Question: As Medicare has expanded bundled payments, have commercial/managed care payers done the same? I have heard that commercial rates for dialysis services can be two to three times what Medicare pays. Is this the same for skilled nursing facilities (i.e., commercial payers paying the Medicare RUGs IV rates)? 

This question was submitted by John M. Cousins, senior vice president healthcare intelligence, CIT Healthcare, Tallahassee, Fla. (john.cousins@cit.com). 


Answer 1: For dialysis and nursing home commercial/managed care, payers have had bundled rates for years and, generally, include those items previously excluded outside the composite for dialysis. With any payer, the rates depend on one’s negotiating leverage. I have seen higher commercial/managed care reimbursement for both services anywhere from 25 percent to 80 percent higher than Medicare, but it varied depending on the facility’s market share. 

This question was answered by Caswell Samms, III, vice president of revenue cycle, St. Barnabas Hospital, Bronx, N.Y., and a member of HFMA’s Metropolitan New York Chapter (csamms@sbhny.org).


Answer 2: I am in agreement with Samms. The commercial rates are driven by the local market and negotiating power. I see some percent-of-charge agreements in addition to bundled rates.

This question was answered by Michele Marcum, hospital contract executive, Humana, Inc., Meridian, Idaho, and a member of HFMA’s Idaho Chapter (mmarcum2@humana.com).


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Publication Date: Monday, March 25, 2013