
Adjustments for End Stage Renal Disease (ESRD) Claims
June 27, 2011End Stage Renal Disease (ESRD) facilities may begin to see some of their claims being adjusted to correct various issues that have been found after the implementation of the new ESRD Prospective Payment System (PPS). One of the issues involves ESRD claims containing outlier payments; in some cases, outlier payments for home dialysis patients of facilities transitioning into the PPS were being overpaid and other outlier payments were underpaid as a result of deductible and coinsurance being applied to the Medicare-allowed payments for outlier. Where an outlier payment was already made these adjustments will be automated by the contractor and no action is required by the provider. However, if an ESRD facility believes they were entitled to an outlier payment but did not receive one, they may notify their Medicare Contractor and request the adjustment. In addition, for facilities transitioning into the PPS, the 3.1% budget neutrality adjustment was not being applied to the separately billable ESRD services between Saturday, January 1, 2011 and Thursday, March 31, 2011, and contractors will be required to adjust those claims. Source: CMS TDL- 11328