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Session Reading

 

Advanced Achievement in Transplant Management

 

Claims & Contract Terms: Applying Terms to Contract Cases

 

 

This section of the AATMC addresses the larger concept of applying contract terms to a fictional case and evaluating the impact on claims. There is an emerging trend in which reinsurers and MGUs have been moving transplant cases to nurses with proven transplant experience because of the enormous cost implications of transplants gone-bad. A post test must be passed before this section is complete.

 

Section Objectives:

 

•     To become aware of the four phases of the standard transplant contracting process and how they relate to the standard candidate evaluation through transplant

      •     To become familiar with the length of time and accrued costs occurring within each phase

      •     To become familiar with the contract terms that apply to each section

      •     To understand the composition of the repriced case rate package

•     To understand in the post transplant phase, the claims transition between transplant center to local community

 

 

 

The Four Phase Transplant Contracting Process

 

For contracting convenience purposes, most centers and most networks contract using a standard four phase transplant format. For 2008, Milliman USA (most prominent consulting firm for transplant frequency and cost predictions) forecasted a transplant frequency of 15.6 transplants to occur annually from a population of 100,000 members under the age of 65. Considering that only 50% of the identified transplant candidates actually progress all the way to transplant an AATMC nurse must be able to determine and direct likely transplant candidates to appropriate centers for improved outcomes for their condition. Acknowledging that candidates drop-out for various reasons at various times, the transplant contract process has been segmented into evaluation, pre-transplant, transplant, and post-transplant care.

 

Phase 1: Evaluation

 

Defining the stage: The Evaluation often begins in the candidate’s local medical community and finishes at the transplant center. In the past, transplant centers rarely accepted the test results of specialists from the local treating professionals, but more and more often, test results can be forwarded to the transplant center. With advanced planning and communication some evaluations can be done in one day, while more complex transplant evaluations may last one week or longer. Although there may be no clear start date, there will be a definite end date. At the conclusion of the evaluation, the transplant center will provide their recommendation and declare the patient a transplant candidate or not, which would lead to UNOS listing for solid organ transplant candidates and authorization to proceed for bone marrow transplant

(BMT) candidates.

 

 

Relevant Contract Terms:

 

 

“Centers of Excellence” networks do not offer their clients a complete copy of the network/facility contract; what most do supply is a contract summary in various formats detailing relevant terms. In those summaries, some of the following terms will be listed:

 

Pre-Transplant Discount – Hospital: This contract provision addresses hospital charges; often all hospital charges are included such as inpatient, outpatient, laboratory and pharmacy. In the past many of the evaluations came with a mini phase case rate, but given that parts of the transplant evaluation occur outside the transplant center, they are less and less common. Most network contracts offer a percent discount for services rendered at the transplant center. Claims and services from the local community are not covered under the network contract and local PPO discounts and/or negotiations must be arranged by the nurse case manager.

 

Pre-Transplant  Discount  –  Professional:  Unless  specifically  excluded  on  the  contract summary, this contract provision is applied to all professionals involved in the evaluation at the transplant center. There are a few professional evaluation case rates, but most centers offer this service under a percent discount. Claims and services from the local community are not covered under the network contract and local PPO discounts and/or negotiations must be arranged by the nurse case manager.

 

Mechanical/Implantable Devices: In some instances, such as heart failure, mechanical devices are surgically implanted as a bridge to transplant. Devices are severely marked-up (200-300%) and those costs must be addressed. COE networks have negotiated provisions for such instances. One provision is that the plan agrees to pay invoice cost, or invoice plus a reasonable percentage additional for profit, for the device. Another provision may be that it is included in the case rate, but often there will be a maximum achievable discount.

 

Housing: Housing discounts and provisions are seldom included in the evaluation part of a network contract, although important for all traveling candidates. Networks and transplant center coordinators will work directly with the nurses to identify housing options for potential transplant candidates. Since most centers have subsidized housing, and not all transplant candidates travel, networks do not negotiate their costs. This is an important task for nurses to consider.

 

Evaluation Approximate Costs

 

To provide you with some sense of the costs involved with a transplant evaluation, please refer to the table listed on the next page. Most COE networks do not capture and discount all these costs, because these projections include services provided at the transplant center plus those provided at the local level. Network discounts apply to hospital and professional services rendered at the transplant center only.

Referral Timing / Other Case Management Considerations

 

It seems as though more and more INTERLINK network referrals (and likely those of our competitors) are referred after the evaluation has already occurred or in the process of being completed. From a case manager’s work prospective, this could mean more time allocation spent on negotiation/PPO discount arrangement for services rendered at the non-transplant center. Those claims should not be directed to the network.

