END-STAGE RENAL 

DISEASE

CMS Should Improve 

Design and Strengthen 

Monitoring of LowVolume Adjustment

Report to Congressional Committees

March 2013

GAO-13-287

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-287, a report to 

congressional committees

March 2013

END-STAGE RENAL DISEASE

CMS Should Improve Design and Strengthen 

Monitoring of Low-Volume Adjustment

Why GAO Did This Study

Medicare spent about $10.1 billion in 

2011 on dialysis treatments and 

related items and services for about 

365,000 beneficiaries with end-stage 

renal disease (ESRD). Most individuals 

with ESRD are eligible for Medicare.

As required by the Medicare 

Improvements for Patients and 

Providers Act of 2008 (MIPPA), CMS 

implemented the LVPA to compensate 

dialysis facilities that provided a low 

volume of dialysis treatments for the 

higher costs they incurred. MIPPA 

required GAO to study the LVPA; GAO 

examined (1) the extent to which the 

LVPA targeted low-volume, high-cost 

facilities that appeared necessary for 

ensuring access to care and (2) CMS’s 

implementation of the LVPA, including 

the extent to which CMS paid the 2011 

LVPA to facilities eligible to receive it.

To do this work, GAO reviewed 

Medicare claims, facilities’ annual 

reports of their costs, and data on 

dialysis facilities’ location to identify 

and compare facilities that were 

eligible for the LVPA with those that 

received it.

What GAO Recommends

To more effectively target the LVPA 

and ensure LVPA payment accuracy, 

GAO recommends that the 

Administrator of CMS consider 

restricting payments to low-volume 

facilities that are isolated; consider 

changing the LVPA to a tiered 

adjustment; recoup 2011 LVPA 

payments that the Medicare 

contractors made in error; improve 

monitoring of those contractors; and 

improve the clarity and timeliness of 

guidance. The Department of Health 

and Human Services, which oversees 

CMS, agreed with GAO’s 

recommendations.

What GAO Found

The low-volume payment adjustment (LVPA) did not effectively target lowvolume facilities that had high costs and appeared necessary for ensuring access 

to care. Nearly 30 percent of LVPA-eligible facilities were located within 1 mile of 

another facility in 2011, and about 54 percent were within 5 miles, indicating 

these facilities might not have been necessary for ensuring access to care. 

Furthermore, in many cases, LVPA-eligible facilities were located near highvolume facilities. Among the freestanding facilities in GAO’s analysis, LVPAeligible facilities had substantially higher costs per dialysis treatment than the

average facility ($272 compared with $235); however, so did other facilities that 

provided a relatively low volume of treatments (and were isolated) but were 

ineligible for the LVPA. The design of the LVPA gives facilities an adverse 

incentive to restrict service provision because facilities could lose a substantial 

amount of Medicare revenue over 3 years if they reach the treatment threshold. 

In another payment system, the Centers for Medicare & Medicaid Services 

(CMS) implemented a tiered adjustment that decreases as facility volume 

increases. Such an adjustment could diminish the incentive for dialysis facilities 

to limit service provision and also more closely align the LVPA with the decline in 

costs per treatment that occurs as volume increases.

Medicare overpaid an estimated $5.3 million in 2011 to dialysis facilities that 

were ineligible for the LVPA and did not pay an estimated $6.7 million that same 

year to facilities that were eligible. The payment problems occurred primarily 

because the guidance issued by CMS on facility eligibility was sometimes not 

clear or timely and CMS’s monitoring of the LVPA was limited. For example, the 

majority of the ineligible facilities that received the LVPA were hospital-affiliated 

facilities that failed the volume requirement. Although CMS gave the Medicare 

contractors guidance for determining how to count treatments when facilities are 

affiliated with hospitals, the agency did not issue that guidance until July 2012. 

CMS has conducted limited monitoring of the LVPA, which has left CMS with 

incomplete information about LVPA administration and payments. For example, 

CMS was unaware as of January 2013 whether its contractors had recouped 

erroneous 2011 LVPA payments. In addition, CMS had requested information 

from its contractors about the implementation of the 2011 LVPA, such as which 

facilities were eligible for or had received the LVPA, but had not yet verified 

whether the information it received was complete or in a usable form. Without 

complete information about the administration of this payment adjustment, CMS 

is not in a position to ensure that the LVPA is reaching low-volume facilities as 

intended or that erroneous payments to ineligible facilities are recouped.

View GAO-13-287. For more information, 

contact James C. Cosgrove at (202) 512-7114 

or cosgrovej@gao.gov.
 

Page i GAO-13-287 Medicare Payment for ESRD Treatments

Letter 1 

Background 5

LVPA Did Not Effectively Target Low-Volume Facilities That 

Appeared Necessary for Ensuring Access to Care and Had High 

Costs 7

Medicare Overpaid Facilities Ineligible for the 2011 LVPA and Did 

Not Pay Some Eligible Facilities; Primary Causes Were Unclear 

Guidance and Insufficient Monitoring 11

Conclusions 17

Recommendations for Executive Action 18

Agency and Industry Comments and Our Evaluation 18

Appendix I Comments from the Department of Health and Human 

Services 23

Appendix II GAO Contact and Staff Acknowledgments 26

Figures

Figure 1: Distance to Nearest Dialysis Facility, Facilities Eligible 

for 2011 LVPA Compared with All Facilities 8

Figure 2: Analysis of Payments Associated with the 2011 LVPA 12

Contents 
 

Page ii GAO-13-287 Medicare Payment for ESRD Treatments

Abbreviations

CMS Centers for Medicare & Medicaid Services

ESRD end-stage renal disease

DFC Dialysis Facility Compare

HHS Department of Health and Human Services

KCC Kidney Care Council

LVPA low-volume payment adjustment

MIPPA Medicare Improvements for Patients and Providers Act 

 of 2008

NRAA National Renal Administrators Association

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-13-287 Medicare Payment for ESRD Treatments

United States Government Accountability Office

Washington, DC 20548

March 1, 2013

Congressional Committees

In 2011, Medicare spent about $10.1 billion on dialysis care—including 

dialysis treatments and related items and services—for about 365,000 

beneficiaries.1 Dialysis removes excess fluids and toxins from the 

bloodstream and is the most common treatment for end-stage renal 

disease (ESRD)—a condition of permanent kidney failure. Most 

individuals with ESRD are eligible for Medicare regardless of their age.2

As required by the Medicare Improvements for Patients and Providers Act 

of 2008 (MIPPA), the Department of Health and Human Services’ (HHS) 

Centers for Medicare & Medicaid Services (CMS) recently implemented 

several changes to the way Medicare pays for dialysis care, including the 

introduction of a low-volume payment adjustment (LVPA) for services 

furnished on or after January 1, 2011, to increase the payment rate for 

facilities that provide a low volume of dialysis treatments.3

 

1

Medicare expenditure amounts throughout this report include beneficiary cost sharing. 

