In the Kidney Paired Donation Pilot Project (KPDPP), donors may choose to have their nephrectomy performed at the hospital where their evaluation occurred. This arrangement allows the donor to remain close to his transplant team and support system for the nephrectomy and follow-up.
It also increases complexity for the donor and recipient hospitals. The kidney must be shipped and the hospitals will need to work together to coordinate finances. There may be some restrictions when the candidate is covered by Medicaid.
The KPDPP Financial Subgroup developed these guidelines to help transplant hospitals with the financial aspects in the KPD Pilot Project (KPDPP).
These recommendations are based on the following:
- The donor shall not be billed for any transplant related medical expenses per Medicare guidelines (Medicare Benefit Policy Manual 100-02, Chapter 11, Section 140).
- The cost of the donor’s transplant-related medical care follows the paired candidate pre-match and the matched candidate post-match.
Candidate Financial Screening
Financially screen potential candidates, per internal hospital policy, before entering the KPDPP, to ensure that they have appropriate insurance.
- Include an assessment of insurance coverage for the candidate and donor. Note if the candidate’s insurance excludes donor coverage or self-pay candidates).
- Counsel candidates to notify the transplant hospital of any changes in insurance coverage.
- If the candidate loses insurance coverage, inactivate the pair in the KPDPP until new insurance coverage is established.
- Confirm coverage prior to nephrectomy.
Medicaid only candidates
When the candidate is covered by Medicaid only, an exchange may be limited to the candidate’s state, as donation-related procedures would need to occur and be billed at the recovery hospital within that state’s Medicaid program.
If the exchange must occur in the candidate’s state,
- Confirm coverage for paired donation on each case before registering pair. Failure to do so may result in a financial liability for the patient and the hospital.
- Enter the appropriate information in the KPDPP application in UNetSM.
- For example: if the candidate needs to be transplanted in Virginia, go to the candidate choices tab and choose “Yes” for the question “Will candidate accept a shipped kidney?”
- Select only Virginia hospitals to only allow matches with donors in Virginia, or willing to travel to a Virginia hospital.
Managed Medicaid plans may provide coverage for out-of-state providers.
Donor Costs and Charges
- Pre-match and post-match living donor evaluation hospital and provider services
- Donor nephrectomy, surgical complications, and hospitalization
- Post-donation follow-up
For each KPDPP match, transplant hospitals need to comply with CMS guidelines and execute a KPDPP financial agreement between the transplant hospitals to address regulatory requirements and determine the agreed-upon billing method. All transplant hospitals involved in a match must agree to the same method of billing for donor costs, per CMS Provider Reimbursement Manual CMS Pub.15-1, Chapter 31; Section 3106: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1608.pdf, or the transfer of cost will not be compliant.
Transplant hospitals must treat the billing of KPDPP transplants consistently per the CMS Medicare cost reporting guidelines.
- Every donor cost recorded to the cost report must be associated with a named recipient: the paired candidate prior to matching and the matched candidate/recipient post-matching.
- Donor costs charged to the matched candidate/recipient transplant hospital are included in the donor recovery hospital acquisition cost center and Medicare Cost Report, then offset by the revenue received from the recipient hospital.
- Continue to bill the SAC to third party payers, including Medicare on the recipient’s claim, Departmental charges cannot be used for this purpose.
- The donor is associated with the paired candidate’s transplant hospital until the point of match.
- Donor evaluation costs prior to entering and matching in KPDPP remain with the paired candidate’s transplant hospital.
- Pre-match donor evaluation costs do not transfer to the matched candidate’s transplant hospital.
- Repeat or additional donor costs incurred after a match is found follow the donor’s matched candidate.
- Recipient transplant hospital documents requested testing in writing, and provides to donor hospital.
- Donor hospital bills the matched candidate/recipient hospital at the time of the transplant, using departmental charges method.
- Departmental charges are provided by line item and revenue code.
- Departmental charges are reimbursed at the line item cost-to-charge ratio, per the transplant hospital’s most recent Medicare Cost Report.
- The transplant hospital’s Finance and Medicare Cost Reporting team establishes processes to properly and compliantly transfer the costs of the donor for a paired donation transplant.