 

Phase 2: Pre-transplant Care

 

Defining the stage: The pre-transplant phase begins once the evaluation is complete and the patient is listed or authorized for transplant. This phase can be very short for emergent transplants, or can last years for those candidates waiting for a cadaveric donor transplant. Many solid organ and bone marrow candidates wait and prepare themselves for transplantation in their local community and transition to the transplant center as their condition deteriorates.

 

Relevant Contract Terms:

 

“Centers of Excellence” networks do not offer their clients a complete copy of the network/facility contract; what most do supply is a contract summary in various formats detailing relevant terms.  In those summaries, some of the following pre-transplant terms will be listed:

 

Pre-Transplant Discount - Hospital: This contract provision addresses hospital charges; often all hospital charges are included such as inpatient, outpatient, laboratory and pharmacy. In the pre-transplant phase case managers help candidates deal with progressively more complicated disease management issues, and monitor their status on the waiting list for solid organ transplants as  their  condition  deteriorates.  Inpatient  per  diems  can  be  very valuable, along with  center

dialysis and percent discounts on many of the general hospital services.

 

 

 

 

 

Non-Transplant   Center   Related   Care:   With   much   improved   communication   between transplant centers and local treating physicians, candidates spend much more time in their local community during this phase. Case managers must arrange PPO discounts or negotiate those claims.

 

 

 

Marrow Harvest, Marrow Acquisition and Mobilization Provisions: Although these services and costs are incurred before the transplant, in most instances those claims are pulled aside and included in the case rate. Some BMT candidates will not progress to transplant and in this instance these services will then be paid under the pre-transplant provision. As a case manager, it is important to understand these terms.

 

NMDP  Search:  A  search  of  the  NMDP  (National  Marrow  Donor  Program)  for  a  suitably matched unrelated donor will likely occur in the pre-transplant phase of care. These services usually have a provision specific to the search which the facility funds at the time a search is initiated. The most common provision will have these searches passed through and paid at the cost of the facility.  Keep in mind the search identifies a possible match and is not the acquisition of the cells, which will normally fall into the case rate.

 

Housing/Accommodations: Candidates and their families spend time at the transplant center before and immediately after the transplant. Some wait for quite some time. Unless they wait on an inpatient basis, those claims fall outside most network agreements.

 

Pre-transplant Approximate Costs

 

It is nearly impossible to provide an estimate for pre-transplant costs. Most services during this period are related to disease management. Although they are disease related, most often, network pre-transplant discounts will be applied at the transplant facility. For some, this phase is very short, but incurs great costs as the center seeks to stabilize and prepare the candidate for transplant.

 

Referral Timing / Other Case Management Considerations

 

Even if the evaluation is complete and the candidate is waiting in their community, it is best to make sure the pre-transplant agreement is in place. All networks accept referrals in this phase.

 

Phase 3: Transplant Phase

 

Defining the stage: Most network contracts will include all organ, professional and hospital services into a  single  case  rate  in  the  transplant  phase  unless  specifically  noted  in  the  contract  summary  as  an exclusion. As a general rule, solid organ transplant case rates begin one day prior to transplant, and include hospital, professional and organ acquisition charges for a defined period of time. BMT case rates generally start seven days prior to reinfusion (transplant) to capture all ablative therapies and reinfusion prep services, and include hospital, professional and marrow harvest/acquisition fees for a stated length of time.

 

Relevant Contract Terms:

 

“Centers of Excellence” networks do not offer their clients a complete copy of the network/facility contract; what most do supply is a contract summary in various formats detailing relevant terms. In those summaries, some of the following transplant terms will be listed:

 

Case Rate Inclusions: It is important that case rates address all aspects of the transplant episode. It  is  most  common  for  case  rates  to  include  all  hospital,  professional  and  marrow/organ acquisition charges in some fashion. Organ/marrow acquisition terms may be outside the case rate, but there should be specific negotiated terms.

 

Case Rate Length of Stay (LOS): There are two types of case rates: one is the classic structure where there is a defined inpatient LOS which ends upon discharge from the inpatient hospital stay or has additional payment provisions for days of care beyond the case rate LOS; the other is a bank-of-days model which includes all care, whether rendered on an inpatient or outpatient basis, for a set amount of days. Most BMT case rates are now banks-of-days, with more and more of the solid organ case rates migrating to that model as contracts are renegotiated.

 

Lesser-of Provisions: This in an important term to consider, especially when the case rate is high. This provision is activated when the billed hospital, professional and organ/marrow charges total less than the case rate. There are centers like Johns Hopkins Hospital that do not negotiate this specific term, and your client may have to pay the case rate total amount, even if charges are less. It is often a nominal discount, but a great outcome transplant can total much less than a case rate.

