WELL MAY IS HERE, but the bundle final rule is not. At least not here as of when I am writing this article. So this seems like a great time to do a little spring cleaning and address several items of interest.
Outliers Again
One of our readers pointed out that the example of an outlier had a typographical error which failed to clearly identify an exponential term.
The example, which is from the proposed rule, is presented below and the exponential term clearly and correctly re-stated. The key point is still the same: don’t forget to model outliers when you estimate how the new bundle will impact you.
Example—Outlier Payments
John normally receives HD 3 times weekly. However, in January 2011 he suffered a compound ankle fracture and was hospitalized for 5 days. During the hospitalization John did not undergo any dialysis treatments. After John was discharged and he resumed receiving outpatient dialysis, it was noted that John’s dialysis clinical indicators were depressed, requiring additional laboratory testing and above average doses of several injectable drugs, particularly EPO, to bring them to normal levels. During January, John, who received HD at his usual facility, received only 9 treatments. The facility submitted a bill for allowable total SB drugs and biologicals, laboratory tests, and supplies for January totaling $3,000.
John’s dialysis facility would receive $231.52 for each of the 9 treatments it furnished. The SB MAP per treatment averaged $3,000/9 or $333.33 per session. We first determine if John’s dialysis facility would be entitled to outlier payments.
Using Table 29 we compute the predicted SB MAP [Separately Billable Medicare Allowable Payment] per treatment based on SB case-mix adjustments for BSA and age.
BSA PmtMultSB = 1.033 (2.2161-1.87) / 0.1
Age PmtMultSB = 1.000
PMSB = 1.1189 * 1.000 = 1.1189
SB MAP per treatment is $64.54
The case-mix adjusted predicted SB MAP is: $64.54 * 1.1189 = $72.21
The fixed dollar loss amount for the predicted SB MAP, reflecting the case-mix adjustments for BSA and age, becomes: $72.21 + $134.96 = $207.17
Because John’s average SB MAP for services furnished was $333.33, which exceeds the case-mix adjusted fixed dollar loss amount of $207.17, John’s ESRD facility is eligible for outlier payments beyond the otherwise applicable $231.52 ESRD PPS amount.
The outlier payments are computed as follows:
Amount in excess of fixed dollar loss amount ($333.33 - $207.17) = $126.16
Loss sharing ratio = 80%
Outlier payments per treatment = ($126.16 * .80) = $100.93
Outlier payments = ($100.93 * 9 treatments) = $908.37
The total ESRD payments to this facility on behalf of John for January would be:
Regular ESRD payments $231.52 * 9 = $2,083.68
Outlier payments = $ 908.37
Total payments = $2,992.05
ObamaCare
Above and beyond questions regarding the new Medicare payment bundle for ESRD services, I receive a lot of questions regarding how the newly enacted federal healthcare plan will impact dialysis facilities. Since Medicare patients are, by definition, covered under Medicare and as such are not among the uninsured they should not be directly affected by the federal health plan. However, for those ESRD patients or pre-ESRD patients who are uninsured, ObamaCare may have some measurable financial impact. So, as I see it, an increase in the number of commercially insured renal patients is highly likely.