MIPPA 

required that the adjustment reflect the extent to which costs incurred by 

low-volume facilities exceed the costs incurred by other facilities and 

authorized CMS to define the level at which a facility’s treatments are 

2

Medicare coverage generally begins in the 4th month after patients start dialysis. For 

individuals who have employer group coverage, Medicare is the secondary payer for the 

first 30 months of Medicare entitlement, after which Medicare becomes the primary payer. 

42 U.S.C. § 1395y(b)(1)(C). Most individuals diagnosed with ESRD are eligible to receive 

Medicare benefits under Medicare Part A, Part B, and Part D. 42 U.S.C. §§ 426-1, 1395w101(a)(3)(A). Medicare Part A covers inpatient hospital, skilled nursing facility, and 

hospice care, as well as some home health care, and generally does not require a 

monthly premium. Medicare Part B covers outpatient dialysis treatment, injectable ESRD 

drugs, certain oral ESRD drugs, physician services, hospital outpatient services, and 

certain other services, such as physical therapy. Beneficiaries enrolled in Part B are 

required to pay a monthly premium. To receive most Part B-covered services, 

beneficiaries are required to meet an annual deductible and typically pay 20 percent 

coinsurance. Medicare Part D covers outpatient prescription drugs and generally requires 

payment of a monthly premium, meeting an annual deductible, and paying part of the cost 

associated with each prescription.

3

Pub. L. No. 110-275, §153, 122 Stat. 2494, 2553-59 (codified at 42 U.S.C. § 1395rr).

Medicare pays dialysis facilities a single, bundled rate for providing dialysis. Beginning in 

2011, this bundled rate includes payment for a dialysis treatment and dialysis-related 

items and services, such as injectable ESRD drugs.

 
 

Page 2 GAO-13-287 Medicare Payment for ESRD Treatments

considered low volume and to determine the amount of the adjustment.

CMS defined the criteria for identifying a facility eligible for the 2011 LVPA 

as a facility that, during each of the 3 previous years, (1) provided fewer 

than 4,000 total dialysis treatments—including treatments covered by 

Medicare and those that were not—and (2) had not opened, closed, or 

changed ownership.4 CMS set the magnitude of the adjustment at 

18.9 percent and indicated that the LVPA was designed to encourage 

small ESRD facilities to continue operating in areas where beneficiary 

access might be jeopardized if such facilities closed.5

Medicare’s payment adjustment for low-volume dialysis facilities is one of 

several modifications in Medicare’s various payment systems designed to 

help maintain beneficiaries’ access to care. These payment modifications 

include those that were developed to target small and geographically 

isolated providers.6

 

4

See 42 C.F.R. § 413.232(b) (2011). CMS subsequently amended the requirement related 

to change of ownership to read “or received a new provider number due to a change in 

ownership” to correct an inadvertent omission in the 2011 final rule and provided 

clarification that the 3 years for purposes of determining eligibility are cost-reporting years, 

as opposed to calendar (or payment) years. See 76 Fed. Reg. 70228, 70236-37, 70314 

(Nov. 10, 2011) (codified at 42 C.F.R. § 413.232(b) (2012)).

Providers that furnish a low volume of services may 

incur higher costs of care because they cannot achieve the economies of 

scale that are possible for larger providers. Low-volume providers in 

areas where other care options are limited may warrant higher payments 

because, if Medicare’s payment methods did not account for these 

providers’ higher costs of care, beneficiary access to care could be 

reduced if these providers were unable to continue operating. In contrast, 

low-volume providers that are in close proximity to other providers may 

not warrant an adjustment because beneficiaries have other care options 

nearby.

5

See 75 Fed. Reg. 49,030, 49,118, 49,125) (Aug. 12, 2010).

6

The Medicare Payment Advisory Commission has recently developed three principles 

that should guide Medicare’s special payment adjustments for rural providers. In order for 

beneficiaries’ needs to be met most efficiently, such payment adjustments should (1) be 

targeted toward low-volume isolated providers, (2) increase to the extent that factors 

beyond the provider’s control increase their costs, and (3) be designed in such a way that 

encourages cost control on the part of providers. See Medicare Payment Advisory 

Commission, Report to the Congress: Medicare and the Health Care Delivery System

(Washington, D.C.: June 2012).
 

Page 3 GAO-13-287 Medicare Payment for ESRD Treatments

MIPPA required us to conduct a study of the LVPA.7

To examine the extent to which the 2011 LVPA targeted low-volume 

facilities that appeared necessary for ensuring access to care and had 

high costs, we used three different Medicare data sources—claims data, 

cost reports, and the Dialysis Facility Compare (DFC) database.

As discussed with 

the committees of jurisdiction, this report: (1) examines the design of the 

adjustment and the extent to which it targeted low-volume facilities that 

appeared necessary for ensuring access to care and had high costs; and 

(2) examines how CMS implemented the LVPA, including the extent to 

which CMS paid the 2011 adjustment to facilities that were eligible to 

receive it.

8 We first 

identified facilities that were available to beneficiaries at the beginning of 

2011 using Medicare claims data from 2010 and 2011.9 Using the 

methods specified by CMS in applicable guidance10 and clarified through 

our interviews with the agency, we used Medicare cost reports for 2008, 

2009, and 2010 to identify facilities that were eligible for the 2011 LVPA.

We determined the extent to which a facility appeared necessary for 

ensuring access to care by evaluating whether it was isolated from other 

facilities, which we measured using the facility’s address obtained from 

Medicare’s DFC database to calculate the distance to the nearest 

facility.11

 

7

Pub. L. No. 110-275, § 153(d), 122 Stat. 2559. This provision also required us to report 

on trends in the utilization of ESRD drugs. See GAO, End-Stage Renal Disease: 

Reduction in Drug Utilization Suggests Bundled Payment Is Too High, 

To compare the average cost per dialysis treatment of LVPAGAO-13-190R

(Washington, D.C.: Dec. 7, 2012).

