Four contractors that process Medicare payments for dialysis care –– covering 31 states and close to 60% of the U.S. end-stage renal disease population –– are proposing nearly identical policy changes that would tighten rules for paying for more than three-times-a-week dialysis treatments. The exception would be treatment for patients with acute comorbid conditions outside the plan of care.

While the proposed policies do offer billing codes and indicate more frequent dialysis can be covered with medical justification, the four Medicare Administrative Contractors––Novitas Solutions, Noridian Healthcare Solutions, WPS Government Help Administrators, and First Coast Service Options––make it clear in the language of the policies that nephrologists who prescribe more intensive treatment must include the patient assessment as part of the plan of care in order to get the therapy covered by the MACs.

“While there are no set frequency limitations for these services, continued use of additional sessions by a given provider or for a given beneficiary or unusual patterns of billing, verification of need for services will generate reviews,” wrote Novitas Solutions Inc., which covers Pennsylvania, New Jersey, Maryland, Delaware, and the Washington D.C. Metro area.

MACs have leeway to interpret CMS rule

While the Centers for Medicare & Medicaid Services creates policy and regulations for treating individuals with ESRD, the agency uses 10 MACs across the country to pay dialysis providers for services. The MACs are given the flexibility to interpret CMS policy and create local coverage determinations for states that are included in their jurisdiction.

CMS has adopted policies that encourage alternative modalities and offers dialysis clinics financial incentives to start patients on home dialysis. Paying the Medicare bundled payment rate for more than three treatments a week––often as a fourth treatment––has been approved in the past by the MACs with medical justification.

In a letter sent this week to renal association presidents and other organizations with the headline, “MACs launch coordinated assault to interfere with physician judgment about dialysis,” Allan Collins, MD, FACP, Chief Medical Officer of NxStage Medical, said the proposed policies would “effectively deny access to more frequent hemodialysis.

“The draft LCDs include a reasonable list of diagnosis codes that could serve as medical justification for reimbursable sessions, but would not permit reimbursement for an ongoing regimen of more frequent hemodialysis that a nephrologist judges to be a reasonable and necessary plan of care to meet the clinical needs of a patient.”

Collins said use of more intensive therapy, such as short daily or nocturnal hemodialysis, is “a reasonable and necessary therapy because we understand many of its effects: regressing left ventricular hypertrophy; lowering blood pressure and reducing the need for antihypertensive medications; lowering serum phosphorus; and reducing ultrafiltration intensity, thereby resulting in lower risk of intradialytic hypotension and shorter post-dialysis recovery times.

“The MACs’ blatant attempt to fix hemodialysis reimbursement at 3 sessions per week limits our ability to practice medicine and can ultimately do harm, as seen in unnecessary hospitalizations, diminished quality of life, and shortened lives,” Collins wrote.

Proposed MAC policies

 Many of these proposals have a short comment period. Visit the websites to see deadlines and locations where hearings are being held.

Novitas Solutions

Noridian Healthcare Solutions

WPS Government Help Administrators

First Coast Service Options