 

Stop Loss Provisions: There are many kinds of terms hospitals negotiate to protect themselves from catastrophic losses due to a case rate. Generically, they are called “stop loss provisions” and what they have in common is that they all limit the size of the discount in some way. Pay specific attention to this provision and ask the network how they work because there is a huge difference

on the size of the discount they allow.

 

Phase 3 – Estimated Transplant Episode Billed Charges & Example Network Payable Amounts

 

The data table contains information gathered from many sources. Although BMT harvest, ablative therapies and marrow acquisition costs are incurred before the transplant, most networks negotiate those costs into the case rate. The Total Estimated Transplant Costs information was gathered from the 2008 Milliman USA Research Report, which includes claims information from COE centers along with costs from non-COE centers. A good outcome transplant incurs fewer billed charges, and thus provides lower payable amounts.

Referral Timing / Other Case Management Considerations

 

It is important that you make a referral and complete all network arrangement tasks with the network, before  the  transplant  occurs.  Emergency  and  weekend  transplants  are  often  allowed  access  to negotiated agreements from the transplant center, but routine transplants are seldom allowed access. Network transplant billing often occurs in different departments in transplant centers and the process of cancelling claims, rebilling claims and all the associated collection and reconciliation problems make transplant centers hesitant to back-date agreements.

 

As the table above clearly shows, even with a network discount, the transplant bill will be large. Standard payment terms for hospital bills is 30 days from receipt, so as an AATMC candidate it is important that you communicate and prepare the parties paying the bill to recognize the discounts. Networks can often extend payment terms if needed, but you must communicate with them in advance. Some network centers do not extend payment terms under any circumstance, which is out of the control of the network. Each year, there are cases in which hundreds of thousands of dollars of savings are lost because of late payments. Reinsurers have different viewpoints on instances where self-funded employers lose discounts because of late payment, and your client may not be reimbursed for lost discounts. Some reinsurers have early reimbursement programs, so check with them on large claims before they are billed…it may help

you help your client and the reinsurer in a tight situation.

 

 

 

 

Phase 4: Post Transplant Phase

 

 

 

Defining the stage: The post transplant phase either starts upon discharge or at the conclusion of the bank-of-days in the case rate. Some network contracts provide a 90-day window of claims in the case rate and others a discount for up to one year. These services are good for inpatient, outpatient, hospital and professional charges. Most networks offer a percent discount from billed charges.

 

Relevant Contract Terms:

 

“Centers of Excellence” networks do not offer their clients a complete copy of the network/facility contract; what most do supply is a contract summary in various formats detailing relevant terms.  In those summaries, some of the following post transplant terms will be listed:

 

Re-admission  Provisions:  These  are  special  terms  should  the  member  be  admitted  for  an inpatient stay within a specified period of time after discharge from the transplant event.

 

Re-transplant Provisions: Many networks negotiate special terms should the recipient require a transplant within the transplant admission or within 10 days post discharge. This provision is mostly applicable to solid organ transplants.

 

Post Care Follow-up Provisions:  Many recipients stay in the area for 30 days, then transition back to their local network of care. This provision is typically a percentage discount and is good for up to one year post discharge. Typically in place for the one year post transplant evaluation.

 

Phase 4 – Estimated Post Transplant Episode Billed Charges

 

The data table on the next page compares and contrasts selected information gathered from two sources: inflation adjusted 2007 USA post transplant projections and 2007 INTERLINK actual post transplant billed charges. For reinsurance budgeting and planning purposes, the inflated Milliman numbers are used. The INTERLINK numbers are lower for three reasons: 1) good outcome transplants often have fewer complications resulting in lower post transplant service needs; 2) a majority of INTERLINK transplants occurred at COE centers; and 3) transplant candidates spend a short period at the transplant center (unless it is in their immediate vicinity) and the remainder of the charges are incurred in their local community. Transplant networks do not collect or reprice claims coming from the recipient’s local community.

 

As an AATMC candidate, it is expected that you become familiar with these costs and are able to pass them along in your reports to TPAs, MGUs, Reinsurance carriers and consultants. What is interesting to note in this example is how much transplant follow-up care is likely occurring outside the transplant center. It is important that you focus much attention on the costs and utilization of services in the local community too.

 

Referral Timing / Other Case Management Considerations

 

Part of your goal is to educate candidates on the benefits of a good outcome transplant. This decision is likely one of the most important decisions they will make and will control the quality of their life thereafter. This section also points out the benefit of planning the discharge and taking control of the services rendered in the recipient’s local community.