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ESRD (End Stage Renal Disease) PPS (Prospective Payment System) Low Volume Payment Adjustment Instructions for Yearly Attestations
Last Modified: 4/17/2024
Location: FL, PR, USVI
Business: Part A
End Stage Renal Dialysis (ESRD) Providers may be eligible to receive a Low Volume Payment Adjustment to their rate if they meet certain criteria outlined below.
ESRD Providers that are currently receiving the Low Volume Adjustment are required to submit an annual Attestation prior to November 1st proceeding the next payment year. Attestations will not be accepted after the November 1st deadline.
Note: Attestations can be accepted for individual ESRD facilities only. Each facility must submit its own attestation. Master lists of ESRD facilities that are owned by one organization will not be accepted. Each facility must indicate on its own attestation that it believes it is eligible for the low-volume payment adjustment.
If a Provider determines that they are no longer qualified to receive the Low Volume Facility Adjustment based on the following criteria, they must notify Novitas Solutions immediately. If Novitas Solutions discovers that claims have received the Low Volume adjustment in error, Novitas Solutions has 6 months to reprocess to remove the LV adjustment.
Current Low Volume Criteria under 42 CFR 413.232(b):
Note: The proposed rule for 2019 includes changes to the criteria controlling low volume eligibility – see next page. Comments to the proposed rules are due to CMS by 09/10. If any or all of these proposed rules are finalized, Novitas will take these into consideration when processing your facility’s low-volume request.
1. The facility has furnished less than 4,000 treatments in each of the 3 years preceding the payment year.
Note:
• The 3 eligibility years are based on cost reporting years
• The number of treatments considered furnished by the ESRD facility shall equal the aggregate number of treatments furnished by the ESRD facility and the number of treatments furnished by other ESRD facilities that are both:
1. Under common ownership with, and
2. Five (5) miles or less from the ESRD facility in question
3. Common ownership means the same individual, individuals, entity, or entities, directly, or indirectly, own 5 percent or more of each ESRD facility.
2. The facility has not opened, closed, or had a change of ownership that resulted in a change in PTAN in the 3 years preceding the payment year.(**) See proposed rule summary below.
Note:
• The Low Volume Adjustment applies only for dialysis treatments provided to adults (18 years or older).
(**) Summary of proposed rule changes:
• An ESRD facility will qualify for low-volume when there is a Change-of-Ownership (CHOW) that results in issuance of a new provider number due to a change in the facility type (hospital-based to freestanding and vice versa) if the new owner accepts assignment of the previous owner’s existing Medicare agreement.
• MACs are to accept extraordinary circumstance exceptions for meeting the 11/01 attestation deadline due to unforeseen circumstances, such as a natural disaster, but these circumstances will be reviewed on a case-by-case basis before an exception is granted.
• Facilities that change their Fiscal Year End date for reasons other than a CHOW are now eligible for the Low Volume Adjustment.
• Within the existing requirements, CMS has clarified that “miles” means “road miles.”
The proposed rules are discussed starting on page 14 on the PDF proposed rule file “CMS-1691-P.”
Documentation needed:
To receive the Low Volume Adjustment, ESRD providers must submit an attestation signed by the Managing Director or Official of their organization by November 1st preceding the next ESRD PPS (Prospective Payment System) Payment Year that includes the following information:
• Provider Name
• Medicare Provider Number and NPI (National Provider Identifier)
• Provider's Physical Address (including building/suite/room number, etc.)
• ESRD Certification Date
• Is your facility a Free Standing Facility or Hospital Based?
• Has the facility opened, closed or had a change in ownership in the 3 years preceding the payment year?
• Is this ESRD part of common ownership?
• If yes, please provide the following information
• Organization's Name
• Exact Distance between ESRD Provider and nearest commonly owned ESRD providers (within 25 miles or less)
• Provider Contact Name (please print)
• Provider Contact Phone Number
• Provider Contact E-mail Address
• Director or Official signature
In addition, providers should submit Cost Report worksheets C-1 (for Free Standing ESRD Providers) and Cost Report worksheet I-4 (for Hospital Based ESRD Providers) for the three 12 month cost reporting periods immediately preceding the ESRD PPS payment year. For ESRD providers with a 12/31 Fiscal Year End, please provide a projection of the number of treatments for the 3rd eligibility year. Once the current year 12/31 cost report is received, treatment numbers will be verified.
Send this notification to:
JN:
Yongmei Zheng, Senior Auditor
First Coast Service Options
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
Phone: (904) 791-8369
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
