According to the National Institute of Diabetes and Digestive and Kidney Diseases, approximately 808,000 people in the United States have end-stage renal disease (ESRD), representing 0.2% of the population. Without a kidney transplant, ESRD patients experience a permanent and almost complete loss of kidney function and need to undergo dialysis, a process to clean waste, toxins, and other buildup from the blood, several times a week for the rest of their lives.
ESRD and Medicare Advantage
Regardless of their age, most ESRD patients are eligible for Medicare Advantage. Medicare Advantage plans are reimbursed through the federal government by the Centers for Medicare and Medicaid Services (CMS). In order for the reimbursement to occur, CMS must designate the member as having ESRD. If the member is not correctly identified as having ESRD, the plan will not be reimbursed.
ESRD premium restoration solutions help ensure Medicare Advantage plans are properly reimbursed for ESRD patients by identifying members with missing ESRD statuses and restoring the premiums. However, because of the low number of ESRD patients, plans often underestimate the potential impact of using an ESRD premium restoration solution and decide against using one. The following suggests that these plans should reconsider their decision:
- Providing care to ESRD beneficiaries, particularly dialysis treatment, is very expensive. The average cost at a dialysis center is reported to be approximately $72,000 to $88,000 per year. The cost per session ranges from approximately $250 to more than $350 per session with three sessions typically needed per week.
- Medicare spending on ESRD is increasing. According to CMS, Medicare is expected to pay approximately $6.7 billion in total payments to ESRD facilities in 2024, up from $5.4 billion in 2023.
- ESRD patients account for less than 1% of the total Medicare population but account for 7% of Medicare spending.
- While the exact difference in premiums depends on the specific Medicare Advantage plan and geographic location, our data indicates the Medicare Advantage premium per ESRD member per month is generally more than $5,000 more than the average Medicare Advantage premium.
How the ESRD Process Ideally Works
In an ideal world, the ESRD process works as follows:
- The ESRD patient visits a dialysis clinic for treatment.
- The dialysis clinic or submitting authority completes a 2728 form, which is primarily a nephrologist’s attestation to CMS that a patient is eligible to receive ESRD Medicare benefits, and submits this to CMS.
- CMS is alerted to the patient’s ESRD status and an ESRD indicator flag is turned on that will adjust the premium for that patient.
- The plan then receives a higher premium for covering these patients.
Opportunities for the ESRD Process to Break Down
While the process doesn’t seem complicated, there are several reasons it breaks down:
- Members have ESRD diagnoses that the plan never knew about.
- The dialysis clinic or provider doesn’t complete the 2728 form or sends incomplete or incorrect forms.
- The clinic saves the form, but never “submits” it to CMS.
- The flag is temporarily turned off and not turned back on—for example, because the member went to hospice for a period of time.
- CMS fails to set the flag or had inaccurate dialysis start date.
ESRD Premium Restoration Services
ESRD Premium Restoration Services dig through the plan’s data to identify potential ESRD patients and compare the findings with CMS data. If there is a discrepancy, the service works with CMS to correct it so the plan is reimbursed with the higher premium. Adjustments can be made going back seven years.
ESRD Premium Restoration Results
Our relationships with dialysis centers and our proven processes with CMS separate us from other ESRD vendors and contribute to our success. One hundred percent of our ESRD clients with more than 2,500 Medicare Advantage members have had premiums restored.
Several of our clients see results with our ESRD Premium Restoration service in just a few months. For one plan with 230,000 members and multiple lines of business, we restored $4 million in seven months.
Another plan with 100,000 members worked with us to restore $3 million in 12 months.
Similar to our Medicare Secondary Payer Validation and Premium Restoration service, our ESRD service delivers successful results for small health plans as well as large. One of our newest clients has only 10,000 members, and in just two months, we restored over $300,000 for that plan.
Strong Partner for Medicare Advantage Plans
In addition to our ESRD service, we offer other payment and revenue integrity services such as editing. We also offer network building services, helping Medicare Advantage plans expand existing networks and fill in network gaps to maintain CMS adequacy. Learn more about how we can work together to strengthen your Medicare Advantage plan.
