Plasma Exchange & Medicare
September 12, 2011 at 3:37 pm
Been a while since I’ve posted, as I had a long run with no decline in my physical situation and got lazy. Unfortunately, the disease has again become very active. My insurance status has changed from a private group plan to medicare parts A&B with a supplemental. Doctor has started me back on IV prednisone infusions, but they are not showing any results (500 mg three consecutive days once a month).
In the past, plasma exchange has always been my go to treatment, and has always helped, but I can’t get an answer from medicare regarding payment for this treatment. They said I have to have the treatment and when the bill is submitted they will make a decision and if it is denied, I have the option to appeal. If the appeal fails I get stuck with the total cost.
Is anyone on medicare having plasma exchange and the cost paid through medicare? Thanks for your help.
AnonymousSeptember 12, 2011 at 7:09 pm
That’s a good question. In an ideal world, the provider of the service you want will have a Financial person. Sit down and talk to them. You have to get past the front desk workers.
If you have medical service or condition code (ahh hha, I got it now- a diagnosis code) the provider can determine, immediately, if the procedure is covered.
Why? If a procedure is not covered, and the provider has not had you sign an Advanced Beneficiary Notice (ABN), then the provider does not get paid.
What you need is a determination which tells the provider this procedure is covered, or this procedure MAY NOT be covered. Hopefully, you get the former answer.
September 12, 2011 at 7:26 pm
Thanks for the response. Medicare supplemental pays the deductible and co-payments for medicare approved services, which is where the problem is. Medicare will not tell you up front if a procedure is covered, thus you do not know about either coverage until after the services are used.
This is why I am hopeful someone has been down this road and knows first hand about PE coverage.
Unfortunately, IVIG hasn’t worked for me in the past on a consistent basis. I did get some short term relief using the Gamunex brand (other brands had no effect) for about a year, but heart problems forced me to discontinue it.
You would think medicare would have a pre-cert division like private insurance, but I guess that would be too efficient for the government.
September 13, 2011 at 12:57 pm
Was not familiar with the ABN, but will now check it out. When I asked my doctor about medicare coverage, he said have to “make a case” for the PE treatments, but did not mention the ABN, nor that medicare would tell the provider if a procedure would be covered.
Will also check out the link provided. Thanks for the feed back.
AnonymousSeptember 13, 2011 at 6:28 pm
Yes, it is essential that anyone on Medicare have a thorough understanding of the purpose of an ABN. In particular, how an ABN affects your pocket book, and that of the provider.
However, in response to your original question regarding plasmapheresis see the following:
1. Medicare National Coverage Determinations Manual
If you cannot open a .pdf document please download either the free Adobe Reader or the free Foxit PDF reader.
After you open the document go to section 110.14 Aspheresis (Therapeutic Pheresis) Section B, bullet #10 (or so)
2. For clarification on why some procedures were denied, in the past, please see: [url]http://www.apheresis.org/apheresis_reimbursement/[/url]
In the article the explanation includes this “…[I]On occasion, Medicare contractors have denied payment for apheresis services based upon the lack of evidence that the apheresis professional was personally present to the patient during the entirety of the procedure….”[/I]
It is helpful to read the entire article to understand the reasoning, and resolution, of this roadblock.
Another document, dated Dated November, 2000 the [U]Medicare Coverage Issues Manual [/U] also has inf on this. See section 35-60 bullets 10 and 13
AnonymousSeptember 13, 2011 at 6:35 pm
I forgot to mention that if a provider does not have you sign an ABN for a procedure either not covered, or maybe not covered, not only does the provider not get paid- [COLOR=”Red”]You Don’t Have to Pay Either![/COLOR].
Believe me, the Provider will make sure the procedure is covered or make sure you have signed an ABN.
September 15, 2011 at 8:43 pm
On some of the links suggested, and others I found from those searches, most of the guidelines separate apheresis and plasma exchange. They define theraputic pheresis as extracting the plasma and returning only the processed blood vs plasma exchange which returns a plasma substitute such as albumin. The CMS guidelines state theraputic pheresis for CIDP, but do not list plasma exchange which is some what confusing.
When you have your procedure, do you have just the pheresis or the complete exchange?
The info on the ABN was very helpful and I will ask my doctor about that when I see him next week. Appreciate the responses and helpful links. Thanks everyone.
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