Show Me the Money

By Sarah Tolson - March 7, 2023

From the Field

One of the common struggles many medical practices are encountering is a significant increase in the cost of medications, supplies, and the labor necessary to run the practice. Unfortunately, reimbursement is increasing at a much slower rate. Significant increase in costs and minimal increase in revenue seems to be amplified in the renal industry, as the majority of patients have insurance coverage through plans that are funded by a state or the federal government. This puts many practices in a position where they need to increase their incoming revenue without adding any costs.

Recently, I gave a presentation to a group of leaders in the renal industry about maximizing reimbursement. A very popular topic during the Q&A portion of the presentation was discussing services that are separately reimbursable for patients with end-stage renal disease (ESRD) that fit well in a nephrology practice. Several great ideas were discussed that may be helpful to the readers of this column, so I am sharing them here.

The most straightforward reimbursement is to ensure you are billing for services furnished to a patient with ESRD that are categorized as excluded from the Monthly Capitation Payment (MCP). Many dialysis patients see their nephrologist as their primary care provider and seek care from their nephrologist for problems unrelated to ESRD. I’ve talked to many providers over the years who are unclear on when they can bill for office visits and other services furnished to their ESRD patients, so they opt to just not bill and accept the MCP as payment in full.

Another reimbursable service that some providers seem hesitant to bill for is the professional portion of home dialysis training. The dialysis program and the nephrologist both play a role in providing home training, and there is separate reimbursement for each provider type. Nephrologists may bill for home dialysis training on a per-session basis or for the entire course of training once it has been completed.

The next line of revenue to explore would be Transitional Care Management (TCM) services. For nephrologists who round at a hospital and see patients in their office, TCM can be a relatively simple revenue stream to add to your practice. TCM services have specific criteria to meet to qualify for reimbursement, but meeting the criteria may only require minor changes to a practice’s current policies and procedures for following up with patients who have been discharged from the hospital. In addition to providing a pathway for nephrologists to obtain reimbursement for the work they are already doing, TCM services may help to reduce hospital readmissions for patients.

Other potential revenue streams for a nephrology practice to consider include add-on services such as Remote Patient Monitoring (RPM) or Chronic Care Management (CCM). When evaluating add-on services to see what will fit best with your practice, it’s helpful to consider the percentage of your current patient population that would qualify for or benefit from the services you are considering, how      the workload of your practice need to change to handle the new services, and whether the additional work outweighs the benefit to your patients and the additional reimbursement. There are a multitude of vendors that provide RPM assistance or even handle the lion’s share of CCM, including the labor portion of connecting with patients.

In speaking with a number of nephrologists, the underlying factor to not capturing all available reimbursement seems to be a lack of awareness of what exactly is reimbursable. In the event your program is looking to increase revenue, I would recommend starting with an audit of chart notes to identify any services currently being rendered but not billed. After reviewing the audit results, practices may consider evaluating additional services like TCM, RPM, and CCM to see if they are a fit for your practice. There may also be some benefit to connecting with a consultant who has experience implementing the services your practice is considering.

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,  

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