8

DFC is a database on Medicare’s website that allows users to compare dialysis facilities 

nationwide based on factors such as the types of services and quality of care provided. 

Medicare-certified providers are required to submit an annual cost report to Medicare 

contractors. Dialysis facilities’ cost reports contain provider information, such as the total 

number of dialysis treatments and the number covered by Medicare, and the providers’ 

costs associated with those services. Providers are allowed to define their own costreporting year; for example, cost reports may span from January 1 through December 31 

or July 1 through June 30. 

9

We defined facilities available at the beginning of 2011 as those for which Medicare paid 

at least one dialysis claim in both 2010 and 2011.

10As used in this report, the term “guidance” refers to information provided by CMS to 

explain and supplement the regulatory criteria for identifying a facility eligible for the LVPA 

and includes but is not limited to information found in preambles to pertinent proposed and 

final CMS rules.

11If an address for a facility could not be found through DFC, we used a facility’s zip code 

or the address of a facility’s parent hospital, depending on the type of facility.
 

Page 4 GAO-13-287 Medicare Payment for ESRD Treatments

eligible facilities with the average cost per treatment for facilities overall, 

we analyzed data from 2010 Medicare cost reports for freestanding 

facilities and adjusted those costs for differences in wages and 

beneficiaries’ health status.12 We excluded from our analysis certain 

freestanding facilities that had an extremely high or low average cost per 

treatment or failed other validity checks, such as reporting more Medicare 

treatments than total treatments.13

To examine how CMS implemented the LVPA, including the extent to 

which CMS paid the 2011 LVPA to facilities that were eligible to receive 

the adjustment, we compared the set of facilities that received the 

adjustment with those that were eligible to receive it, and interviewed 

CMS officials and representatives of dialysis organizations about the 

potential sources of any discrepancies. We identified dialysis facilities that 

received the LVPA in 2011 using Medicare claims for dialysis treatments 

provided in that year and compared these facilities with those that were 

eligible. To estimate the amount that Medicare overpaid to ineligible 

facilities, we used payment information from Medicare claims. We also 

used Medicare claims data to estimate the amount that LVPA-eligible 

facilities did not receive—that is, the additional amount that Medicare 

would have paid if all eligible facilities had received the adjustment for all 

treatments provided to adult beneficiaries in 2011.

Beyond these exclusions, we did not 

independently verify whether the information reported in 2010 cost reports 

for freestanding facilities represented an accurate or complete picture of 

dialysis facilities’ costs. 

14

 

12When adjusting freestanding facilities’ costs for the health status of their patients, we 

used the basic case-mix adjustment CMS used in 2010 and, like CMS, applied it to costs 

that were paid under a single bundled rate in 2010. Because we only had information on 

the health status of Medicare beneficiaries, we assumed that the average health status of 

the facility’s non-Medicare patients was the same as that of its Medicare patients. To 

adjust for wages, we used CMS’s 2010 wage index file. We did not analyze costs for 

facilities affiliated with a hospital, primarily because these facilities’ costs may be driven in 

part by hospitals’ methods for allocating overhead costs within hospitals rather than by the 

costs of the dialysis facility itself.

To examine other 

aspects of CMS’s implementation of the LVPA, we reviewed CMS 

regulations and guidance, interviewed CMS officials, and interviewed 

groups representing large and small dialysis organizations. 

13To identify extreme values, we used a standard statistical distribution (the lognormal) 

and excluded facilities whose average cost per treatment was three or more standard 

deviations above or below the mean.

14The LVPA applies only to dialysis treatments provided to adults (age 18 years or older).
 

Page 5 GAO-13-287 Medicare Payment for ESRD Treatments

We took several steps to ensure that the data used to produce this report 

were sufficiently reliable. Specifically, we assessed the reliability of the 

CMS data we used by interviewing officials responsible for overseeing 

these data sources, reviewing relevant documentation, and examining the 

data for obvious errors. We determined that the data were sufficiently 

reliable for the purposes of our study.

We conducted this performance audit from May 2012 through January 

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Treatment options for individuals with ESRD include kidney transplants or 

maintenance dialysis. Kidney transplants are not a practical option on a 

wide scale, as suitable donated organs are scarce. Consequently, dialysis 

is the treatment used by most individuals with ESRD. Hemodialysis, the 

most common form of dialysis, is generally administered three times a 

week at facilities that provide these services. During hemodialysis, a 

machine pumps blood through an artificial kidney and returns the 

cleansed blood to the body. Other dialysis options include receiving 

hemodialysis at home and peritoneal dialysis.15

 

15Peritoneal dialysis, which usually occurs in an individual’s home, utilizes the peritoneal 

membrane, which surrounds the patient’s abdomen, as a natural blood filter. Patients 

remove wastes and excess fluids from their abdomen manually throughout the day, or a 

machine automates the process while patients sleep at night. As of December 31, 2010, 

the percentage of all dialysis patients receiving hemodialysis at a facility, peritoneal 

dialysis, and home hemodialysis was approximately 91 percent, 7 percent, and 1 percent,

respectively.

Background 

End-Stage Renal Disease 

(ESRD) 
 

Page 6 GAO-13-287 Medicare Payment for ESRD Treatments

To have been eligible to receive the LVPA in 2011, a facility must have 

established that it met the CMS regulatory criteria that, during each of the 

3 previous years, it (1) provided fewer than 4,000 total dialysis treatments 

and (2) had not opened, closed, or changed ownership.16 CMS guidance 

provided additional detail on the application of these criteria.17

To establish eligibility, a facility must provide an attestation statement to 

its designated Medicare contractor, which is responsible for verifying that 

the facility has met the eligibility criteria.18 Only after the facility has 

submitted its attestation and its designated Medicare contractor has 

verified that the facility meets the eligibility criteria will a facility begin to 

receive the LVPA for its Medicare-covered dialysis treatments provided to 

adult beneficiaries. CMS requires facilities to provide an attestation 

because some of the information the Medicare contractors need to 

assess a facility’s eligibility—in particular, facilities’ cost reports for the 

year preceding the payment year—may be unavailable to the Medicare 

contractors until several months after the payment year begins. In cases 

where the Medicare contractors could not make a final eligibility 

determination at the beginning of the payment year, they were to 

conditionally approve LVPA payments; then, once the necessary 

information becomes available, the Medicare contractors are required to 

reassess the facility’s eligibility for the LVPA. If a Medicare contractor 

determines that a facility that received the LVPA was actually ineligible, 

the contractor is expected to recoup all LVPA payments made to that 

facility within 6 months of that determination.

