[Transplant Center Letterhead]
2/5/2016
Name
Title
Name
Title
Name
Title
Re: Paired kidney exchange
Dear [insert names]:
This letter is to confirm the agreement between Transplant Center, X Medical
Faculty Foundation, _____ Hospital, and ______Hospital and associated physician
practice plans__________ to participate in paired kidney exchanges. The parties have
agreed to follow the UNOS Kidney Paired Donation Pilot Program Operational
Guidelines (Interim Implementation – Version 4.0), attached as Exhibit 1 to this letter,
and further agree to the additional terms set forth on Exhibit 2 to this letter.
Please acknowledge your agreement to this letter by signing in the signature block
below and returning the same to me.
Sincerely,
Name
Title
ACKNOWLEDGED AND AGREED as of the date stated above.
XXX
XXX
By:
Name:
Title:
By:
Name:
Title:
By:
Name:
Title:
1
EXHIBIT 1
Attach UNOS Kidney Paired Donation Pilot Program Operational Guidelines (Interim
Implementation – Version 4.0)
2
Exhibit 2
Additional Terms
I.
Operational
A. Donor hospital shall provide a copy of the donor’s medical record for review by
recipient hospital prior to the point of donation. Both parties agree to confirm that
readiness of both the donor and recipient prior to the donor procedure start.
B. Donor hospital agrees to inform recipient hospital if it loses approval from UNOS
to perform living donor service or loses certification from CMS.
C. ABO typing and Organ Recovery Verification:
1. Donor hospital will provide recipient hospital with laboratory copy evidence
of two separate blood typing tests performed on the donor prior to the agreed
upon procedure date.
2. Recipient hospital shall provide the Transplant Center X laboratory copy
evidence of two separate blood typing tests performed on the recipient prior to
the procedure date.
D.
Both parties agree to disclose any relevant Adverse Event related to the
donation or transplant procedure such as disease transmission or donated
organ injury to one another as would be necessary to continue care for the
donor or recipient. Actions to prevent reoccurrence of the event will also be
disclosed if appropriate.
II.
Financial: Recipient Reimbursement to Donor Facility/Physicians
A. Facility Fees:
1. Participating hospitals will develop a Standard Acquisition Charge (SAC)
representing the average full cost of living donor evaluation and donation
(including routine follow-up) at their institution. This charge will be
constructed in a manner compliant with Medicare Cost Reports and be
updated yearly. (Reference: Medicare Claims Processing Manual (“MCPM”)
§ 90.1.1 )
2. As Medicare also allows invoicing by departmental charges (individual full
costs for that particular donor’s evaluation and donation); this billing method
will also be accepted. Transplant Center X will use the SAC methodology.
3. The donor hospital will provide an invoice representing the Medicare living
donor standard acquisition charge or departmental charges to the recipient
hospital
4. Recipient hospital will remit payment to the donor hospital within 90 days
5. Transportation costs are billed to the recipient hospital directly or by the donor
hospital
6. Donor complications: For all complications the donor hospital will bill the
recipient’s insurer directly. The recipient hospital will facilitate this billing by
sharing appropriate billing information with donor hospital. The recipient
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hospital will remain responsible for the costs of any donor complication in the
event the recipient's insurer denies any claims related to donor complications. .
7. The determination of donor complications is solely the judgment of the donor
surgeon or his/her designate as documented in the patient medical record.
B. Physician professional fees
1. Donation Event
a. Medicare Primary – physicians bill recipient hospital’s CMS carrier under
recipient hospital ID
b. Other insurance/fee for service – Recipient hospital will work with payor
and donor physician(s) to cause a single letter of agreement to be created.
Letter will specify physician reimbursement.
2. Donor routine follow-up and donor complications (solely by the judgment of
donor surgeon documented in the patient’s medical record)
a. Medicare Primary – Donor physician(s) will bill CMS; if denied – donor
physicians will write off the expense
b. Case rate – will be billed to recipient insurance; if denied, paid by
recipient hospital at CMS allowable rate
c. Other insurance/fee for service – will be handled in single letter as
referenced above.
II.
Incomplete or failed transplant
A. In the event that a donation happens but implantation cannot occur into intended
recipient due to recipient factors, recipient hospital will use its best effort to find a
listed recipient for the kidney consistent with UNOS allocation rules by running a
match run list for the recipient hospital’s center and make the donated kidney
available for transplantation. Recipient hospital should have run this list as part of
a viable back-up plan prior to transplant surgery. If recipient factors that made
transplant impossible resolve at a later time, the initial intended recipient should
be considered a stranded recipient.
B. If for any reason one transplant occurs but another cannot be completed, and it is
not possible to abort the other procedure(s) without risking the donor or kidney,
the transplant will proceed to completion and the recipient considered stranded.
This provision applies to situations that would also include a transportation failure
or other mishap resulting in an unusable kidney. The participating hospitals must
notify affected hospital immediately upon discovering an issue that may prevent
successful completion of planned transplant.
Treatment of stranded recipients: The parties in this agreement agree to prioritize finding
a donor for a stranded recipient in any chains or exchanges involving unpaired or
anonymous donors (donors who present with no intended recipient).
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C. Once a donor kidney enters recipient’s surgical field, the transplant will be
considered to be complete, regardless of its outcome beyond that point, and the
intended recipient will not be considered to be a stranded recipient.
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