Huge savings after ClaimDOC audit team analyzes outpatient dialysis billing
Background
ClaimDOC’ s comprehensive line-by-line analysis of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings to health plans and beneficiaries. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplicate claims, correct coding initiative edits, unbundling of services, improper coding/billing of services, and others. Our claims review is not intended to impact care decisions or medical practice.
In this Claims Audit Spotlight, the focus is on coding, billing, and compliant reporting of dialysis services for patients with the diagnosis of end-stage renal disease (ESRD).
We analyze numerous claims billed by or on behalf of freestanding dialysis centers. Free-standing dialysis centers provide chronic maintenance dialysis to ESRD patients on an outpatient basis, and some centers may additionally provide dialysis services in the patient’s place of residence.
A dialysis center may be designated as an independent or hospital-based unit (that is, either hospital units or hospital satellites). Most individuals select a dialysis center that is a location convenient to where they reside and/or work. There are thousands of dialysis facilities across the country.
There are two main types of kidney dialysis: hemodialysis and peritoneal dialysis (PD). If it is determined hemodialysis is the selected care and treatment management, then the decision is whether the individual will have traditional in-center hemodialysis or home hemodialysis (HHD). Traditional in-center hemodialysis is typically performed in a dialysis center by trained health care professionals three days a week, usually for about four hours per treatment. If it is determined PD is the selected plan of care and treatment management, then patients are trained to perform dialysis at home.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, “More than 661,000 Americans have kidney failure. Of these, 468,000 individuals are on dialysis, and roughly 193,000 live with a functioning kidney transplant.”
The Centers for Medicare and Medicaid Services (CMS) has specific payment policies under the ESRD Prospective Payment System (PPS) for renal dialysis services. Policies also address acute kidney injury (AKI) for renal dialysis services furnished by ESRD facilities. With few exceptions, the ESRD PPS payment methodology provides a single payment to ESRD facilities and covers the resources used in furnishing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis (in the ESRD facility or at a patient’s home), drugs, biologicals, laboratory tests, training, and support services.
Dialysis Case Scenarios
Outlined below are two (2) claim examples ClaimDOC’s audit team analyzed the reporting and billing of outpatient dialysis services.
Case One
An independent dialysis center located in Michigan submitted their claim and related charges to insurance with total charges of $121,920.19. High dollar charges included thirteen (13) dialysis treatments for $99,182.46 ($7,629.42 per treatment), pharmacy for $16,747.86, and laboratory for $4,315.47.
Summary
$121,920.19 total billed charges, ClaimDOC pricing $4,918.21. 96% reduction based on pricing using the 2021 Medicare ESRD dialysis rate with markup.
- Total dialysis center charges: $121,920.19
- Medicare pricing based on ESRD dialysis rate: $3,934.57
- ClaimDOC Pricing: $4,918.21 based on Medicare ESRD dialysis rate with markup
- Plan Savings: $117,001.98
- Percentage of Savings: 96%
Case Two
An independent dialysis center located in Connecticut submitted their claim and related charges to insurance with total charges of $67,951.25. High dollar charges included pharmacy for $43,266.27 and three (3) dialysis treatments for $22,888.26 ($7,629.42 per treatment).
Summary
$67,951.25 total billed charges, ClaimDOC pricing $925.44. 99% reduction based on pricing using the 2021 Medicare ESRD dialysis rate with markup.
- Total dialysis center charges: $67,951.25
- Medicare pricing based on ESRD dialysis rate: $740.34
- ClaimDOC Pricing: $925.44 based on Medicare ESRD dialysis rate with markup
- Plan Savings: $67,025.81
- Percentage of Savings: 99%
The Takeaway
Dialysis is expensive. Analyses of these dialysis center claims identified high charges for pharmacy, dialysis treatment, and laboratory services. While dialysis centers may bill and charge any amount they choose for provided services(s), egregious charges can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of charging high fees, create burdens for uninsured patients and a host of other concerns.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.