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AHIP, Blue Cross, SEIU Seek Action on Dialysis 'Gaming'

News  |  By John Commins  
   April 17, 2018

Insurers, unions, consumer groups urge CMS to re-issue a rule on steering in the individual market and prohibit third-party premium assistance payments made by a financially-interested party.

An unlikely ad hoc group of insurers, businesses, unions, and consumer groups want the federal government to crack down on what they say is the inappropriate steering of Medicaid and Medicare-eligible patients with end stage renal disease into higher-paying commercial coverage.

The group said dialysis providers are "gaming" a provision in the Affordable Care Act that allows them to provide premium assistance for patients enrolled in Exchange plans through a "financially interested third party – the American Kidney Fund."

In exchange for the premium assistance, the dialysis providers collect higher reimbursements from commercial plans, even though the patients are Medicare- or Medicaid-eligible.  

"What may appear to be innocent assistance to a patient, may in fact be an effort to change that individual’s coverage and caregiving in a way that benefits the third party or others, and not the patient," the ad hoc group said in a joint letter to Health and Human Services Secretary Alex Azar.

American Kidney Fund President and CEO LaVarne A. Burton said the letter to Azar is the latest shot in a long-term, coordinated "discrimination strategy against ESRD patients."

"It’s appalling," Burton said. "The real steering playbook is outlined in today’s letter spearheaded by insurers, employers and labor unions: let’s get these people off employer-provided insurance and let’s push them onto the government rolls whether that works for them or not."

The letter to Azar was signed by groups including America’s Health Insurance Plans, Blue Cross Blue Shield Association, Families USA, National Partnership for Women & Families, National Association of Wholesalers-Distributors, and Service Employees International Union.

The group has called on the Centers for Medicare & Medicaid Services to re-issue its rule on steering in the individual market and prohibit third-party payments made directly or indirectly by a financially-interested party. They also want policymakers to protect the employer market from inappropriate steering.

"This gaming of the Affordable Care Act’s guaranteed issue rules generates significant profit for dialysis providers engaged in these schemes. J.P. Morgan estimated that the return on 'charitable' donations by dialysis providers to the American Kidney Fund likely exceeds 500%," the letter said.


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John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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