Billing Solutions: Adjusting the Adjustments


By Rick Collins

Hard to believe, but the end-stage renal disease (ESRD) industry has been living under the bundle for nearly two full years. You would think that would be plenty of time for payment issues and problems to be worked out with payers and dialysis providers. However, there are a number of areas that continue to be challenges and we will focus on two of those this month.

The most persistent problems under the bundle are receiving payments from Medicare for adjustments intended to increase reimbursement, especially the onset of dialysis adjustment and comorbidity adjustments.


Offering a 51 percent increase in payment, the onset of dialysis adjustment can make a significant impact in reimbursement for ESRD programs. However, the way in which Medicare contractors identify and pay for the onset adjustment can result in facilities missing one or two months of adjusted payments.

Normally, items that affect reimbursement are reported on claims. This puts the burden on the biller to report the information needed by the Medicare contractor for generating appropriate reimbursement for the services billed. In the case of the onset of dialysis adjustment, nothing is reported on the claim to indicate the patient should receive the adjustment. Instead, the ESRD facility must submit information entered into the Medicare Common Working File (CWF). Thus, a biller can file a claim perfectly for a patient new to dialysis, but the reimbursement for the claim may be incorrect if the CWF was not updated at the time a claim was processed.

Instead of the burden being on the biller to report complete information, billers must rely on the facility to report onset information correctly, and speedily and then hope that the Medicare contractor enters the information into its system promptly.

This process is normally not an issue for a new ESRD patient who is also new to Medicare and chooses to dialyze in a facility because these patients have a mandatory 90 day waiting period before Medicare becomes their primary payer. However, the process is not working for patients without a waiting period, which include home patients and in facility patients who were Medicare primary when they started dialysis.

These patients have no waiting period and the first claims filed for their ESRD services normally reach the Medicare claim processing system before the CWF is updated. This results in the onset adjustment not being paid on the first and sometimes subsequent claims filed. Not only do ESRD billers have to closely monitor the payments made on all new ESRD patients, they also must monitor the Medicare CWF to see when it has been updated to indicate the patients first date of dialysis. Once the CWF is updated, billers have to adjust the underpaid claims.


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