 

1642 C.F.R. § 413.232 (2011). For facilities certified on or after January 1, 2011, the 

regulations state that the number of treatments determined to have been provided by a 

facility be equal to the aggregate number of treatments provided by the facility and all 

other facilities that are under common ownership and located within 25 miles. Because the 

regulations also require that a facility be in operation for at least 3 years in order to be 

eligible for the LVPA, the earliest this additional requirement would affect eligibility would 

be 2014. 

17See, e.g., 74 Fed. Reg. 49,922 (Sept. 29, 2009); 75 Fed. Reg. 49,030 (Aug. 12, 2010); 

CMS, JSM/TDL-10444 (Oct. 8, 2010); 76 Fed. Reg. 40,498 (July 8, 2011).

18See 42 C.F.R. § 413.232(f) (2012). In 2011, the designated Medicare contractors—

Fiscal Intermediaries and Medicare Administrative Contractors—were expected to verify a 

facility’s eligibility within 60 days of receiving the facility’s attestation. 

Low-Volume Payment 

Adjustment (LVPA)
 

Page 7 GAO-13-287 Medicare Payment for ESRD Treatments

Many of the 326 facilities eligible for the 2011 LVPA were located near 

other facilities, indicating that they might not have been necessary for 

ensuring access to care. Certain facilities with relatively low volume that 

were not eligible for the LVPA had above-average costs and appeared to 

have been necessary for ensuring access to care. Moreover, the design 

of the LVPA provides facilities with an adverse incentive to restrict their 

service provision to avoid reaching the 4,000 treatment threshold.

Many LVPA-eligible facilities in 2011 were located near other dialysis 

facilities, indicating that they might not have been necessary for ensuring 

access to care. While LVPA-eligible facilities were more isolated 

compared with all dialysis facilities (see fig. 1), nearly 30 percent of 

LVPA-eligible facilities were located within a mile of another facility, and 

more than 3 percent of LVPA-eligible facilities shared an address with 

another facility that was not eligible and was owned by the same 

company.19

 

19For instance, we found several examples of a company having two facilities located at 

the same address, one providing in-center hemodialysis and the second providing other 

services, such as training services.

In addition, more than half—approximately 54 percent—of 

LVPA-eligible facilities were 5 miles or less from another facility. These 

results indicate that the patients using many LVPA-eligible facilities may 

have had access to multiple facilities for receiving dialysis care, which 

suggests that the LVPA does not effectively target facilities that appear 

necessary for ensuring access to dialysis care.

LVPA Did Not 

Effectively Target 

Low-Volume Facilities 

That Appeared 

Necessary for 

Ensuring Access to 

Care and Had High 

Costs 

Many LVPA-Eligible 

Facilities Appeared 

Unnecessary for Ensuring 

Access to Care—Nearly 

30 Percent Were Located 

within 1 Mile of Another 

Facility
 

Page 8 GAO-13-287 Medicare Payment for ESRD Treatments

Figure 1: Distance to Nearest Dialysis Facility, Facilities Eligible for 2011 LVPA Compared with All Facilities

Notes: CMS data sources examined include cost reports, claims, and the Dialysis Facility Compare 

database. Percentages may not sum to 100 due to rounding.

Many LVPA-eligible facilities were located near high-volume facilities, 

suggesting that these LVPA-eligible facilities may not have warranted a 

payment adjustment because they were located in areas with a 

population base sufficient to support high-volume facilities. Approximately 

35 percent of the 326 LVPA-eligible facilities were located within 5 miles 

of a high-volume facility.20 Further, of these facilities, approximately 

94 percent were located in urban areas, compared with 51 percent of all 

LVPA-eligible facilities.

 

20The average number of Medicare dialysis treatments per facility was 7,462 in 2011. We 

defined a facility as high-volume if it provided more than that number of Medicare dialysis 

treatments in 2011. The average number of Medicare dialysis treatments provided by 

high-volume facilities in 2011 was 12,027.
 

Page 9 GAO-13-287 Medicare Payment for ESRD Treatments

Compared with all freestanding facilities in our cost analysis, freestanding 

LVPA-eligible facilities had substantially higher costs per dialysis 

treatment in 2011, but other freestanding facilities that provided a 

relatively low volume of treatments were ineligible for the LVPA, even 

though they were isolated and incurred above-average costs, because 

they exceeded the treatment threshold.21 The average cost per treatment 

for the 216 freestanding facilities that were LVPA-eligible was $272, 

compared with $235 for all freestanding facilities—a difference of 

approximately 16 percent.22

The design of the LVPA also raises concerns because it provides facilities 

with an adverse incentive to restrict their service provision to avoid 

reaching the 4,000 treatment threshold. Facilities that reach this threshold 

lose eligibility for the next 3 calendar years.

However, the 2011 LVPA did not target other 

freestanding facilities that provided a relatively low volume of treatments, 

were isolated, and incurred above-average costs. For example, if the 

volume threshold was raised to 5,000 dialysis treatments, 203 additional 

freestanding facilities would have been eligible for the 2011 LVPA. Of 

these 203 facilities, 68 and 25 were located more than 15 miles and 

25 miles, respectively, from another facility, indicating that these facilities 

likely were important for ensuring access to care. On average, costs per 

dialysis treatment for these two groups of isolated facilities exceeded the 

average for all freestanding facilities by approximately 9 percent each—

$21 and $22, respectively.

23

 

21For our cost analysis, hospital-affiliated facilities and certain freestanding facilities were 

excluded. In total, we analyzed cost information for 4,429 facilities, approximately 

81 percent of the 5,501 dialysis facilities open as of January 1, 2011.

