From the Field: AKI Billing Update and Insurance Refund Limitations

Rick Collins and Sarah Tolson

Recognizing that key differences exist in the reimbursement of services for acute kidney injury (AKI) patients, the Centers for Medicare & Medicaid Services (CMS) issued important clarifications in June that significantly impact physician and outpatient dialysis facility claims.

End-stage renal disease (ESRD) Conditions for Coverage, the Low Volume Payment Adjustment, home dialysis, physician services, payment for erythropoietin stimulating agents (ESAs), telehealth, modifiers, value codes, condition codes, and occurrence codes were all impacted by Change Request 9987 and the June 19 update to MLN Matters MM9598.

For outpatient dialysis facilities, the information required on claims for AKI patients will be significantly different from claims for ESRD patients. For example, the heights and weights of AKI patients need not be reported on claims. While reimbursement for ESRD patients vary because of each patient’s height and weight, there are no such payment adjustments related to an AKI patient’s height and weight.

Other clarifications noted that outpatient dialysis facilities no longer need to report values and/or modifiers for vascular access, urea reduction ratios, hemoglobin, or hematocrits.

ESAs given to AKI patients should be billed by outpatient dialysis facilities using non-ESRD Healthcare Common Procedure Coding System codes. Also, CMS clarified that there will be no separate payment for ESAs for AKI patients because it is included in the bundled rate for ESRD patients, which is the basis for the amount reimbursed for services provided to AKI patients.

CMS also noted that AKI patients do not qualify for reimbursement for telehealth services at this time, “unless other criteria are met.”

Physicians received good news as CMS confirmed in the update that they will reimburse for services provided to AKI patients in ESRD facilities as well as in physician offices. Depending on how physician visits to patients in ESRD facilities are captured and reported to billing staff, physicians and billers may want to flag visits to AKI patients to ensure that billers use the correct codes for these visits.

Statute of Limitations on Insurance Refund or Recoupment

Over the years, we have worked with providers who receive refund notices from payers for claims paid months or even years earlier. These refund notices often come as a complete surprise and are frequently due to some kind of internal issue experienced by the payer. Examples include errors in the payer’s claim processing system and internal audits or reviews that indicate a claim should have been paid at a different rate or not at all. Of course, providers have long since spent the money received and may be financially unprepared to pay back tens or hundreds of thousands of dollars demanded by the payer. Fortunately, your state’s laws regarding insurance refunds and your contracts with payers may be able to save you both headaches and money.

Some states have laws that place a statute of limitations on how much time payers have to request refunds for paid claims. The length of time varies for each of these states and can be as short as 6 months or as long as 5 years. Some of the state laws include exceptions to their time limits, such as coordination of benefit errors, fraud, or intentional misconduct by the provider.

To find resources for your state, a simple internet search for recoupment laws by state can point you in the right direction. Many states also have a department of insurance with customer service representatives that can assist in finding the state documents that provide the details of the law.

However, regardless of whether your state has a statute of limitations, you can always protect yourself by carefully contracting with payers. Whenever you negotiate a payer contract, make sure the contract specifies acceptable time limits for the payer to request refunds or recoup payments.

Payer contracts can also work against you, even in states with statutes of limitations regarding payer recoupment. If you agreed to longer recoupment/refund times in your contract, such clauses can lessen or even nullify the protections provided by the laws in your state.

Whenever you negotiate a new or updated payer contract, carefully review any clauses regarding the length of time the payer has to request refunds or recoup payments. If no such language exists in the contract, you may want to include a time limit in order to protect yourself.

Rick Collins is the chief operating officer and Sarah Tolson is the director of training for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD facilities, nephrology practices, and vascular access. Your questions are welcome and they can be reached at rcollins@sceptremanagement.com, stolson@sceptremanagement.com, or 801.775.8010.