Skilled nursing providers and ambulance companies are worried that a looming cut to ambulance reimbursement could limit access to care for dialysis patients, as the new rate drives payment below actual cost for some.

The Centers for Medicare & Medicaid Services has issued notice to providers and Medicare administrative contractors alerting them that the 13% reduction in reimbursement for non-emergency ambulance trips to dialysis starts Oct. 1.

An estimated 65,000 U.S. dialysis patients live in skilled nursing facilities, according to federal data. Unless their nursing home has on-site dialysis, residents typically must travel to a free-standing clinic or hospital for treatment three times weekly.

In South Carolina, ambulance provider MedTrust has stopped accepting most transports of dialysis patients as revenues dropped.

CEO Josh Watts told Modern Healthcare that patients in his territory have other transport options, but getting to treatment will be hard in rural areas without ambulance service.

“In these areas, this will absolutely devastate the access to care transportation for at-risk patients,” Watts said.

According to federal data cited by NX Stage, which partners with skilled nursing facilities to provide on-site dialysis, Medicare patients pay an average $411 per roundtrip for ambulance transportation to dialysis, adding up to an annual average of $13,148 per patient.

The industry has long been prone to abuse. A Health and Human Services report in 2010 found 20% of the department’s spending on non-emergency ambulance trips were improper due to overbilling or transport of ineligible recipients.

A 10% cut for dialysis patients with end-stage renal failure first went into effect in 2013. With the 13% reduction included in the continuing resolution passed by Congress in February,  the cuts total 23% in five years.