For example, for a facility 

that provided 3,999 total treatments in 2010 and met all other eligibility 

22The payment increase for the 2011 LVPA was 18.9 percent. While we found the actual 

cost difference to be slightly lower at 16 percent, this report does not comment on the 

appropriateness of the size of the adjustment because the methodology we used was not 

directly comparable to the one used by CMS. For instance, CMS included hospitalaffiliated facilities, which we did not because of our concerns regarding the reliability of the 

cost data from these facilities, and CMS used a regression-based methodology, while we 

averaged the cost per treatment across different groups of facilities. In our comparison of 

costs between low-volume and all freestanding facilities, we were only able to adjust a 

portion of a facility’s costs—those that were part of the set of services paid under a single 

rate in 2010—for differences in wage levels and patients’ health status; however, we 

found that the variation in facilities’ total costs per treatment was due almost entirely to 

services for which we were able to apply these adjustments.

23A facility may also lose eligibility for the remainder of the current year, if the facility was 

receiving the LVPA in the year in which it reached the threshold.

Certain Ineligible Facilities 

Had Above-Average Costs 

and Appeared Necessary 

for Ensuring Access to 

Care; LVPA Design May 

Introduce Adverse 

Incentives
 

Page 10 GAO-13-287 Medicare Payment for ESRD Treatments

criteria for the LVPA, providing an additional treatment would have 

caused the facility to lose eligibility for the LVPA for the next 3 calendar 

years, resulting in an estimated $390,000 in lost revenue from Medicare 

for 2011 through 2013.24

CMS has implemented an adjustment in another payment system that 

decreases as facility volume increases—an approach which, if applied to 

the LVPA, could diminish the incentive for providers to limit service 

provision by making the loss of potential revenue smaller for supplying 

additional services.25 In addition, such an adjustment—referred to as a 

tiered or phased-out adjustment—could more closely align the LVPA with 

the decline in cost per treatment that occurs as volume increases. For 

example, among freestanding facilities that met the other LVPA eligibility 

criteria, the average cost per treatment for facilities that would have 

qualified under a 3,000 treatment threshold was $290; the average cost 

per treatment for facilities that would have failed a 3,000 treatment 

threshold but qualified under a 4,000 treatment threshold was $263, and 

the average cost per treatment for facilities that would have failed a 4,000 

treatment threshold but qualified under a 5,000 treatment threshold was 

$256.

 

24We assumed that the proportion of this facility’s total services that are paid by Medicare 

is equal to the average proportion for LVPA-eligible facilities in our cost analysis— 

73 percent. We did not analyze 2011 cost-report data for evidence of facilities restricting 

their service provision to obtain or maintain eligibility for the LVPA because such data 

were not available at the time of our analysis. However, numerous facilities could be 

affected by the incentive to restrict service provision, based on the total volume of 

treatments the facilities recorded in their 2010 cost reports. For instance, 284 facilities—

over 6 percent of all freestanding facilities in our analysis—provided from 3,500 to 4,499 

total treatments in 2010.

25Under the adjustment, hospitals received increased payments per discharge if the 

hospital provided fewer than 1,600 discharges a year. The amount of the adjustment was 

as much as 25 percent for hospitals with fewer than 200 discharges and decreased 

linearly until it was phased out for hospitals with 1,600 or more discharges.
 

Page 11 GAO-13-287 Medicare Payment for ESRD Treatments

Medicare overpaid an estimated $5.3 million for the LVPA to dialysis 

facilities that did not meet the eligibility requirements established by CMS 

and did not pay about $6.7 million to facilities eligible for the LVPA. The 

guidance that CMS issued for implementation of the regulatory 

requirements was sometimes unclear and not always available when 

needed, and the misunderstanding of LVPA eligibility likely was 

exacerbated because CMS conducted limited monitoring of the Medicare 

contractors’ administration of LVPA payments.

Medicare overpaid 83 dialysis facilities that were ineligible for the LVPA in 

2011 by an estimated $5.3 million, which was nearly one-quarter of the 

approximately $22.7 million in LVPA payments made that year. (See 

fig. 2.) These facilities were ineligible because, on the basis of applicable 

data and methods specified by CMS in its guidance (and clarified through 

our interviews with CMS), they did not meet the regulatory requirements 

of having (1) provided under 4,000 dialysis treatments in each of the 

3 years preceding the payment year and (2) not opened, closed, or had a 

change of ownership in the 3 years preceding the payment year.

Medicare contractors are expected to recoup payments made in error 

within 6 months of detecting the error,26

 

26CMS, TDL-12034 (Oct. 21, 2011).

but as of January 2013, CMS did 

not know whether any of these overpayments had been recouped.

Medicare Overpaid 

Facilities Ineligible 

for the 2011 LVPA and 

Did Not Pay Some 

Eligible Facilities; 

Primary Causes Were 

Unclear Guidance and 

Insufficient 

Monitoring 

Medicare Overpaid 

Facilities Ineligible for 

the 2011 LVPA by an 

Estimated $5.3 Million and 

Did Not Pay an Estimated 

$6.7 Million to Some 

Eligible Facilities, 

including Those That Did 

Not Request Payments
 

Page 12 GAO-13-287 Medicare Payment for ESRD Treatments

Figure 2: Analysis of Payments Associated with the 2011 LVPA

Note: The overpayments were made to 73 dialysis facilities that were ineligible at the beginning of 

2011 and to 10 facilities that were potentially eligible at the beginning of 2011 but failed one or more 

criteria when all pertinent information became available. Seventy-nine eligible facilities did not receive 

any LVPA payments and an additional 194 facilities received payments for only some treatments.

These nonpayments may have occurred because facilities did not promptly—or ever—attest to their 

eligibility or because Medicare contractors did not pay correctly. Accurate payments were made to 

249 facilities, including 55 facilities that received accurate payments for all their treatments. Eligible 

facilities include those that met the eligibility criteria for 2008 and 2009 but for which the data to 

assess the criteria in 2010 were not yet publicly available.

These overpayments were of two types: payments to dialysis facilities 

that were ineligible at the beginning of 2011 and payments to facilities 

that were potentially eligible given the data available at the beginning of 

2011 but proved ineligible when all pertinent information became 

available.27

 

27Because cost reports—the data source CMS specified Medicare contractors should use 

to assess eligibility for the LVPA—can be submitted up to 5 months after the end of the 

cost-reporting year, facilities’ cost reports for the prior year may not be available until part 

way through the payment year.

