Federal regulators take aim at dialysis providers steering patients into private plans

Federal regulators take aim at dialysis providers steering patients into private plans

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Federal regulators are proposing a new rule that seeks to protect dialysis patients from being steered into private insurance plans that are more lucrative for dialysis centers but may not offer the best coverage option for patients.

The main aim of the new interim final rule, published Wednesday in the Federal Register, is to require dialysis centers to be more transparent with patients and insurance companies, the Centers for Medicare and Medicaid Services says.

The rule, which would go into effect on Jan. 14 after a public comment period, requires the more than 6,000 dialysis centers across the United States to provide comprehensive information about all local health insurance plans available to patients including risks and benefits associated with each.

CMS, however, warns it is considering banning third-party payments altogether when patients have the option of enrolling in Medicare or Medicaid.

Noting the magnitude of the potential financial conflicts of interest and “abusive practices,” the agency said in a written summary explaining the new rule, “We are unsure if disclosure standards will be sufficient to protect patients.” So the agency is asking stakeholders to comment on whether patients would benefit from further restricting premium assistance payments.

The new rule also requires dialysis centers to get insurers to agree to accepting third-party payments before helping a patient enroll in a private plan. Dialysis centers sometimes help patients get premium assistance for health insurance coverage from a third party, including nonprofit foundations. The measure to confer with insurers ensures the patient has consistent coverage throughout the year, the interim rule states.

But Tim Jost, a law professor at Washington and Lee University, wrote in Health Affairs that it is likely the new rule on third parties paying patient premiums will “effectively end the practice for most patients.”

The new rule also calls for dialysis centers to disclose to patients how much private plans pay for services.

CMS said steering patients to private plans poses three harms to patients: It can negatively affect their ability to receive a transplant, it potentially exposes patients to greater out-of-pocket costs and it puts patients at risk for losing insurance coverage midyear since some insurers do not accept third-party payments.

A transplant may not be available to patients who cannot show that they will have consistent insurance coverage after receiving the new organ.

“Since dialysis facilities typically stop paying premiums for coverage once the patient no longer needs dialysis, individuals insured through third-party payments may not be able to demonstrate continuing coverage and thus may lose their place in transplant queues,” Jost said in Health Affairs.

The American Kidney Fund, a nonprofit that helps patients pay for premiums, said in a statement that the move protects insurance companies at the expense of patients.

“The message to low-income kidney failure patients is loud and clear: the Affordable Care Act is not for you. In sending such a message, CMS sets a dangerous precedent for people with any chronic condition who depend on charitable assistance to afford premiums,” the foundation said.

Patient advocacy groups said they were “outraged” by the new rule that they say could cut patients off from their current coverage. Dialysis Patient Citizens, in a statement, said the rule allows insurers to discriminate against patients based on their health condition.

Federal regulators have been concerned about the practice of third parties paying for patient premiums, particularly within the dialysis industry.

Earlier this year, CMS requested comments from the public about the practice and received more than 800 from various stakeholders, according to the interim rule. What was disclosed in those public comments was used to craft the new interim final rule, it said.

In recent years, there have been large increases in end-stage renal patients enrolled in private plans, the agency said.

Thanks to the Affordable Care Act, patients cannot be denied health insurance due to pre-existing conditions. Prior to the Affordable Care Act, anyone, regardless of age, who was diagnosed with end-stage renal disease was eligible for Medicare coverage.

Still, dialysis centers have helped enroll patients in private health insurance plans, promising patients their monthly health insurance premiums would be covered by an outside group, such as the American Kidney Fund. Health insurance companies have complained the practice has caused sudden spikes in payments to dialysis centers and has caused instability in the individual market.

CMS fears providers are inappropriately steering patients to enroll in these plans based on the higher payments dialysis providers receive from private plans, the agency says. Typically, government-run programs such as Medicare and Medicaid pay less for services than private plans.

The agency is concerned that the dialysis centers may not be providing patients with a clear picture of the risks associated with private plans.

Dialysis is very costly and a lifesaving treatment for patients with failing kidneys, also known as end-stage renal disease.

Dialysis mimics the work of healthy kidneys by filtering out toxins from the blood. Patients receive outpatient dialysis treatment multiple times a week for hours at a time.

A recent Post-Dispatch article, which was cited by CMS in the interim final rule, discussed concerns that dialysis providers were trying to persuade patients to buy commercial insurance they did not necessarily need, saying their premiums would be paid by the American Kidney Fund and thereby obtaining more lucrative reimbursement arrangements than would be received from Medicaid- or Medicare-insured patients.

Samantha Liss • 314-340-8017

@samanthann on Twitter


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