1. Paired Kidney Reimbursement Center Experience
Sena Wilson-Sheehan, MBE
Revenue Integrity
UNOS Region 5 Collaborative Meeting Roundtable
March 16, 2017
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2. Sena Wilson-Sheehan, Senior Revenue Analyst, Mayo Clinic
Presenter Disclaimer
Sena Wilson-Sheehan, Senior Revenue Analyst, Mayo Clinic
The opinions expressed in this presentation are solely those of the presenter in her role at Mayo Clinic. The accuracy or reliability of the information provided herein are not guaranteed solutions or approaches. Please consult the appropriate Revenue and Compliance experts at your institutions.

4. Kidney Program 319 kidney transplants July 2015 – June 2016
56 living donor transplants
9 paired kidney transplants
Srtr.org kidney transplants. 56 were living donors. July 2015 thru June 2016 cohort. Show of hands, who is part of a program that is doing paired kidney transplants? Sharing Mayo Clinic blog.

5. Transplant Finance Team
Patient Access (eligibility and prior auth), Revenue Analysts (charge capture and billing compliance, revenue integrity), Management Accounting, Medicare Strategy Unit, Transplant Billing, Contracting.

6. Why is KPD Reimbursement unique?
The big challenge: getting donor expenses incurred at another center reimbursed by the recipient’s payer
Donor/recipient claims confidentiality, donor and recipient in different states, different payer contracts/participating status for donor charges, “global/case rate” lump payments, transfer of funds between institutions, Medicaid.

7. Mayo Clinic Locations
Initial challenges with FL transportation overcome. Internal database and matching.

8. Benefits of Internal Exchanges
Relationships
Straightforward
Fewer contracts
Access
Shared resources
Payer Contracts
Less cost
Expedient agreement on terms
Cross-site financial coordinator relationships
Shared billing and accounts receivable staff for support
Shared electronic medical record, accessibility of information
Same or similar payer contract terms and participation status at all sites
Limitation: Fewer matches, potential to increase patient benefit by expanding donor pool

9. Patient Access Considerations for KPD
Donor coverage?
Separate authorization?
Are the donor’s providers contracted with the recipient’s payer (including out-of-state benefits)?
Complications? For how long?
Most do, but we have challenges with Arizona Medicaid (AHCCCS). Most of our payers do not require a separate auth for the donor surgery, but one does. We do have one or two contracts where this could be an issue – not the same status at different sites. Complications coverage – varies with payer. Ask and document. One payer only covered complications for 10 days. Make sure coverage is active at the time of the event.

10. Donor Services Charge Capture
Evaluation - (Pre-match and Post-match)
Professional Services – Donor nephrectomy surgeon and anesthesiologist
Facility – Donor nephrectomy, transportation
Paired Kidney SAC vs. Donor Charges Reduced to Cost
History – Capture and be reimbursed for these via SAC fee for costs incurred to acquire the organ or departmental charges reduced to cost. We have done both. Ch 31 directs us toward departmental charges, but there are still programs and pilots working on the concept of a standardized paired kidney acquisition charge. Thoughts – billing would be simplified, surely, but standardizing cost is challenging – market differences, efficiency differences across institutions, etc. Before we get into departmental charges, let’s review what goes into a SAC fee.

11. Living Donor SAC Fee Definition – “average”
What costs may be included?
Cadaveric
Living
UNOS Listing Fees
HLA/Tissue typing
Preservation, perfusion costs
Transportation
Surgeon fees for excising cadaveric organs ($1,250)
Donor and recipient pre-tx eval and workup
OPO organ acquisition charges
Donor facility charges
SAC is an average. Represents “average of the total actual costs associated with procuring a cadaveric donor organ or a living donor organ, by organ type.” All costs (not just Medicare), direct and indirect costs. Refer to full list in Ch 31. No separate payment from Medicare, but do include on your facility claim. Commercial payers reimburse according to contract terms. Consider contractual adjustments when passing on a cost-based charge. What’s different about living donor SAC vs cadaveric SAC? Instead of OPO organ acquisition charge, include donor and recipient work up (all donors, even those that don’t donate) and facility charges.
Refer to CMS PRM, Ch 31, Section 3101.

12. Who puts this together?
When to prepare the SAC fee? What timeframe for data pull? Fee updates from OPO. Remember to consider what your commercial payers are paying you since this is only COST. Remember to keep your finance team close – we are motivated by the exciting work you are doing.

