The Medicare Prospective Payment System and Quality Incentive Program

By David White

Now that the Final Rule is released, what does it mean?

Trick or treating started a little early in Washington.  When Medicare released the final rule regarding the Prospective Payment System and the Quality Incentive Program (QIP) on Friday, October 28, ASN found itself holding a mixed bag. 

Home Dialysis Training Payment

Medicare nearly doubled the home dialysis training payment to $95.60.  ASN believes patients with ESRD need greater access to home dialysis and any barriers to that access should be removed.  However, the increase was made “budget neutral” meaning “you have to rob Peter to pay Paul” and no new money was added to the bundle, as ASN had recommended.  

AKI-D Care

In a major change in Medicare policy, beginning January 1, 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be seen at ESRD facilities for ongoing dialysis treatments. In light of this change, ASN advocated for several adjustments that were included in the final rule.  Medicare will pay separately for services patients with AKI undergoing dialysis need—such as drugs and lab tests—that are not in the ESRD bundle. 

CMS also agreed with ASN’s position that patients with AKI and ESRD have very different use rates of items and services with their health care. The agency agreed to monitor those utilization rates for use in future payment policy. 

Hemodialysis more than 3X per Week

ASN supports policies that protect the physician-patient relationship and defer to the judgment of the nephrologists as to the amount and/or frequency of dialysis for patients with ESRD. CMS reiterated that Medicare Administrative Contractors (MACs) will “consider medical justification and the appropriateness of payment for the additional sessions.”

CMS reversed its proposal to create a new “equivalency rate” for dialysis in situations where a nephrologist prescribed more than 3 dialysis sessions in one week.  The total reimbursement rate would not change, just the denominator by which it was divided. The policy did not advance any major objectives for improved quality of care, and created administrative burden. ASN and peer societies encouraged CMS to abandon the plan and removing this proposal is a very positive step for providers.

Questions about this Final Rule? Write policy@asn-online.org

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Now that the Final Rule is released, what does it mean?

Trick or treating started a little early in Washington.  When Medicare released the final rule regarding the Prospective Payment System and the Quality Incentive Program (QIP) on Friday, October 28, ASN found itself holding a mixed bag. 

Home Dialysis Training Payment

Medicare nearly doubled the home dialysis training payment to $95.60.  ASN believes patients with ESRD need greater access to home dialysis and any barriers to that access should be removed.  However, the increase was made “budget neutral” meaning “you have to rob Peter to pay Paul” and no new money was added to the bundle, as ASN had recommended.  

AKI-D Care

In a major change in Medicare policy, beginning January 1, 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be seen at ESRD facilities for ongoing dialysis treatments. In light of this change, ASN advocated for several adjustments that were included in the final rule.  Medicare will pay separately for services patients with AKI undergoing dialysis need—such as drugs and lab tests—that are not in the ESRD bundle. 

CMS also agreed with ASN’s position that patients with AKI and ESRD have very different use rates of items and services with their health care. The agency agreed to monitor those utilization rates for use in future payment policy. 

Hemodialysis more than 3X per Week

ASN supports policies that protect the physician-patient relationship and defer to the judgment of the nephrologists as to the amount and/or frequency of dialysis for patients with ESRD. CMS reiterated that Medicare Administrative Contractors (MACs) will “consider medical justification and the appropriateness of payment for the additional sessions.”

CMS reversed its proposal to create a new “equivalency rate” for dialysis in situations where a nephrologist prescribed more than 3 dialysis sessions in one week.  The total reimbursement rate would not change, just the denominator by which it was divided. The policy did not advance any major objectives for improved quality of care, and created administrative burden. ASN and peer societies encouraged CMS to abandon the plan and removing this proposal is a very positive step for providers.

Questions about this Final Rule? Write policy@asn-online.org