- When the exchange is terminated prior to transplant, the pairs go back into the KPDPP pool to wait for another match.
- Additional testing performed while not in a pending exchange follows rules for pre-match costs.
- If a new matched candidate is found for the donor, additional testing follows rules for post-matched costs.
Donor Surgery – Hospitalization Fees
- Donor hospitalization costs are covered by the matched candidate (individual who will receive the donor’s kidney)
- Donor hospital bills the matched recipient hospital at the time of the transplant using the departmental charges method
- Donor hospital Finance and Medicare Cost Reporting team establishes processes to properly and compliantly transfer donor costs for a paired donation transplant
Donor Surgery – Physician/Professional Fees
Physicians bill the recipient transplant hospital or recipient’s insurance for services rendered according to the following:
- If Medicare is the Primary insurance for the transplant recipient, physicians bill the Medicare carrier utilizing the recipient’s Medicare number
- If the recipient has commercial insurance, and the recipient transplant hospital does not have a “global” or “case rate” arrangement with a payor that includes reimbursement for both facility and provider charges, the donor’s providers bill the recipient’s insurance
- If the recipient has commercial insurance, and the recipient transplant hospital has a “global” or “case rate” arrangement with a payor that includes reimbursement for both facility and provider charges, the recipient transplant hospital will work with the donor hospital/providers to negotiate a mutually agreeable rate for the donor physicians/providers
Packaging and Shipping KPDPP Donor Kidneys
The costs of packaging and shipping a living donor kidney to their matched recipient’s transplant hospital is billed to the recipient’s transplant hospital and are allowable on the Medicare Cost Report. If shipping costs are embedded in other fees/charges, the shipping costs must be separated to be considered for reimbursement on the cost report.
The donor recovery hospital manages the donor and assess and treats any post nephrectomy complications that present after discharge. The determination of donor-related complications is solely at the discretion of the donor recovery hospital providers.
- The donor recovery hospital provides the recipient transplant hospital with documentation to support any claim for payment.
- If the donor experiences complications that are directly related to the donation, associated charges are generally billed under the recipient’s Medicare number.
- The donor recovery hospital send bills to matched recipient’s Medicare Part A or B or commercial insurer (per commercial insurer rules).
- If it is determined that the complications were not directly related to the donation, charges associated with the treatment of aforementioned complications, are billed to the donor’s insurance.
- For additional information refer to CMS Transmittal 2334,”Billing for Donor Post-Kidney Transplant Complication Services,” effective November 28, 2011.
- If Medicare is the Primary insurance for the transplant recipient, physicians and the hospital bill the Medicare carrier utilizing the recipient’s Medicare number.
- If the recipient has commercial insurance:
- AND the recipient transplant hospital has a “global” or “case rate” arrangement with a payor,
- AND the case rate includes reimbursement for both facility and provider charges with respect to donor complications,
- The donor recovery hospital is reimbursed as per the global agreement.
- Specify these arrangements in the KPDPP Financial Agreement.
- If Medicare is not primary:
- AND there is not a global arrangement,
- Both physician and hospital services are billed to the recipient’s insurance.
- If denied, and recipient has Medicare secondary, follow CMS guidelines and include denial from primary coverage.
- AND there is not a global arrangement,
- If there is no Medicare involvement, the hospital follows its internal policies.
Post Donation Follow-up
- For post-donation follow-up, follow the policy described in CMS Pub 100-02, Chapter 11, section 140.9.
- UNOS Policy 18.1 Data Submission Requirements for 6 month, 1 year, 2 year follow-up cannot be included in the organ acquisition cost center or separately billed to Medicare.
- Guidelines for payment for donor follow-up:
- If the matched transplant recipient has Medicare as primary insurer, follow CMS guidelines.
- If recipient hospital has a global arrangement with the matched transplant recipient’s hospital insurer, then both physician and hospital services shall be billed to the recipient hospital per the terms of the global agreement (ie complications within 30 days, 90 days, etc.).
- If Medicare is not the match transplant recipient’s primary insurance and there is not a global arrangement in place, then both physician and hospital bill the recipient’s insurance directly.
