Under the ESRD Prospective Payment System (PPS), facilities may be eligible to be paid an adjustment to their PPS rate if the facility furnished less than 4,000 treatments in each of the three years preceding the payment year.
ESRD providers that are currently receiving the low volume adjustment are required to submit an annual attestation prior to November 1st, preceding the next payment year. Attestations will not be accepted after the November 1st deadline.
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 their MAC immediately. If your MAC discovers that claims have received the low volume adjustment in error, the MAC has six months to reprocess to remove the low volume adjustment.
- The three eligibility years are based on the facilities 12/consecutive month cost reports for the cost reporting periods that end in the 3 years immediately preceding the 2019 payment year
- Attestations can be accepted for individual ESRD facilities only
- Each facility must submit its own attestation
- 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:
- Under common ownership with, and
- Five (5) miles or less from the ESRD facility in question
- Common ownership means the same individual, individuals, entity, or entities, directly, or indirectly, own five percent or more of each ESRD facility
- The facility has not opened, closed, or had a change of ownership that resulted in a change in PTAN in the three years proceeding the payment year. (See proposed rule summary below)
- The low volume adjustment applies only for dialysis treatments provided to adults (18 years or older)
The proposed rule for 2019 includes changes to the criteria controlling low volume eligibility. If any or all of these proposed rules are finalized, your MAC will take these into consideration when processing your facility’s low-volume request.
Summary of Proposed Rule Changes:
- An ESRD facility will qualify for low-volume when there is a change-of-ownership (CHOW) that results in the 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.
- Medicare administrative contractors (MACs) are to accept extraordinary circumstance exceptions for meeting the November 1 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, the Centers for Medicare & Medicaid Service (CMS) has clarified that “miles” means “road miles.”
Please refer to the proposed rule on
The proposed rules are discussed starting on page 14 on the PDF proposed rule file “CMS-1691-P.”
Documentation Needed (may vary depending on your MAC requirements):
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 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 three years proceeding the payment year?
- Is this ESRD part of common ownership?
- If yes, please provide the following information
- Organization's name
Exactdistance 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 email address
Directoror official signature
Additionally, Free-Standing ESRD Providers should submit Cost Report worksheets C and Hospital-Based ESRD Providers should submit Cost Report worksheets I-4 for the three 12-month cost reporting periods immediately preceding the ESRD PPS payment year. For ESRD providers with a 12/31 FYE, 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.
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