An organization that operates dialysis centers in small towns and rural areas could not demonstrate that a large health insurance provider's decision to reduce reimbursement rates on dialysis treatment received at out-of-network facilities amounts to taking into account or differentiating the level of coverage provided to patients with end-stage rental disease (ESRD) and those without ESRD. The insurance provider cut its reimbursement rate for out-of-network dialysis by 88 percent in January 2007, to levels below the customary charges associated with such care. The dialysis provider argued that this amounted to a manipulation of reimbursement rates designed to target out-of-network providers and a violation of the antidiscrimination provisions of the Medicare as Secondary Payer Act (see ¶16,987B). The insurer's decision, however, does not violate the statute's implementing regulations because the same level of reimbursement is provided for out-of-network dialysis, regardless of whether the patient suffers from ESRD. Moreover, the insurer's decision does not alter the benefits granted to a Medicare beneficiary as opposed to a patient who is not enrolled in Medicare. The dialysis provider's Medicare as Secondary Payer Act claim is dismissed. The claims alleging breach of contract under state law and violations of the Employment Retirement Insurance Security Act (ERISA) are not dismissed and may proceed.
National Renal Alliance, LLC v. Blue Cross and Blue Shield of Georgia, Inc., N.D. Ga., Feb. 19, 2009.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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