Sarah Tolson

DocwireNews

<p>As someone who has had the privilege of participating in national forums with stakeholders across the renal industry&mdash;particularly those overseeing the financial operations of dialysis programs&mdash;I&rsquo;ve seen firsthand how reimbursement challenges can quickly rise to the top of everyone&rsquo;s agenda. Lately, there&rsquo;s one topic that has dominated these discussions: phosphate binders.<p>Although these medications are critical in managing hyperphosphatemia in patients receiving dialysis, their reimbursement&mdash;especially under the Transitional Drug Add-on Payment Adjustment (TDAPA)&mdash;has proven to be anything but straightforward. The variability in how different payers approach reimbursement has placed added strain on dialysis providers trying to do right by their patients and remain financially viable.</p><h2><strong>Medicare Advantage Plans: A Moving Target</strong></h2><p>One of the most perplexing trends we&rsquo;ve observed relates to Medicare Advantage (MA) plans. Under certain circumstances, these plans are intended to mirror the reimbursement methodologies of traditional Medicare, yet we&rsquo;re seeing significant inconsistencies. Some MA plans are reimbursing claims for phosphate binders well above Medicare rates, and others are paying far less.</p><p>To bring clarity to this process, my organization has turned to the Centers for Medicare and Medicaid Services End Stage Renal Disease Prospective Payment System (CMS ERRD PPS) Web Pricer, a tool designed to estimate the reimbursement Medicare would issue if it were the primary payer. By comparing Web Pricer data with actual payments received from MA plans, we&rsquo;ve uncovered widespread misalignment. Although overpayment may seem like a windfall, it often leads to painful refund requests down the line. Chronic underpayment, on the other hand, can quietly erode a program&rsquo;s financial health.</p><p>Our recommendation? Dialysis programs should actively review MA plan payments against Medicare benchmarks and engage those payers when discrepancies arise. Proactive communication and documentation can help correct course early, avoiding costly retroactive adjustments or protracted disputes.</p><h2><strong>Contracting Concerns: Underpayment by Design?</strong></h2><p>In many cases, MA plans are reimbursing at rates outlined in contracts with dialysis providers. The catch? These contracted rates are, on average, significantly lower than what traditional Medicare would pay.</p><p>This presents a serious concern. If your organization is receiving less than the Medicare-allowed amount for dialysis services from an MA plan, it may be time to revisit that agreement. There is anecdotal evidence that renegotiation is not only possible but can also include retroactive adjustments. I&rsquo;ve heard of successful efforts to amend contracts and backdate new rates to January 1, 2025, ensuring that all medications covered under TDAPA&mdash;including phosphate binders&mdash;are reimbursed fairly from the outset.</p><p>When renegotiating, consider including language that allows for flexibility in the event of future changes by Medicare. Building in triggers for renegotiation or inclusion of newly reimbursed services can safeguard your program against the shifting tides of policy.</p><h2><strong>VA: A Surprising Standout</strong></h2><p>Interestingly, amidst the reimbursement confusion, the US Department of Veterans Affairs (VA) has emerged as a model of consistency.</p><p>Unlike many private MA plans, the VA has been pricing and reimbursing phosphate binder claims at exactly the rates Medicare would have paid. This consistency not only simplifies billing but also ensures reliable reimbursement&mdash;something every dialysis provider can appreciate.</p><h2><strong>Binders in the Bundle: A Barrier to Access? </strong></h2><p>Despite the well-intentioned move to shift phosphate binder provision into dialysis facilities to improve access, the current reality is quite the opposite. Nationwide, dialysis programs are experiencing delays in receiving these medications, leaving patients in limbo.</p><p>This irony should not be lost on policymakers. A mandate intended to streamline access has, in practice, complicated the supply chain and introduced new barriers. Providers must now make case-by-case decisions about the best way to ensure patients receive their medications, all while navigating a patchwork of payer rules and logistic challenges.</p><h2><strong>Final Thoughts</strong></h2><p>Phosphate binders are not just a line item on a spreadsheet. They&rsquo;re essential medications that directly impact patient outcomes. Ensuring fair, timely, and consistent reimbursement is not only a financial imperative but a clinical one.</p><p>As we continue to share insights and experiences across the industry, it&rsquo;s clear that collaboration&mdash;between providers, payers, and regulators&mdash;is essential. Whether it&rsquo;s leveraging tools such as the ESRD Web Pricer, renegotiating contracts with MA plans, or pushing for flexibility in payer policies, every step we take helps secure a stronger, more equitable system for our patients and our programs.</p><p><em><strong>Note:</strong> The opinions expressed in this column are the contributor&rsquo;s own and do not represent those of </em>Nephrology Times<em>.</em></p></p>


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Latest News

Phosphate Binders and Payment Pitfalls: Insights for Dialysis Administrators

From the Field

Sarah Tolson reviews how changes to reimbursement for phosphate binders, particularly TDAPA, have affected dialysis programs.

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