• Reimburses for evaluation services separately
  • Covers care for the patient while waitlisted separately through the cost report (i.e., reimbursed at 100% of cost)
  • Covers organ acquisition costs through cost report (i.e., reimbursed at 100% of cost)
  • Pays for the transplant as a bundle, which includes a post-transplant global period (90 days)
  • After the global period has ended, covers post-transplant services separately
Guidebook
PLEASE SEE OUR REIMBURSEMENT GUIDE FOR MORE INFO.
Download
WEBINARGo To WEBINAR

We look forward to sharing a series of webinars to help you become more familiar with coding, billing, and Medicare cost reporting for lung perfusion and associated services.

MEDICARE REIMBURSEMENT FOR EVLP

While transplant procedures are reimbursed under the Medicare Inpatient Prospective Payment System (IPPS), EVLP is covered and reimbursed separately through the Medicare Cost Report

Transplant centers are not required to obtain approval from local Medicare Administrative Contractors (MACs) for the use of perfusion services

However, each MAC may request additional/different documentation; we recommend contacting your Part A MAC for more information

CLINICAL
  • Transplant centers pay OPOs a pre-determined standard acquisition charge (SAC), which is based on average total actual costs that are considered “reasonable and necessary” to procure organs from deceased donors
  • A transplant center may seek reimbursement from Medicare for additional organ acquisition expenses when using organs from a deceased donor, including preservation and perfusion costs
TRANSPLANT
  • Medicare uses Medicare Severity Diagnosis-Related Groups (MS-DRGs) to classify hospital stays according to patient attributes
    • Attributes include principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status
    • MS-DRG 007 = lung transplantation
  • Medicare reimburses the Certified Transplant Center (CTC) for the organ transplant based on the primary MS-DRG applied to the hospital stay
    • High cost patients may qualify for outlier payments

MEDICARE PAYMENT & RECONCILIATION PROCESS

DURING THE YEAR
  • Transplant centers accrue SACs and additional organ acquisition expenses
    • This includes all costs for all insurance types and costs to acquire organs that may have been discarded
  • Medicare provides biweekly payments based on organ acquisition charges filed by the hospital on previous cost reports
AT THE END OF THE YEAR
  • Transplant centers report all allowable organ acquisition costs to Medicare on the cost report
    • Once submitted and accepted, the Part A MAC has 60 days to review
  • The MAC issues a tentative settlement before the end of the CTC's fiscal year based on the CTC’s past audit history
    • A final, reconciled payment is issued once the cost report has been accepted, reviewed, and potentially audited

Medicare Payment & Reconciliation Process

Total cost for all organ acquisitions (all payers)

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Medicare Usable Organs Divide Total Usable Organs

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Medicare payment to CTCs for organ acquisition costs

COMMERCIAL PAYERS

  • Generally cover pre-transplant evaluation, waitlist services, organ acquisition costs and transplant as one bundle, with post-transplant global periods
  • Post-transplant global periods can vary dramatically (e.g., 30-180 days)
  • After the global period has ended, cover post-transplant services separately
  • Patients who are evaluated or treated but not transplanted are generally reimbursed on a fee-for-service basis outside of a bundle
Guidebook
PLEASE SEE OUR REIMBURSEMENT GUIDE FOR MORE INFO.
DOWNLOAD

COMMERCIAL REIMBURSEMENT FOR EVLP

While Medicare has a cost-based reimbursement model for perfusion services, most commercial insurers pay one lump sum to transplant centers for a transplant patient

  • This single payment is intended to cover care the patient receives while waitlisted, organ acquisition costs, the transplant, and a post-transplant global period
  • Post-transplant global periods vary by payer (e.g., 30-180 days)
  • After the global period has ended, post-transplant services are covered separately
  • Payer contracts may also provide additional payments for high-cost, outlier patients
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Commercial payers will not pay the bundle if the transplant is not completed

This can affect transplant centers as there are significant costs associated with evaluating lungs

Checbox

LBE only charges its fee when the lung is used in an actual transplant, which reduces costs in cases where an organ is not used

ACCOUNTING FOR EVLP IN COMMERCIAL CONTRACTS

  • Transplant centers have a variety of commercial contracts, and including EVLP costs could require renegotiation
  • Many payers use a “transplant benefit manager” to negotiate transplant contracts on their behalf, which could streamline the process for a large portion of the patient population
  • WE OFFER

  • A reimbursement guide for EVLP services
  • Assistance in understanding reimbursement for EVLP
  • Training on using the budget tool to estimate EVLP costs
  • Monthly webinars to educate transplant centers on cost reporting and general reimbursement for perfusion services
  • This information, along with clinical data to support the use of EVLP services, can be used in contract discussions to warrant additional dollars for perfusion
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