Most of these payments—about $4.8 million—were to 

73 facilities that were clearly ineligible at the beginning of the year 
 

Page 13 GAO-13-287 Medicare Payment for ESRD Treatments

because data available prior to 2011 showed that the facility did not meet 

one or more of the eligibility criteria. The remaining $0.5 million was paid 

to 10 facilities that met the eligibility criteria for 2008 and 2009, but when 

data on 2010 activity became available were shown not to have met the 

eligibility criteria for that year. In cases where Medicare contractors could 

not make a final eligibility determination at the beginning of the payment 

year, they were to conditionally approve LVPA payments, reassess 

eligibility when facilities’ 2010 data became available, and, for facilities 

determined to be ineligible, recoup payments within 6 months of 

determining ineligibility.

Furthermore, many eligible dialysis facilities did not receive any LVPA 

payments in 2011 and others received payments for only part of the year.

These nonpayments amounted to about $6.7 million and affected 273 

facilities. Seventy-nine eligible facilities did not receive payments for any 

treatments; these payments would have amounted to about $3.4 million.

It is probable that these facilities did not claim the LVPA—that is, they did 

not attest to their eligibility, as required in regulations—although it is also 

possible that some attested to their eligibility and were incorrectly denied 

by their Medicare contractor. Another 194 facilities received some but not 

all payments for which they were eligible—in total accounting for another 

estimated $3.3 million in nonpayments. Thirty-two facilities did not start 

receiving LVPA payments until part way through the year, but then 

consistently received payments for all treatments for the remainder of the 

year. These are likely facilities that were late in attesting to their eligibility, 

resulting in LVPA nonpayments of about $0.9 million. For the remaining 

estimated $2.4 million in nonpayments to 162 facilities, the reason is less 

clear because there is no discernible pattern. For example, some facilities 

received payments for several months, did not receive payments for 1 or 

more subsequent months, and then started receiving payments again.

Other facilities received payments for some but not all treatments within a 

given month for multiple months in a row. We cannot explain the cause of 

these payment inconsistencies, but the inconsistencies could suggest 

problems with the claims payment system. Many of the overpayments to 

ineligible facilities showed a similar lack of pattern, which also could 

suggest problems with the claims payment system.

In 2011, CMS correctly paid the LVPA to 249 facilities for at least some of 

their treatments; these payments totaled an estimated $17.4 million. 

Fifty-five of these facilities received about $4.2 million in payments for all 

their treatments. CMS paid the remaining estimated $13.2 million to the 

194 eligible facilities that received the LVPA for only some treatments.
 

Page 14 GAO-13-287 Medicare Payment for ESRD Treatments

Although CMS provided opportunities for Medicare contractors and 

facilities to ask clarifying questions regarding its implementation of the 

requirements for LVPA eligibility,28 the guidance for implementing these 

requirements was sometimes unclear and not always available when 

needed. For example, the majority of the facilities that incorrectly received 

the LVPA—54 of 83—were hospital-affiliated facilities that failed the 

volume threshold. Eventually, CMS specified that Medicare contractors 

should combine the treatments of a hospital’s affiliated dialysis facilities in 

determining whether the LVPA requirement for fewer than 4,000 

treatments had been met. While this method of applying the regulatory 

requirement is logical because hospital-affiliated facilities do not file 

individual cost reports,29 CMS did not issue explicit guidance on this topic 

until July 2012.30

CMS guidance to Medicare contractors for determining whether a facility 

had met the LVPA requirement of not having opened, closed, or changed 

ownership during the 3 years preceding the payment year was neither 

clear nor timely. According to our interviews with CMS officials, the 

agency’s intention was for contractors to verify that each of the facility’s 

cost reports for the previous 3 years covered exactly 12 months; however 

the connection between the regulatory requirement and the duration of 

the cost-reporting periods has not been explicitly made in CMS guidance.

(For example, an October 2010 internal technical direction letter stated 

that, in order to meet the LVPA eligibility verification requirements, 

Medicare contractors needed to confirm that fewer than 4,000 total 

treatments were provided for each of the 12-month cost-reporting 

periods—however, it was not clear which regulatory verification 

 

28CMS officials told us that the agency provided several opportunities for Medicare 

contractors and facilities to ask about the ESRD payment changes implemented in 2011, 

but that the agency received very few questions on the LVPA. Opportunities to ask 

questions included a 2010 conference call with all the Medicare contractors, a 2010 town 

hall open to the public, and a frequently asked questions section on CMS’s website.

29Hospital-affiliated facilities do not file individual cost reports, rather, their treatments are 

included in their parent hospital’s cost report as part of the total treatments provided by all 

facilities affiliated with the hospital. According to CMS officials, cost reports are the only 

source of the total dialysis treatments provided by ESRD facilities. 

30CMS, TDL-12419 (July 18, 2012). Previous guidance had specified that the volume 

criterion should be assessed using cost reports, and CMS officials told us they had 

believed that using the total number of treatments reported on a hospital’s cost report as a

method to assess the eligibility of hospital-affiliated facilities did not need specific 

clarification.

Unclear and Late Guidance 

and Insufficient 

Monitoring Were Primary 

Contributors to Payment 

Problems
 

Page 15 GAO-13-287 Medicare Payment for ESRD Treatments

requirement(s) the sentence was implementing.31) CMS officials 

explained that three cost-reporting periods of exactly 12 months (which 

need to be consecutive) are a time frame that would exhibit business 

practice patterns that demonstrate a facility is consistently low-volume 

and that, because cost reports correspond with the facility’s fiscal year, 

using them provides a snapshot of a facility’s financial ability to incur 

costs for furnishing renal dialysis. Furthermore, CMS officials noted that

having three cost-reporting periods of exactly 12 months each was a 

reasonable method of assessing the regulatory requirement because, 

generally, if a facility opened, closed, or had a change in ownership (in 

which case the facility may receive a new provider number), this would 

cause a break in the cost-reporting period and thus lead a facility to have 

one or more cost reports that spanned fewer than 12 months. In July 

2011, CMS issued public guidance clarifying that the relevant periods 

during which a facility had not opened, closed, or had a change in 

ownership were the three cost-reporting periods before the payment year 

and not the 3 calendar years before the payment year.32

Unclear and late guidance for determining whether a facility had opened, 

closed, or changed ownership led to misunderstanding about which 

facilities were eligible, and at least some of the misunderstanding 

persisted as of September 2012. For example, when we questioned a 

representative of a large dialysis organization in September 2012 about 

some of the organization’s facilities that we found to have not received 

the 2011 LVPA despite being eligible, the representative still believed 

those facilities were ineligible because they had a change in ownership 

during the previous 3 calendar years. In fact, these facilities were still 

eligible for the 2011 LVPA because the change in ownership occurred 

While this likely 

helped clarify that the 12-month rule was sufficient for assessing that a 

facility had not opened, closed, or had a change in ownership, as of 

January 2013, no CMS guidance has been explicit on this topic, and no 

guidance has stated that each cost-reporting period must be exactly 

12 months.

