Organ transplantation is an unusually complex and expensive undertaking that depends on organ prostheses from either cadaveric or living donors, as well as long lists of potential recipients whose health fails steadily as they wait for a transplant. During the past thirty years Congress and the Health Care Financing Administration (HCFA) have written the rules that regulate organ transplantation in the United States. It is imperative that transplant centers and their medical directors understand the rules and accounting practices peculiar to transplantation if they are to be fully reimbursed for the cost of their services.

Chronic hemodialysis for end stage renal disease and kidney transplantation following World War II. Reimbursement by insurance was scarce until the mid-1960s. By 1972, approximately 3500 individuals in the United States survived because of regular hemodialysis treatments, yet insurance coverage was still haphazard. After a dramatic demonstration before a U.S. Senate committee in 1972, Congress amended the Social Security Act to include coverage for end stage renal disease as a Medicare entitlement for any worker who had paid into the Social Security system at least fourteen quarters of three-months each. The worker's spouse and all children under the age of 26 were also entitled to the benefit.1 Medicare became the primary insurer for kidney transplantation for over 90% of the United States population.

Thus, Congress and the United States Department of Health and Human Services (HHS), rather than the commercial health insurance industry, wrote the rules and accounting practices for kidney transplantation. As transplantation of heart, lung, liver, pancreas and intestine evolved, the rules and accounting practices applicable to the kidney were extended to the other transplantable organs.2 Even though Congress has moved Medicare coverage of dialysis and kidney transplantation into a secondary position as co-insurer for the first 30 months of care, HCFA rules and accounting practices take precedence.

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