Below is an example of a common conversation being had with brokers several times a week. Since the Circuit Court Rulings late last year allowed Large Dialysis Organizations (LDO’s) to weaponize the Medicare as Secondary Payer Act (MSP), many plans are “hedging their bets” and “hoping for the best” as plans that are using a multiple of Medicare present new, massive risks to the plan. If you are a risk manager, “betting” and “hoping” are not comfortable places to be, especially now when LDO’s can systematically win against plans repricing dialysis using a multiple of Medicare.
How did we get here?
Historically, multiple of Medicare has worked for repricing medical claims; however, it does not work for dialysis repricing. First, with so many variables, it is impossible to determine with any confidence exactly what Medicare would pay for each unique dialysis claim. This alone is shaky ground that presents risk to lose repricing appeals. Add profiteering LDO’s who are litigious and willing to fight for every dollar. It is easy to see how we got here. Using a multiple of Medicare for dialysis is too risky for any health plan.
A Settlement Strategy is Not a Strategy
I am trying to get my head around “settlement strategy.” Based on what I have heard and seen in the marketplace, some of the smartest plan architects take a “we’ll wait and see” approach to repricing methodology, thinking that this is not a “high-risk” that they will lose on appeal. Often, they do not even build it into their short term or long term stop loss.
Now, since the Virginia Mason ruling, the court delivered a hefty precedent for plans using a multiple of Medicare for dialysis repricing, handing LDO’s double damages for three years of claims. Given the fact that claims cost for dialysis amount to about $1.4 million each year, double that and multiple it by the number of years the patient has been on the plan for up to three years. The result could be catastrophic to any group. And it follows that plans that must settle one dialysis re-pricing appeal, are going to have to settle them all. Those who find themselves here are likely to be stuck in that holding pattern for the next dialysis claim and the next.
Our Proactive, Proven Risk Management Strategy
There is a way to protect your plan when it comes to dialysis repricing. The Amy’s Kitchen Ruling validated Renalogic methodology as a safe harbor alternative for plans currently using a multiple of Medicare for dialysis repricing. Our clients save 78% off dialysis claims including claims and fees. They receive legal support and get the most defensible methodology for repricing. Plus, we are putting an end to surprise dialysis claims with CareINSIGHTS.ai, we show our clients their highest risk and claims cohorts, then managing those risks to slow, stop and even reverse their progression toward dialysis. We are on a mission, driven to reduce risk related to chronic kidney disease (CKD) and dialysis.
Learn how to fix the risk to your health plan, contact us today.