Recent News

Dialysis dispute targets billing, health

A patient receiving blood dialysis treatment. (Photo: Khajornkiat Limsagul, via Shutterstock)

Dialysis patient Mike Adames is grateful for the premium assistance he receives from the American Kidney Fund to stay on his Kaiser insurance plan.

The Madera patient says he likes his Kaiser doctor and has no desire to switch to publicly funded Medicare, even though he qualifies.

But if Senate Bill 1156 is approved, Adames likely wouldn’t get that choice. The bill would require that patients like him receiving third-party assistance would either need to enroll in Medicare or Medi-Cal (for those who are low income), or if they choose to stay on private insurance, they will only receive reimbursement at Medicare or Medi-Cal’s much lower rates.

“They are running up profits by enrolling people in (private health insurance) unnecessarily and that is increasing costs for all other consumers as well.” — Sean Werley

Commercial coverage pays up to 10 times what public insurance pays ($4,000 per treatment vs. $300 per treatment according to the Senate floor analyses).

The bill has moved to the Assembly, where it will be considered by the health committee June 26. Debate over the bill pits unions and insurance committees against the America Kidney Fund, the California Dialysis Council, the California Hospital Association and others.

Supporters of the bill say that what the American Kidney Fund is doing, while seemingly noble on the surface, amounts to a scam to get dialysis providers higher insurance reimbursements. The American Kidney Fund is 80 percent funded from dialysis providers such as DaVita and Fresenius, said Sean Wherley, spokesman for bill supporters Service Employees International Union and United Healthcare Workers West.

Wherley says the dialysis providers are abusing the system.

“They are running up profits by enrolling people in (private health insurance) unnecessarily and that is increasing costs for all other consumers as well.”

Her bill would also require third-party payers like the American Kidney Fund to pay the premiums for a full plan year even if the patient stops treatments that benefit the provider.

Wherley said a similar situation is occurring with some substance abuse rehabilitation centers. According to a 2017 investigation in the Orange County Register, some rehab centers pay for addicts to sign up for insurance and then run up bills for unnecessary services to get high insurance payments.

Sen. Connie M. Levya, D-San Bernardino, the bill’s author, said in a March statement that the problem dates back to the passage of the Affordable Care Act, which states patients cannot be denied health coverage based on a pre-existing condition.

“This profound advancement for consumers has also provided an opportunity for dishonest providers to take advantage of sick people by enrolling them in commercial coverage to maximize high reimbursement rates for services,” she said. “Oftentimes, this coverage is not in the best interest of the patient, results in higher out-of-pocket costs or disruption in care and is being imposed upon consumers even though these patients are eligible for public coverage like Medicare or Medi-Cal.

Her bill would also require third-party payers like the American Kidney Fund to pay the premiums for a full plan year even if the patient stops treatments that benefit the provider.

The American Kidney Fund in April agreed to extend patient premiums to the full plan year from a few months.

Mary Ellen Grant, spokeswoman for the California Association of Health Plans, said the bill separates the bad actors from the good actors. She emphasized that people with End Stage Renal Disease always have access to coverage from Medicare. Groups like the American Kidney Fund, she said, “are not really moving the people into commercial coverage for the patients’ benefit.”

Holly Bode, vice president of government affairs for the American Kidney Fund, said the bill is very harmful to dialysis patients and would make it “extremely difficult’ for them to receive private coverage.” The fund currently offers premium assistance to more than 3,800 California dialysis patients.

The American Kidney Fund in April agreed to extend patient premiums to the full plan year from a few months, a move Werley says was in response to bad publicity.  Bode denied that and said the group was already planning to extend insurance payments.

Adames had to suddenly leave his job as a GM service technician and wasn’t able to go back.

Mike Spigler, vice president of patient services and kidney disease education at the American Kidney Fund said the premium payments are “not the quid pro quo that bill sponsors make it out to be,” pointing out that about half the providers with patients in the program do not contribute.

He added that 30% to 40% of dialysis patients find out they need the treatments suddenly. They are no longer able to work and face the prospect of suddenly losing their job-sponsored health insurance. There is a waiting period to get on Medi-Cal and Medicare that can be up to 90 days, Spigler said. The American Kidney Fund’s premium assistance help patients keep their health insurance and not get dropped.

Adames, the Madera dialysis patient, said he received an early morning call from his doctor last fall telling him to go to the emergency room because his kidneys were failing. He had to suddenly leave his job as a GM service technician and wasn’t able to go back.

He doesn’t want to leave Kaiser in Fresno, where he has a primary care physician and is used to the level of service.

“I would not like my service to be interrupted,” he said. “I don’t like to have things forced down my throat.”

Ed’s Note: Corrects spelling of Wherley, 6th-9th grafs, puts number at 3,800, 14th graf.

 


Support for Capitol Weekly is Provided by: