Independent dialysis providers face challenges with patient care under Medicare Advantage
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Passage of the 21st Century Cures Act in 2021 allowed Medicare beneficiaries with end-stage kidney disease to enroll in Medicare Advantage plans regardless of their previous coverage or when they were diagnosed.
In codifying these regulatory revisions, CMS sought to “empower [ESKD beneficiaries] to choose the type of Medicare coverage that best meets their needs.” As a result of this statutory change, CMS projected that an additional 83,000 beneficiaries would be enrolled in a Medicare Advantage (MA) plan by 2026, making the share of ESRD beneficiaries enrolled in MA roughly equal to that of non-ESKD beneficiaries.
That estimate has changed significantly. According to an analysis by the Medicare Payment Advisory Commission in its March report to Congress, enrollment of dialysis beneficiaries in MA plans has increased more rapidly than was initially anticipated. Between December 2020 and January 2021, enrollment increased from 27% of the MA population to 36%. By December 2022, just 2 years after the 21st Century Cures Act (Cures Act) revisions, the share of dialysis beneficiaries enrolled in MA plans had already reached 47%.
While the growth of ESRD beneficiary enrollment in MA was significantly greater and faster than CMS anticipated, MA payment policies, data insufficiencies and reimbursement have not kept up with the growth of enrollment. These challenges are currently threatening independent dialysis providers’ ability to sustain equitable care for patients enrolled in MA plans. This rapid growth is also undermining the intended outcomes of the Cures Act.
Open enrollment
MA health and drug plans receive a rating from CMS ranging from one to five stars. A five-star MA plan meets the highest ratings for customer service, care coordination, preventative maintenance and drug coverage. The average score for a MA plan is four stars.
MA plans offer open enrollment periods every quarter, which results in an aggressive marketing reach to patients and often misleading potential customers about services and promising continuity of care. Transportation is promised as a covered service, for example, but transportation to dialysis is not included – only to other health care providers. Patients are often told that joining an MA plan will not require a change of dialysis provider, but the plan rarely provide details of in-network dialysis and nephrology providers when selling their MA plan design.
MA plans also fail to inform patients on dialysis that changing plans mid-year will result in a reset of the maximum out-of-pocket (MOOP) costs they will be responsible for covering.
When a patient with traditional Medicare switches to an MA plan, they are permitted to keep their Medigap secondary coverage. However, we have found that most MA plans advise against doing so, telling patients they will no longer need secondary coverage. Medicare patient pamphlets actually recommend against keeping a Medigap policy if patients join an MA plan and state that patient would be better off directing those dollars to fund their out-of-pocket expenses.
Unfortunately, if the decision is made to return to traditional Medicare, the patient is required to go through medical underwriting to re-instate the Medigap policy. Medical underwriting rules are different for each state.
Access to care
In addition to the financial burdens of MA plans, patients also face access to care issues. Dialysis and transplant providers may suddenly be out of network, which usually has an additional out-of-pocket requirement associated with the cost of care to the patient. Innovative care options managed through the Transitional Drug Add-on Payment Adjustment (TDAPA) and Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES) programs are not readily adopted by MA plans or require arduous pre-authorizations, making prescribing new care options nearly impossible.
Finally, we have witnessed many patients receiving denials on transplant options because transplant providers are either out of network or the patients annual out-of-pocket expenses are yet to be exhausted.
Impact on providers
It is common for MA plans to deny contracting for small and medium dialysis providers that do not qualify for national contracting. Although CMS guidelines require MA plans to pay providers the full Medicare payment for dialysis services, most patients with MA do not have out-of-network benefits. This results in dialysis providers receiving no payment when providing out-of-network dialysis care.
Dialysis providers are accustomed to caring for all patients using the same set of treatment options. Now that more than half of the dialysis patient population is split among eight to 12 MA plans, dialysis providers are forced to have multiple sets of treatment options and medication protocols. That means not all patients are treated equally.
Billing challenges are constant with MA plans. Guidelines are not published, and MA plans often change their billing requirements without notice. It is common for MA plans to require dialysis providers to omit condition codes, bill AKI services as ESKD services and omit oral medications, lab results, non-dialysis modifiers and medication national drug codes.
Most MA plans base agreements off a percent of a base rate because claims systems do not have Prospective Payment System (PPS) pricer logic capabilities (the pricer is the case mix rate built from the PPS bundle with condition codes, such as height, weight, age, sex, etc.)
It is becoming common for MA plans to utilize third-party claim analysis companies to identify overpayments. We have seen these result in takebacks from 2 years prior, without providing an error code or reason for the decision.
Providers are forced to resubmit claims dating back 2 years, which often result in timely filing issues. In 2023, Express Scripts audited MA dialysis claims focusing on medications included in the PPS and billed by non-dialysis providers. Some of the medication review focused on opioids, which are not in the PPS but still resulted in takebacks and arduous claims resubmissions.
Bad debt
Each year, dialysis providers file a CMS cost report. The bad debt included in the report, typically from uncollected secondary payments when traditional Medicare is primary, is something that dialysis providers have come to depend on. Now that more than half of the dialysis population is in an MA plan, bad debt recoupment through the Medicare cost report is no longer an option. The increasing MOOP cost and the constant volleys of takebacks through third-party analysis does not qualify as bad debt and does not get reported on the CMS cost report (see Table).
CMS designs the PPS reimbursement on the cost of care described by the Medicare cost reports. MA plans are forcing dialysis providers to survive on 80% of the Medicare reimbursement. Many dialysis providers started to utilize collection agencies to assist with the ever increasing out-of-pocket exposure because of the Cures Act.
Impact on policy
The United States Renal Data System (USRDS) registry was established in 1988 and published its first report in 1994. It is the most data-rich registry in U.S. health care and has been heavily utilized by CMS policymakers. The registry gathers data from Medicare claims, facility surveys (CROWNWeb), CDC and the United Network for Organ Sharing.
MA plans have started to submit claims information to the USRDS dataset, but concerns remain (see the Healio Exclusive article.)
In 1978, Congress enacted modifications to the Medicare ESRD Program to improve cost-effectiveness, ensure quality of care, encourage kidney transplantation and home dialysis, and assist patients to return to work. Those changes evolved into the ESRD Networks. These are currently funded through a $0.50 per treatment fee collected through traditional Medicare claims.
Networks are now referred to as Quality Improvement Organizations (QIOs). These collect quality metrics from dialysis providers and translate those findings for patients to use when selecting a provider. The QIOs develop quality projects and materials for provider participation based on CMS directives. MA plans do not fund ESRD Networks.
As independent providers, we have had the opportunity to share our thoughts with CMS officials, who seem to be aware of the challenges presented by MA plans on the ESKD landscape. Unfortunately, section 1854(a)(6)(B)(iii) of the Social Security Act prohibits CMS from interfering with MA contracting strategies. This is commonly referred to as the non-interference clause. Many of the issues we have discussed in this article are known by CMS but would take an act of Congress to change.
In 2018, CMS created TDAPA and TPNIES as add-on payments to the PPS for innovative therapies. MA plans can add these therapies to the formularies at their discretion. This makes it challenging for providers to adopt new services and creates a dynamic where patients are treated differently within the same center. This has resulted in lack luster adoption of new therapies by providers, which in turn has led pharmaceutical companies to forfeit innovation in the ESKD space.
On the surface, MA plans appear to offer patients more benefits and appear to offer lower premiums. Patient enrollment has increased dramatically – and so has the cost to Medicare. Independent dialysis providers need a level playing field so patients in MA plans get the care they need, and we are paid a fair rate for the services we provide. MA plans have created a financial inequity among patients and the care they receive demands a solution.
- References:
- Contract year 2021 and 2022 Medicare Advantage and Part D proposed rule (CMS-4190-P). https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-and-2022-medicare-advantage-and-part-d-proposed-rule-cms-4190-p. Published Feb. 5, 2020. Accessed Aug. 22, 2024.
- Report to the Congress: Medicare payment policy. March 2024. https://www.medpac.gov/document/march-2024-report-to-the-congress-medicare-payment-policy/. Published March 15, 2024. Accessed Aug. 22, 2024.
- For more information:
- Adrian Amedia, MHA, CMPE is president of Independent Dialysis Group, based in Youngstown, Ohio. He can be reached at aamedia@xcdms.com.
- Julie Williams, BSA, is the administrator for Branson (Mo.) Dialysis and is part owner with multiple physician groups of six independent dialysis programs. She can be reached at jwilliams@bransondialysis.com.
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