BILLING UNDER THE BUNDLE SO FAR

[okarol]

BILLING UNDER THE BUNDLE SO FAR

By Rick Collins

As the first payments were received under the new ESRD Prospective Payment System, a consistent cry was heard throughout the nation: “I thought I was going to receive more money than that.”

Regardless of whether facilities transitioned or went straight to the bundle, many were initially unhappy with their reimbursement. Part of the disappointment had to do with misunderstandings about how the new payment system worked.

Facilities that decided to transition over three years were disappointed largely because of misunderstandings regarding the transition. Many believed that only 25 percent of their patients would be paid under the bundle while the other 75 percent would continue to be paid as they always had under the Composite Rate. The reality is that payments for all patients are calculated by paying 75 percent of what they would have received under the Composite Rate and adding that amount to 25 percent of what they would have been paid under the bundle.

Misunderstandings also ruled the day for facilities that opted out of the transition. Many were disappointed because they believed the Bundle would pay considerably more than the Composite Rate. This disappointment was due to unrealistic expectations created by rumors about significant increases in reimbursement under the Final Bundle Rule. When the Proposed Rule was announced, a number of industry prophets projected doom and gloom for the dialysis industry. Losses of 10 percent to 25 percent of revenue were forecasted. Of course, some of the prophets said the best solution to this problem would be for independently owned facilities to sell. Some independents seemed oblivious to the fact that many of the prophets of doom worked for or had been contracted by chains.

When the Final Rule was announced, the industry collectively breathed a sigh of relief. While there were still uncomfortable or unpopular elements, things were not as bad as they would have been under the Proposed Rule. Suddenly, the feeling of doom disappeared and was replaced by a rumor that the Bundle was now going to provide significant increases in reimbursement for virtually everyone in the industry. These rumors gained credibility when large chains decided to opt out of the transition so they could be paid solely under the Bundle.

Lost in this temporary feeling of euphoria was the fact that the Bundle was to result in an overall two percent decrease in reimbursement for dialysis facilities. Also forgotten and overlooked was the 3.1 percent payment reduction that would be assessed to every facility that decided to not transition to the Bundle over the next three years.

The bubble burst when the first payments were received. The reality was that some facilities experienced increases and some experienced decreases. None of the increases or decreases were particularly large, but in dialysis even the slightest increases or decreases are significant.

One group happy with their new reimbursement rates was the low-volume facilities. The 18.9 percent increase in their reimbursement was a godsend for these facilities, many of which serve small rural areas.

The processing of claims by Medicare since the first of the year has been a source of frustration for facilities as a variety of claim system errors caused significant payment delays and incorrect payment amounts. Even pre-Bundle claims were caught in the Medicare claim system errors. When Medicare released its claim processing system update on January 1, home dialysis claims for December were rejected for not having a Method Selection Form on file even if the forms had been on file for years. Additionally, the Medicare system added zeroes to many of the fields on dialysis claims causing them to deny in error. For example, a claim filed for a patient who received 5,000 units of Epogen per treatment might be altered by the Medicare system to indicate the patient had received 50,000 or 500,000 units of Epogen per treatment, resulting in the claim rejecting for a Medically Unbelievable Edit. Another claim for a patient who weighed 80 kilos might be changed by the Medicare system to show the patient weighed 800 kilos.

Both of these problems took weeks to resolve and caused delays in reimbursement.

http://www.renalbusiness.com/articles/2011/05/billing-under-the-bundle-so-far.aspx?

[rsudock]

can someone shed some more light on this for me in layman terms? My biggest question is with this new payment plan are more centers going to allow folks to get daily treatments in center? I thought I read this somewhere??

[greg10]

can someone shed some more light on this for me in layman terms? My biggest question is with this new payment plan are more centers going to allow folks to get daily treatments in center? I thought I read this somewhere??

I doubt very much has changed.  You are likely to be with a large chain (most patients are) and the payments therefore has not changed much.

"The bubble burst when the first payments were received. The reality was that some facilities experienced increases and some experienced decreases. None of the increases or decreases were particularly large, but in dialysis even the slightest increases or decreases are significant.

One group happy with their new reimbursement rates was the low-volume facilities. The 18.9 percent increase in their reimbursement was a godsend for these facilities, many of which serve small rural areas."

"Low Volume Payment Adjustment (LVPA) for low-volume facilities.
The facility must have furnished less than 4,000 treatments in each of the 3 years preceding the payment year.  The preceding 3 years of treatment data should be reflected on the last 2 settled Medicare Cost Reports and the most recent Cost Report must be  filed.
The facility has not opened, closed, or had a change of ownership in the 3 years preceding the payment year.
The ESRD facility must not be located within 25 road miles of another facility under common ownership (applies only to ESRD facilities newly certified for Medicare on or after January 1, 2011)."