 

31CMS, JSM/TDL-10444 (Oct. 8, 2010), pp. 2-4. Subsequent guidance only partially 

addressed this issue. For example, TDL-12419 in July 2012 stated that the cost-reporting 

years must report costs for 12 consecutive months and Medicare contractors shall not 

accept two short cost-reporting periods and add them together to create a 12-consecutivemonth cost report. In addition, this guidance was provided more than 17 months after the 

beginning of the 2011 payment year.

3276 Fed. Reg. 40,506.
 

Page 16 GAO-13-287 Medicare Payment for ESRD Treatments

after the end of the facilities’ 2010 cost-reporting period and they 

therefore had 2008, 2009, and 2010 cost reports that each covered 

exactly 12 months. In addition, when we questioned the representative 

about some of the organization’s facilities that we found to have 

incorrectly received the 2011 LVPA, the representative still believed those 

facilities met all the regulatory requirements and therefore had been 

eligible. However, because these facilities opened in December 2007 and 

complied with CMS’s general requirement that cost reports not span less 

than a month, they had a 2008 cost report that spanned slightly more 

than 12 months. This made these facilities ineligible for the 2011 LVPA. 

When we shared this example with CMS, a CMS official stated that the 

agency had not considered the possibility that a facility could have a cost 

report spanning more than 12 months. Additionally, when we questioned 

a representative from a different large dialysis organization in September 

2012 about some of that organization’s facilities that we found to have 

incorrectly received the 2011 LVPA, the representative still believed that 

those facilities had been eligible because the changes in ownership for 

those facilities did not result in new provider numbers. However, these 

facilities were ineligible because the changes in ownership caused a 

break in the cost-reporting period and thus the facilities had at least one 

cost report that spanned fewer than 12 months.

While CMS has continued to issue clarifying guidance and provide 

Medicare contractors and facilities with opportunities to ask clarifying 

questions, evidence shows that CMS’s guidance for determining LVPA 

eligibility was not fully and correctly implemented. In particular, none of 

the estimated $5.3 million in 2011 overpayments had been recouped by 

June 2012, based on an analysis of claims, and CMS was not aware of 

any overpayments that had been recouped by January 2013. This

suggests that many Medicare contractors either had not yet discovered 

the payments made in error or were not aware of their obligation to 

reassess facilities’ eligibility once the cost report for the previous year 

became available and to recoup overpayments within 6 months of 

discovery. Another possible reason for overpayment or nonpayment of 

the LVPA is that some of the guidance was sent only to Medicare 

contractors and was not publicly available. Medicare contractors are 

responsible for ensuring that facilities receive any required information 

based on this guidance, and that function is particularly important for the 

LVPA because in order to receive the LVPA a facility must first attest to 

its eligibility, which it will do only if it believes it is eligible. We do not know 

the extent to which continued misunderstanding of LVPA eligibility stems 

from Medicare contractors’ failure to share the relevant portions of this 
 

Page 17 GAO-13-287 Medicare Payment for ESRD Treatments

nonpublic guidance or from facilities’ not understanding the guidance that 

they received.

Much of the misunderstanding and resulting payment problems related to 

eligibility were exacerbated by CMS’s limited monitoring of the Medicare 

contractors and its consequent limited knowledge about implementation 

of the LVPA. While CMS requested information about the 2011 LVPA 

from Medicare contractors in October 2011 and again in July 2012, as of 

January 2013, it had not yet verified whether the information it received 

was complete or in a usable form. In particular, CMS still did not know 

which facilities were eligible for the 2011 LVPA, which facilities had 

attested to being eligible for the adjustment, nor which facilities received 

the 2011 LVPA.

CMS intended the LVPA to encourage small ESRD facilities to continue 

operating in areas where beneficiary access might be jeopardized if such 

facilities closed. However, as designed, the LVPA does not effectively 

achieve this goal because it does not target all relatively low-volume, 

high-cost facilities that are in areas where beneficiaries may lack other

dialysis care options, and it targets some facilities that appeared 

unnecessary for ensuring access to dialysis, such as dialysis facilities 

located in close proximity to other facilities. In addition, facilities currently 

face a large loss in potential revenue if they reach the LVPA treatment 

threshold. This creates an adverse incentive for facilities to restrict their 

service provision to avoid reaching the treatment threshold.

In addition to these concerns about more appropriately targeting the 

LVPA, we also found significant issues associated with its 

implementation, including frequent LVPA overpayments. These 

overpayments primarily stemmed from unclear and untimely CMS 

guidance and persisted because of CMS’s insufficient monitoring of 

Medicare contractors. Without clear, timely guidance and stronger 

monitoring of Medicare contractors’ implementation of the guidance, 

Medicare may continue to pay facilities that are not eligible for the LVPA 

and to not pay many facilities that are eligible. Although the amount of 

money involved was small—overpayments and nonpayments totaling 

about $12 million in 2011 for the $10.1 billion ESRD program—payment 

problems with the adjustment undermined its purpose, which is to 

encourage small ESRD facilities to continue operating in areas where 

beneficiary access might be jeopardized without them.

Conclusions 
 

Page 18 GAO-13-287 Medicare Payment for ESRD Treatments

To more effectively target facilities necessary for ensuring access to care, 

we recommend that the Administrator of CMS consider restricting the

LVPA to low-volume facilities that are isolated.

To reduce the incentive for facilities to restrict their service provision to 

avoid reaching the LVPA treatment threshold, we recommend that the 

Administrator of CMS consider revisions such as changing the LVPA to a 

tiered adjustment.

