts laser-focused on negotiating the best possible billing outcomes for you. We provide significantly reduced claims costs, exceptional quality of service, and super-fast turnaround times for our clients. That's why so many health insurance payers partner with H.H.C.

Let H.H.C. take a bite out of your medical claims!

Why wait? Get in touch with one of our claims specialists today to discuss your customized ESRD claims reduction solution. Call 301-960-7092, or schedule a meeting today.