As we’ve all experienced over the past year, the pandemic has had a significant impact on almost every aspect of our personal and professional lives. So it comes as no surprise that we’ve been seeing the effect COVID is having on our premium restoration world as well. This impact shows up as an uptick in missed premiums for Medicare Advantage plans that manage members with End-Stage Renal Disease (ESRD). Here’s why this is happening and how it can impact your plan.
The average cost to treat a patient with ESRD can run well over $60,000 a year because members may require dialysis several times a week. To offset this higher cost of care, the Centers for Medicare and Medicaid Services (CMS) typically pays health plans a premium of $7,100 for managing members with ESRD, compared to a premium of $815 for non-ESRD members.
When a patient with ESRD visits a dialysis center for treatment, the dialysis center is required to submit a 2728 form to CMS. CMS receives this form and then pays the health plan the higher premium, as indicated in the monthly membership report (MMR) file.
However, circumstances arise that cause a plan to not receive the higher ESRD premium from CMS. Most of the time, errors that result in incorrect premium payments from CMS are either the result of something that happened on the provider side or directly with CMS. Read more on how the ESRD process works. And why it sometimes doesn’t.
In the past 12 months, Discovery has seen an increase in the number of ESRD form submission errors occurring on the provider end because of COVID.
A provider error occurs when the dialysis center does not properly send documentation to CMS. In order to submit the 2728 form, a provider must sign off. Similar to every other profession, many doctors are working remotely at times now because of COVID. Working remotely is a rather new concept for many dialysis centers; understandably, new processes and administrative tasks have taken some getting used to. Unfortunately, this has meant that some dialysis centers are either submitting 2728 forms without a provider signature or simply not submitting the form because of the provider’s absence. This disconnect is resulting in a monthly missed premium across our client base.
These dollars add up quickly and can become a significant source of lost revenue. To combat this trend, plans should reach out to their providers. An educational session with the provider and their staff can help reduce these errors from occurring in the future. We recommend that plans make sure their network is aware and to have a process in place in catch these mistakes.
If you have been seeing this error, no need to fear! CMS allows an 84-month look back across data to identify these errors. Plans can review their claims data to identify potential instances and then work with the provider to remediate.
Today, Discovery does this work on behalf of over 40 health plan clients. Our team uses proprietary analytics to identify these potential instances. Discovery’s provider relations team then coordinates to update proper documentation. Our team works with CMS to make sure the documentation is correct if the error is on their end. The result is restored premiums for the health plan! If you are interested in learning more, please reach out.