Financial Risk Responsibilities
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Financial responsibility and risk ownership for major organ transplant services are based on post-discharge timeframes, service types, involved providers, and coverage phases from evaluation through follow-up care.
Division of Financial Responsibility (DOFR) for Post-Transplant
The table below outlines financial responsibility for post-transplant services based on the timing after discharge, the type of service and the rendering provider.
Post-discharge timeframe | Type of service | Rendering provider | Financial responsibility |
|---|---|---|---|
0–365 days | Transplant-related services Services are limited to care provided by the designated transplant team or transplant facility. | Transplant team or transplant facility | Health Net |
0–365 days | Non-transplant-related services Includes all services provided by any other provider, regardless of diagnosis. | All other providers (Providers not part of the transplant team or transplant facility) | PPG or Health Net, as applicable |
More than 1 year post-discharge (standard DOFR applies) | All services After 1 year post-discharge, the special transplant categorization period ends, and all services fall under the respective category in accordance with the DOFR | All providers (Includes transplant team and transplant facility providers) | PPG or Health Net, as applicable |
Risk Ownership for Major Organ Transplant
Risk ownership for major organ transplant services across each phase of care are outlined in the table below, from pre-transplant evaluation through follow-up care and organ acquisition.
Period of care | Medi-Cal major organ transplant definition | Risk owner |
|---|---|---|
Phase I – Pre-transplant evaluation | Includes all transplant-related covered services required to assess and evaluate a covered person for acceptance into provider's transplant program. Phase I begins when a covered person starts the evaluation process and ends upon listing with United Network for Organ Sharing (UNOS), the acceptance or non-acceptance of covered person. | Health Net |
Phase II – Pre-transplant care | Includes all health services related to transplants provided to a covered person following acceptance into provider's transplant program, or listing with UNOS, until 2 days prior to the authorized transplant procedure. | Health Net |
Phase III – Transplant procedure | Facility – Based on All Patient Refined Diagnosis Related Groups (APR-DRG) until discharge. Includes all transplant-related covered services provided to a covered person. Begins the day prior to the transplant procedure and ends the day of discharge. | Health Net |
Phase IV – Follow-up care post-discharge | Includes all transplant-related covered services provided to a covered person during the 90 days following the date of discharge from the transplant procedure. | Health Net |
Phase V – Follow-up care | Includes all transplant-related covered services provided to a covered person 91 through 365 days following the date of discharge for solid organs from the transplant procedure. For stem cell, it is from the date of last infusion. | Health Net |
Organ acquisition | ||
Acquisition services include but are not limited to: donor hospital, surgeon and anesthesiologist fees, laboratory, radiology, pharmaceuticals, ancillary, and other services associated with donor activity. Acquisition charges are to be reported on the recipient’s bill (inpatient or outpatient), at the time of the transplant (i.e. same date of service). – Health Net risk, included in reimbursement under APR-DRG. No separate reimbursement. | ||