13. CMS Provider Reimbursement Manual Chapter 31, Section 3106 - KPD
Transmittal 471 April 1, 2016
MLN Matters SE1608
Donor costs follow the recipient
Donor Center “Safety Net” – counted as organ acquisition offset by recipient center payments
Departmental Charges over SAC
“CMS issued ch 31 of the PRM “Organ Donation and Transplant Reimbursement” to clarify Medicare’s payment policy regarding org acq costs, formerly found in ch 27.” Includes KPD accounting and reporting for cost report (3106)
Ch 31 – An effort to match “extras” with recipient center, donor services are reimbursed via the cost report at a minimum (safety net for donor centeR).
“Safety net” for donor surgery facility charges and packaging/transport
Departmental Charges = line item billing. Absorb other overhead and indirect costs
Defer highlights of organ counting to other speaker

14. Donor Center Donor Evaluation Pre-match (Donor MCR)
Post-match (Recipient Center)
Donor Procurement and Transportation
Costs counted as OAC and billed to recipient center
Payments received offset OAC
Donor Center
Recipient Center
Line item billing. Use Medicare cost to charge ratio for donor institution to reduce facility charges to cost.
Question – need to identify a process for “additional testing” pre-transplant – how will your billers know that these are at the request of the other center?
Costs /charges = CCR (example, 0.47) Where are these published? Medicare IPPS Final Rule Impact File.
Easy to track donor-to-recipient specific charges with internal exchanges
Best practice – separate accounts for paired kidney acquisition costs for the donor and payments received
Recipient Center

15. Donor Center (cont.) Donor Surgery Pro Fees
Bill to Recipient Medicare Part B MPFS
Routine Post-op Care
Global surgery payment
Recipient Medicare Part B MPFS
Donor Complications
Recipient Medicare Part A & B
Contractor review
Reminder (essentially the same as regular living donor for Donor Pro, Post-op, and Complications).
“Medicare does not consider the UNOS-required 6-month, 1-year and 2-year follow-up visits to be routine donor follow-up care. As such, the UNOS required follow-up visits are not allowable nor reported as organ acquisition costs on the MCR and cannot be billed to the recipient’s health insurance claim number “

16. Recipient Center Reimburses donor center for costs
Records payments made as organ acquisition, reimbursed via Medicare cost report
Provides Recipient Payer information
Reimburse donor center for post-match testing/additional requests. Count on Medicare cost report for known recipient.
Record all payments made for donor services to organ acquisition for reimbursement via cost report.
Provide insurance information as needed to donor center.

17. Medicare Example:
Section 3106

18. What about commercial payers?
Same logic for responsible party
Impact of the Recipient Center Contract
Global/Lump-sum payment
Fee for Service/Percent of Charges
Living Donor SAC Fee
Donor Center
Recipient Center
Donor Center
Recipient Payer

19. Commercial Payers (cont.)
Donor Services
Commercial Recipient (Reimbursement)*
Eval (pre-match)
Reimbursed via living donor SAC fee on recipient bill.
Repeats or additional testing post-match performed by donor center
Follows post-match recipient. Donor Center bills Recipient Center charges reduced to cost. Recipient Center reimburses Donor Center. Recipient Center reimbursed via living donor SAC fee on recipient bill.
Donor Surgery/Facility charges
Donor Center - Reimbursed by Recipient Center (charges reduced to cost). Recipient Center - reimbursed via living donor SAC fee on recipient bill.
Donor Surgery/Professional charges
1) If Recipient Center reimbursement is lump-sum payment from payer, Donor Center bills Recipient Center agreed upon rate. 2) If Recipient Center has fee-for-service contract, Donor Center bills recipient insurance directly.
Packaging and Transport
Donor Center reimbursed by Recipient Center. Recipient Center reimbursed via living donor SAC fee on recipient bill.
Routine Post-op Care
Complications
Following the same/similar logic for responsible party. Refer to NKR and OPTN guidelines (website or via internal contacts). Notes – some matching programs provide price per unit for anesthesia, or agree to bill a percentage of Medicare rates for pro services (150% or 200%). Agreements between centers may include that if the recipient insurance doesn’t cover the donor follow-up the recipient center will reimburse the donor center. Complications – Does the recipient contract payment include complications? What is your Center’s policy? NKR Donor Protection Program.
*Refer to individual payer policies and contracts for your institution
as well as OPTN, NKR, and other guidelines as applicable.

20. In Summary Give your finance team a good seat at the table
Review compliance guidelines and reimbursement policies annually
Develop reimbursement grids/tools
Achieve mission advancing financial performance!

21. Thank you!