Navigating Medicare’s Phosphate Binder Challenge: Insights From the Field

During the latter part of 2024, I met with dialysis program administrators to assess the impact of Medicare’s change requests 13686 and 13865 on their programs. These changes, which implement system modifications for the 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS), have significant implications for compliance, documentation, and billing—particularly for phosphate binders.  

My discussions included administrators from a variety of dialysis programs, ranging from hospital-based and nursing home–based programs to small rural and pediatric centers, with both for-profit and nonprofit structures represented. This column highlights the most frequently voiced concerns and challenges program administrators face under the 2025 ESRD PPS requirements. 

Billing Challenges, Reimbursement Surprises 

One universal challenge reported was the difficulty of documenting phosphate binders in a way that seamlessly integrates with billing processes. Dialysis-specific electronic health records (EHRs) are designed to track and report medications administered during dialysis treatments, but oral medications taken at home, such as phosphate binders, historically have not been separately billable on dialysis claims. Even with prior experience managing oral calcimimetic documentation, dialysis EHR systems still struggle to efficiently capture and communicate the necessary data for phosphate binders, leading to administrative burdens and potential reimbursement issues. 

Adding to the complexity, most programs entered supply contracts for phosphate binders before the end of 2024, yet the Centers for Medicare & Medicaid Services (CMS) did not release its allowed reimbursement amounts until January 2025. When these figures became available, several program administrators contacted me, questioning whether the CMS had published incorrect rates—only to realize that their contracted rates were nearly double the Medicare reimbursement amount. Without prior access to these figures, many programs inadvertently overpaid for essential medications, creating financial strain. 

Strained Resources 

Another widespread concern was the financial viability of covering phosphate binder costs, particularly in states where Medicaid functions as a secondary payer and only issues payment when Medicare reimburses less than the Medicaid-allowed amount. Programs with a significant Medicare Advantage patient population faced additional financial pressures because many contracts provided a flat per-treatment payment for dialysis, with no added reimbursement for phosphate binders. In some cases, these agreements barely covered operational costs, let alone the additional expenses of these medications. 

In response, many programs have opted to provide patients with only generic phosphate binders, regardless of patient preferences. This raises an ethical dilemma: In healthcare, we strive to provide care regardless of a patient’s ability to pay, yet here, programs are forced to determine whether they can afford to supply the necessary medication. 

In discussing these concerns, it is important to acknowledge that program administrators are navigating an increasingly complex landscape of financial constraints, regulatory requirements, and patient needs. Many administrators expressed frustration that, despite their best efforts to ensure compliance, they still found themselves facing unexpected financial shortfalls. Others pointed to the added administrative burden of tracking and reconciling medications, which pulls valuable time and resources away from direct patient care. These ongoing challenges make it clear that dialysis programs are being asked to do more with less, putting additional strain on already stretched teams. 

Counting on Resilience 

Despite these challenges, one thing remains clear: Dialysis programs have a history of adaptability and perseverance. When the ESRD PPS was first implemented in 2011, programs found creative solutions to sustain operations despite increased administrative demands and reduced reimbursement. Similarly, when calcimimetics lost Transitional Drug Add-On Payment Adjustment status, dialysis programs innovated with ways to ensure patients continued receiving calcimimetics when necessary. The current challenges with phosphate binders will require the same resourcefulness, and I have no doubt that the dialysis community will rise to the occasion once again. 

Although uncertainty remains, the dedication of dialysis program administrators to problem-solving and patient care is unwavering. The resilience that has carried this industry through past payment model changes will continue to drive solutions, ensuring that patients receive the medications they need. The road ahead may be difficult, but history has shown that dialysis programs don’t just survive change—they find ways to thrive.

The opinions expressed in this column are the contributor’s own and do not represent those of Nephrology Times.