- If denied and recipient has Medicare secondary, follow CMS guidelines and include denial from primary coverage.
KPDPP Match Financial Checklist
Discuss information sharing with donors and candidates.
- There is no secure website to list recipients’ insurance information in UNet.
- Medicare providers and hospitals are considered covered entities under HIPAA, therefore, a separate agreement is not required. NOTE: 13.6.A Requirements for Match Run Eligibility for Candidates and 136.6B Requirements for Match Run Eligibility for Donors does require a signed a release of protected health information.
- Transplant hospital’s follow internal policies and procedures about educating and consenting transplant recipients and donors that demographic and financial information will be shared with the matched transplant hospital.
- To preserve confidentiality, establish a process to blind donor claims and anonymity throughout the KPDPP process.
- Educate and consent patients to the fact that while every effort will be made to protect their confidentiality, information may be shared.
Once a KPDPP match offer has been accepted by all transplant hospitals in the exchange:
1. Verify Medicare approval
At the time of the match acceptance, the recipient transplant hospital verifies donor recovery hospital CMS status.
OR - Requests the donor recover hospital sends a copy of their most recent Medicare-approval letter.
2. Review insurance information
- KPDPP primary contact (usually the living donor transplant coordinator) provides all matched transplant hospitals with name and contact information of the financial coordinator at their hospital.
- After preliminary acceptance by all transplant hospitals in an exchange, donor and recipient transplant hospitals obtain and review matched candidate insurance information to ensure that donor nephrectomy and transplant would be covered by the recipient’s insurance carrier.
- This review is time-sensitive and begins upon notification of match acceptance.
- If the match is not viable from an insurance perspective, the match can be refused and the exchange terminated allowing pairs to re-enter for the next match run.
3. Share information with matched transplant hospitals
The donor recovery hospital provides the donor’s demographic information (ie, name, date of birth and address, etc) via secured method to the matched candidate’s transplant hospital.
The matched candidate transplant hospital completes the KPDPP Financial Memo and provides the donor recovery hospital with information (to ensure donor’s providers will be paid by candidate’s insurance):
- candidate’s name
- insurance coverage information (policy name and number)
- authorization number
- case manager name and contact information (if applicable)
- Both donor recovery hospital and candidate transplant hospital review insurance information regarding potential match
- Recipient transplant hospital confirms recipient insurance covers donor at donor recovery hospital
- For example, if recipient is receiving a kidney from an out-of-state donor, does recipient have out-of-network coverage for donor’s providers?
- Donor recovery hospital confirms that all providers involved in the case are approved by candidate’s insurance (either in-network or authorized)
- Donor recovery hospital confirms how the donor nephrectomy charges will be paid (section 3.E)
4. Develop and execute KPDPP financial agreements
Each match requires an agreement between the donor recovery hospitals and their respective matched candidate. Elements of the agreement are to include:
- Description of Services and Exchange Process
- Representations and Warranties
- Billing for Transplant Services
- HIPAA and Applicable Law
5. Quality Assessment and Performance Improvement
- As part of the Quality Assessment and Performance Improvement (QAPI) program, transplant hospitals must ensure that there is a feedback system to address any adverse events that occur from a donation and subsequent transplant.
- If an adverse event occurs, there must be notification that an event has occurred and written communication between the two programs of the specific actions taken to prevent repeat incidences of the adverse event.
6. Submit bills for the donation and transplant as follows:
- Bill all candidate/recipient charges (facility and provider) to the recipient ‘s insurer
- Bill donor recovery hospital claims for nephrectomy to matched recipient transplant hospital using departmental charges method
- Bill donor provider charges to the matched recipient’s insurance or per mutual agreement prior to the donation (section 3.E)
- Some payers have indicated that they would prefer to pay providers directly, outside the global and reduce payment amount to the recipient transplant hospital. This is to be determined by each hospital upfront and included in the KPDPP Financial Agreement.
Note: There are no consequences for the transplant hospital who declines a match offer for any reason, including finances. UNOS requires transplant hospitals enter a refusal reason when a match is declined to assist them in working through the more common barriers and process improvement.