Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

ESRD Orgs May See Higher Medicare Reimbursement, Drug Payments

CMS proposed to boost Medicare reimbursement to ESRD facilities by $220 million in 2019 and expand an add-on for drug payments.

End stage renal disease (ESRD) facilities and Medicaire reimbursement

Source: Thinkstock

By Jacqueline LaPointe

- A new proposal from CMS would increase Medicare reimbursement to end-stage renal disease (ESRD) facilities by $220 million and change the way the federal agency pays the facilities for new renal dialysis drugs.

The proposed update to the ESRD prospective payment system includes a 1.7 percent increase in Medicare reimbursement to all facilities in 2019.

For hospital-based ESRD facilities, the update would be slightly larger. The proposal would boost Medicare reimbursement to the hospital-based facilities by a total of 1.8 percent, while free-standing facilities would still see the 1.7 percent bump.

The proposed update to the ESRD facility payment rates would equate to a $90 million increase in Medicare reimbursement in 2019.

In addition, ESRD facilities may also see an additional $30 million increase in Medicare reimbursement because of updates to the outlier threshold amounts, bringing the total payment bump to $220 million in 2019.

If the proposed rule is finalized as is, CMS anticipates paying a total of $10.6 billion to approximately 7,000 ESRD facilities in 2019 to cover the costs of delivering chronic maintenance dialysis services.

The federal agency also plans to foster drug innovation and competition in the ESRD space by expanding the Transitional Drug Add-on Payment Adjustment.

The proposed rule would modify the drug designation process to permit all new renal dialysis drugs and biologicals to be eligible for the Transitional Drug Add-on Payment Adjustment regardless of whether they fit into an existing functional category.

ESRD facilities would, therefore, receive a higher Medicare reimbursement rate for administering the new renal dialysis drugs and biologicals starting on Jan. 1, 2019.

CMS Administrator Seema Verma stated that the proposal will help to “reward dialysis facilities that adopt innovative new therapies.”

Additionally, the recently proposed rule from CMS contained potential changes to how Medicare pays for durable medical equipment.

CMS intends to increase patient access to items and simplify the Medicare Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Budding Program by modifying the bidding and pricing methodologies.

Specifically, the federal agency would implement lead item pricing and redefine composite bid to mean a bid submitted by a supplier for the lead item in the product category.

The proposal also would add payment classes for portable liquid oxygen equipment only, portable gaseous oxygen equipment only, and high flow portable liquid oxygen contents, as well as create new rules for ventilatory payments.

In addition, CMS proposed changes to the durable medical equipment fee schedule. If finalized, the rule would create three temporary fee schedule adjustment methodologies. The proposed changes to the fee schedule include:

  • A specific fee schedule methodology for items and services furnished within former competitive bidding areas during a period when there is a temporary lapse in the areas
  • Addition of provisions in the 21st Century Cures Act that require fee schedule amounts for DMEPOS items and services subject to the Competitive Bidding Program that are furnished in non-competitive bidding areas
  • Revision to the fee schedule adjustment methodology so that items and services furnished in non-competitive bidding areas that are neither rural nor non-contiguous areas have a fee schedule amount for the area equal to 100 percent of the adjustment payment amount

With the proposals, Verma intends to “help secure sustainable access to durable medical equipment.”

Stakeholders can comment on the proposed changes to the ESRD prospective payment system and the DMEPOS Competitive Bidding Program until Sept. 10, 2018. CMS will release a final rule on the payment systems after that date.


Join 30,000 of your peers and get free access to all webcasts and exclusive content

Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...