Last Modified: 11/20/2017 Location: FL, PR, USVI Business: Part A
ESRD low volume adjustment
End-stage renal disease (ESRD) providers may be eligible to receive a low volume payment adjustment to their rate if they meet certain criteria as outlined in this article.
ESRD providers that are currently receiving the low volume adjustment are required to submit an annual Attestation prior to November 1 preceding the next payment year. Attestations will not be accepted after the November 1 deadline.
Note: Attestations can be accepted for individual ESRD facilities only. Each facility must submit their 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 us. If we discover that claims have received the low volume adjustment in error, we have 6 months to reprocess to remove the low volume adjustment.
Low volume criteria:
1. The facility has furnished less than 4,000 treatments in each of the three years preceding the payment year.
Note: The three eligibility years are based on cost reporting years.
Previously, eligibility for ESRD facilities that opened on January 1, 2011, and after were assessed by aggregating their treatments with other facilities that was within a 25 road mile radius and is under common ownership.
For CY 2016, the Centers for Medicare & Medicaid Services (CMS) removed grandfathering from these criteria and revised the geographic proximity criterion from 25 road miles to five road miles. These changes exclude facilities of common ownership that are located within five miles of one another, regardless of when these facilities opened.
2. The facility has not opened, closed, or had a change of ownership that resulted in a change in PTAN in the three years preceding the payment year.
*Please review CR8898 for changes regarding the 4,000 treatment count for hospitals that have multiple locations and changes to the 12 month cost report rule for provider's that have had a change of ownership with no change in provider transaction access number (PTAN).
Note: The low volume adjustment applies only for dialysis treatments provided to adults (18 years or older).
To receive the low volume adjustment, ESRD providers must submit an attestation signed by the managing director or official of their organization by November 1 preceding the next ESRD prospective payment system (PPS) payment year that includes the following information:
• Provider name
• Medicare provider number (PTAN) and National Provider Identifier (NPI)
• 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 three years preceding the payment year?
• If there was a change of ownership, did it result in a change of PTAN?
• Is this ESRD part of common ownership?
• If yes, please provide the organization's name
• Distance between ESRD provider and nearest commonly owned ESRD providers (within five miles or less)
• Treatment counts for other commonly owned ESRD providers that are within five miles or less of each other.
• Provider contact name (please print)
• Provider contact phone number
• Provider contact email address
• Director or official signature
In addition, providers should submit cost report worksheet C (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 December 31 fiscal year end, please provide a projection of the number of treatments for the third eligibility year. Once the current year December 31 cost report is received, treatment numbers will be verified.
This notification should be sent to:
Kathy Town, Senior Auditor
First Coast Service Options, Inc
532 Riverside Ave ROC-3C
Jacksonville, FL 32202
532 Riverside Ave ROC-3C
Jacksonville, FL 32202
Phone: (904) 791-6570
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