To ensure that future LVPA payments are made only to eligible facilities 

and to rectify past overpayments, we recommend that the Administrator 

of CMS take the following four actions:

• require Medicare contractors to promptly recoup 2011 LVPA 

payments that were made in error;

• investigate any errors that contributed to eligible facilities not 

consistently receiving the 2011 LVPA and ensure that such errors are 

corrected;

• take steps to ensure that CMS regulations and guidance regarding the

LVPA are clear, timely, and effectively disseminated to both dialysis 

facilities and Medicare contractors; and

• improve the timeliness and efficacy of CMS’s monitoring regarding the 

extent to which Medicare contractors are determining LVPA eligibility 

correctly and promptly redetermining eligibility when all necessary 

data become available.

We received written comments on a draft of this report from HHS, which 

are reprinted in appendix I. HHS agreed with our recommendations and 

stated it would explore refinements to the design of the LVPA and take 

actions to improve its implementation. HHS also provided technical 

comments, which we incorporated as appropriate. 

With regard to our recommendation that CMS consider restricting the 

LVPA to low-volume facilities that are isolated, HHS stated that CMS will 

explore potential refinements. HHS stated that other factors, in addition to 

geographic isolation, may contribute to an ESRD facility being low-volume 

and that the department had studied the costs of both rural and nonrural 

facilities and decided not to implement an adjustment on the basis of rural 

location. We did not analyze all the reasons facilities were low-volume, 

Recommendations for 

Executive Action

Agency and Industry 

Comments and Our 

Evaluation 
 

Page 19 GAO-13-287 Medicare Payment for ESRD Treatments

nor did we recommend a payment adjustment for rural facilities. However, 

we believe that providing increased payments to facilities in close 

proximity to one another may not be warranted. We also note that, while 

facilities certified on or after January 1, 2011, that apply for the LVPA 

must combine all of the treatments provided by facilities under common 

ownership within 25 miles to determine eligibility, this restriction does not 

ensure that only isolated facilities receive the LVPA. For example, two 

facilities not under common ownership could be located in close proximity 

and still receive the LVPA.

In response to our recommendation to consider revisions such as 

changing the LVPA to a tiered adjustment, HHS stated that it would 

explore whether refinements to the LVPA are necessary. HHS stated that

the incentive for facilities to limit dialysis services would exist regardless 

of where the decrease in payment occurred. We agree that such a 

change would not eliminate the incentive to limit dialysis services, but we 

believe it would reduce the incentive.

HHS concurred with our recommendation about ensuring proper 

payments and rectifying past overpayments. HHS also listed specific 

actions it plans to take to implement the recommendation, including using 

multiple methods to communicate with Medicare contractors and ESRD 

facilities to deliver clear and timely guidance.

We invited two organizations to provide oral comments on our draft 

report: the Kidney Care Council (KCC), which represents dialysis facility 

companies, and the National Renal Administrators Association (NRAA), 

which represents independent dialysis facilities. Representatives from 

these organizations expressed their appreciation for the opportunity to 

review the draft.

Both KCC and NRAA noted that facilities within close proximity to another 

facility may still be necessary for ensuring access to dialysis care (for 

example, if the other facility is operating at capacity) or access to choice 

of dialysis modality (for example, if the other facility does not offer the 

same dialysis options). While these situations may occur, if CMS 

determines a single larger facility could provide appropriate services 

where two or more smaller facilities exist now, paying the LVPA to the 

existing smaller facilities may not be warranted.
 

Page 20 GAO-13-287 Medicare Payment for ESRD Treatments

NRAA agreed with our finding that CMS guidance on LVPA eligibility was 

unclear and not transparent to facilities. Additionally, NRAA noted that 

CMS’s guidance requiring that hospitals—but not large dialysis 

organizations—sum the treatments across all of their affiliated facilities 

when determining eligibility for the LVPA was inconsistent. We agree 

there is some inconsistency; however, it will be somewhat reduced 

starting in 2014 as CMS requires that facilities certified after January 1, 

2011, sum their treatments across all facilities that are under common 

ownership and within 25 miles. NRAA also disagreed with the statement 

that hospital cost reports are the only source of information on total 

treatments provided by hospital-affiliated facilities. As we note in the 

report, CMS officials told us that cost reports are the only source of total 

treatments.

Both KCC and NRAA requested more details on GAO’s 

recommendations related to improving the design of the LVPA. Our 

recommendations—that CMS should (1) more effectively target facilities 

necessary for ensuring access to care by considering restricting the LVPA 

to low-volume facilities that are isolated and (2) reduce the incentive for 

facilities to restrict their service provision by considering revisions such as 

changing the LVPA to a tiered adjustment—outlined the factors CMS 

should consider in improving the LVPA. We did not specify details of the 

design because we believe CMS should have flexibility in how to more 

effectively target facilities necessary for ensuring access to care and 

reduce their incentive to restrict service provision.

KCC urged GAO to recommend that CMS pay out LVPA payments that 

CMS failed to make. We believe facilities are best positioned to determine 

and pursue their own rights to appeal Medicare claims determinations.

Technical comments from KCC and NRAA were incorporated in the draft 

as appropriate.

We are sending copies of this report to the Secretary of Health and 

Human Services. The report will also be available at no charge on our 

website at http://www.gao.gov. 
 

Page 21 GAO-13-287 Medicare Payment for ESRD Treatments

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report.

James C. Cosgrove

Director, Health Care
Page 22 GAO-13-287 Medicare Payment for ESRD Treatments

List of Committees

The Honorable Max Baucus

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry A. Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Dave Camp

Chairman

The Honorable Sander Levin

Ranking Member

Committee on Ways and Means

House of Representatives
Appendix I: Comments from the Department of 

Health and Human Services

Page 23 GAO-13-287 Medicare Payment for ESRD Treatments

Appendix I: Comments from the Department 

of Health and Human Services
Appendix I: Comments from the Department of 

Health and Human Services

Page 24 GAO-13-287 Medicare Payment for ESRD Treatments
Appendix I: Comments from the Department of 

Health and Human Services

Page 25 GAO-13-287 Medicare Payment for ESRD Treatments
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 26 GAO-13-287 Medicare Payment for ESRD Treatments

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the individual named above, Phyllis Thorburn, 

Assistant Director; Todd D. Anderson; Alison Binkowski; 

William Black; George Bogart; Elizabeth T. Morrison; Brian O’Donnell; 

and Jennifer Whitworth made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291095)
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