Simple Tips for Maximizing Dialysis Facility Reimbursement

From the Field

Since the beginning of the pandemic, dialysis facilities have been battling with increasing labor and supply costs, with very few options for increasing revenue. In many dialysis facilities, traditional Medicare is the majority payer and the 2023 ESRD PPS base rate in many cases is not sufficient reimbursement to cover the costs of dialysis treatment. There are a few things that a dialysis facility can do to reduce lost reimbursement and solidify the revenue cycle.

A thorough insurance verification is the foundation to ensuring optimal reimbursement for dialysis treatments. This entails more than simply verifying that a patient has active insurance coverage. The biggest questions to answer are which insurance company should pay for the treatments, how much should you expect, and what do you need to do to get the reimbursement as quickly as possible.

Which Payer Should Be Billed First?

When determining the insurance company that should reimburse patient treatments, important things to consider include what type of plan(s) does the patient have—employer group health plan, Medicare Advantage Plan, Medicaid Managed Care, or maybe a plan from the health insurance exchange? Does the patient have traditional Medicare? What are the original effective dates of that policy? Depending on the plan type, there are different rules for determining who the primary payer is and who the secondary payer is. By figuring out which payer should be primary, you are eliminating delays in reimbursement due to submitting to the wrong payer first as well as reducing the risk for overpayments caused by the wrong payer paying as primary.

How Much Reimbursement Should Be Expected?

Knowing whether the dialysis program is in-network or contracted with the insurance plan is critical. Many insurance plans have different benefit levels for in- and out-of-network providers, which has a significant impact on the amount of reimbursement the dialysis program can expect to receive. Occasionally when a dialysis program is out of network, there is a possibility of obtaining a single case agreement with the insurance company to cover the dialysis treatments. While single case agreements often reimburse at a higher rate, there are typically more administrative barriers to obtaining reimbursement.

In the event the dialysis program is contracted with the insurance company, the contract should detail how much reimbursement can be expected, based on the patient’s plan type. If no contract is in place, many insurance companies can tell you the anticipated reimbursement amount for dialysis based on the codes that will be used for billing and the patient’s plan type. It is also important to determine any out-of-pocket amounts the patient may be assessed. For patients whose primary insurance will likely assign coinsurances and deductibles to the patient, efforts should be made to assist the patient in obtaining secondary insurance coverage to cover any amounts the primary insurance passes on to the patient. The anticipated reimbursement amount should be recorded and communicated to the billing staff to ensure that is what is collected.

What Are the Requirements for Obtaining Reimbursement?

Knowledge of the plan type is key to knowing the requirements for obtaining reimbursement. Medicare Advantage Plans commonly require dialysis claims to meet the same requirements set forth by traditional Medicare and Medicaid Managed Care plans that look for the same billing requirements as traditional Medicaid.

Many insurance companies require an authorization for reimbursement of dialysis services. In the event the patient’s insurance plan requires an authorization, having a solid system in place for obtaining, tracking, and communicating information pertinent to the authorization with those billing for dialysis is just as important as obtaining the authorization. There have been many times in my career where insurance companies deny claims stating no authorization was on file and I have successfully obtained reimbursement by disputing the denial with the name of the representative, date of the phone call, and reference number of the phone call where the authorization was obtained. Had I not recorded and kept organized records regarding authorizations, I would have struggled to win those disputes.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and interventional nephrology. Your questions are welcome, and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website,