Medicare Administrative Contractors Propose More-Strict Policy for Reimbursing Frequent Dialysis

Four Medicare Administrative Contractors (MACs) recently proposed policy changes that would create stricter rules around paying for more than three dialysis treatments per week. These MACs—Novitas Solutions, Noridian Healthcare Solutions, WPS Government Help Administrators and First Coast Service Options—cover 31 states and nearly 60 percent of the U.S. end stage renal disease population. The policies, if enacted, will require a nephrologist to provide a more frequent and detailed patient assessment as part of the plan-of-care in order to reimburse dialysis providers for the cost of more than three dialysis treatments per week, thereby making it more difficult for dialysis patients to receive more-frequent dialysis.

While the Centers for Medicare & Medicaid Services creates policies and regulations for ESRD patients, MACs have the ability to make local coverage decisions, impacting only the states and regions they service. While it is understandable that organizations financially responsible for health care services want to create clear guidelines of what is and is not covered, this particular policy is problematic. It is easy to find examples of situations that many nephrologists frequently encounter that would fall outside this policy’s acceptable reasons for additional dialysis. In addition, the documentation requirements created to justify additional treatments are burdensome and fall outside the typical documentation and care delivery patterns for dialysis patients. In essence, this policy looks and feels similar to the hurdles payers are known to create to de-incentivize utilization, such as prior authorizations, step therapy and excessive documentation burdens.

However, this is more than just an administrative concern. Clinicians and dialysis providers who care for patients with advanced heart and/or liver failure, patients with acute illnesses in the outpatient setting or patients recovering from recent hospitalizations may find real barriers to titrating dialysis therapy in the form of denied payments and increased audits. Also, the policy does not address pediatric patients and certain home dialysis patients with whom medically appropriate care routinely dictates more than three dialysis treatments a week.

Most concerning is the fact that this policy would codify the use of time and Kt/V as the administrative gold standards of appropriate dialysis care. While the best data we have speaks to these as minimum measurable standards, patients and physicians often define successful dialysis with a wider range of measures, including functional status, avoidance of hospitalizations and quality of life. Given the paucity of data available on what “the best” dialysis is and the many concerns about having administrative definitions imposed on the renal community, the question is what is the best way to balance the financial and care considerations? Is now the right time to hinder clinical flexibility with the reasonably foreseeable trade-off of increased hospitalizations and less patient-centered care?