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Financial Support for Health Care Practitioners

On May 4, ACEP's Regulatory Affairs Director, Jeffrey Davis, gave a presentation to a group of ED physician directors in Colorado highlighting the available financial support options for emergency physicians. Listen to Mr. Davis' presentation and download his presentation with links to helpful resources

Grants and Direct Payments

Major Updates on the Provider Relief Fund

  • If you received funding from the first $30 billion tranche and decide to accept the terms and conditions and keep the funding, you must log on to this portal and formally attest to the terms and conditions. HHS announced a 45-day extension to accept the terms and conditions. This means that you now have 90 days from when you received a payment to either accept the terms and conditions or return the funds.
  • HHS also provided nearly $4.9 billion in additional relief funds to skilled nursing facilities (SNFs) and $500 million in payments to the Indian Health Service (IHS) and tribal hospitals, clinics, and urban health centers.
  • HHS stated that providers have until June 3, 2020 to accept the Terms and Conditions and submit their revenue information to support receiving an additional payment from the Provider Relief Fund $50 billion General Distribution. Providers who have cases pending before the department for adjudication with regard to eligibility for general distribution funding will not be impacted by this closure. All cases needing individual adjudication will need to be received by HHS no later than June 3, 2020.
  • HHS has released an extensive set of frequently asked questions (FAQs), which is continually being updated. ACEP strongly recommends that you periodically review these FAQs.
  • In the FAQs, HHS provides additional information on determining how much funding from the “general allocation” providers should expect to receive. The total you are expected to receive from tranche 1 and tranche 2 combined is the lesser of 2% of your 2018 (or most recent complete tax year) net patient revenue or the sum of incurred losses for March and April. If you received equal to or more than 2 percent of your total 2018 revenue in tranche 1, you will not receive additional funding in tranche 2. Those who submitted all the required information for the second tranche should be receiving tranche 2 payments.
  • HHS stated that if you believe you were overpaid or received funds in error, you should return the funds. HHS does not intend to recoup funds as long as your lost revenue and increased expenses exceed the amount of Provider Relief funding you have received. HHS reserves the right to audit Relief Fund recipients in the future to ensure that this requirement is met and collect any Relief Fund amounts that were made in error or exceed lost revenue or increased expenses due to COVID-19. Failure to comply with other Terms and Conditions may also be grounds for recoupment.
  • HHS made some clarifications to the balance billing condition:
    • The prohibition on balance billing applies to “all care for a presumptive or actual case of COVID-19.” A presumptive case of COVID-19 is a case where a patient’s medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in his or her medical record.
    • There are no limitations on the ability of a provider to submit a claim for payment to the patient’s insurance company. However, an out-of-network provider delivering COVID-19-related care to an insured patient may not seek to collect from the patient out-of-pocket expenses, including deductibles, copayments, or balance billing, in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider. According to HHS, “most health insurers have publicly stated their commitment to reimbursing out-of-network providers that treat health plan members for COVID-19-related care at the insurer’s prevailing in-network rate.”
  • You can now start submitting claims for the uninsured program. Please review the information in the registration portal, the program’s home page, and two sets of frequently asked questions (set oneand set two) for more details.
  • HHS has released a provider-level breakout of who has received Provider Relief Funding.

Background on the Provider Relief Fund

The major stimulus bill that was signed into law (the CARES Act) included a $100 billion fund that the U.S. Department of Health and Human services (HHS) has been distributing to health care providers, including physicians, in the form of grants and direct payments. Further, the Paycheck Protection Program and Health Care Enhancement Act (the COVID 3.5 package) added $75 billion to the fund on top of the initial $100 billion. Health care providers are not required to repay any of this funding.

On April 10, HHS distributed $30 billion of the $100 billion CARES Act funding to Medicare “providers” (physicians, hospitals, and other facilities and health professionals that bill Medicare) and on April 22, HHS announced additional, future allocations.

With respect to the $30 billion, the amount was distributed in direct proportion to providers’ total 2019 Medicare fee-for-service (FFS) reimbursement. You or your group should have received approximately 6.2 percent of their Medicare FFS payments. Some of you, depending on where you practice and your patient mix, will receive more or less than others, since again, the amount you receive is simply based on your Medicare payments from last year.

There is also a catch that goes along with the funding. Within 45 days, you must agree to certain terms and conditions. These terms and conditions include the following statement:

“The Secretary has concluded that the COVID-19 public health emergency has caused many healthcare providers to have capacity constraints. As a result, patients that would ordinarily be able to choose to receive all care from in-network healthcare providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, Recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network Recipient.”

ACEP sought clarification on exactly what this condition means and how this may impact you and your patients. HHS has provided some clarification, but more is needed. Specifically, HHS defines a “presumptive case of COVID-19” as a case where a patient’s medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in his or her medical record. HHS also has stated that there are no limitations on the ability of a provider to submit a claim for payment to the patient’s insurance company and that “most health insurers have publicly stated their commitment to reimbursing out-of-network providers that treat health plan members for COVID-19-related care at the insurer’s prevailing in-network rate.”

If you do not agree to all the terms listed, you are required to contact HHS within 45 days of receipt and return the funds. HHS has opened the CARES Act Provider Relief Fund Payment Attestation Portal where providers are required to go and attest to the terms and conditions.

On April 14, we sent a letter to the HHS Secretary that listed all of our questions and concerns about the $30 billion distribution and the associated terms and conditions. We asked for HHS to respond to our questions as soon as possible, so that we can update you and give you or your group enough time to consider whether to accept the terms and conditions or return the funding before the 45-day time period ends (around May 24).

As referenced earlier, HHS announced additional allocations of the funding on April 22. Below is an overview of the announcement.

$20 billion General Allocation: HHS is allocating another $20 billion to all health care providers (“Tranche 2”). The total you or your group receives—both from the initial $30 billion and the new $20 billion—will be based on your 2018 total net revenue.

To estimate how much a provider will receive in total from both the initial $30 billion and additional $20 billion general allocation, HHS provides this formula: (Individual Provider 2018 Revenue/$2.5 Trillion) X $50 Billion = Expected General Distribution.

Note: Total revenues of Medicare facilities and providers in 2018 is estimated to be $2.5 trillion.

This calculation comes out to be around 2 percent of your 2018 provider revenue.  HHS has stated that the total you are expected to receive from tranche 1 and tranche 2 combined is the lesser of 2% of your 2018 patient revenue or the sum of incurred losses for March and April. If you received equal to or more than 2 percent of your total 2018 revenue in tranche 1, you will not receive additional funding in tranche 2.

There are numerous steps you will need to take to receive a portion of this additional $20 billion.

If you received funding from the first $30 billion, you are required to attest to the required terms and conditions. You must attest to the terms and conditions associated with the first $30 billion in order to receive funding from this second $20 billion tranche.

You must log into the General Distribution Portal to provide revenue information. Detailed instructions on what information you need to provide are included in a frequently asked questions (FAQ) document HHS has produced, but overall include:

  • A provider’s “Gross Receipts or Sales” or “Program Service Revenue” as submitted on its federal income tax return
  • The provider’s estimated revenue losses in March 2020 and April 2020 due to COVID-19;
  • A copy of the provider’s most recently filed federal income tax return; and
  • A listing of the TINs any of the provider’s subsidiary organizations that have received relief funds but that DO NOT file separate tax returns.

HHS provides the following table highlighting exactly what revenue to report from your tax returns based on what type of group/organization you are:

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You will also need your W-9 and Medicare or Medicaid ID number.

HHS will use this information to calculate your payment, which as stated above, is based on 2018 net revenue. Like your first payment, HHS will deposit the money electronically into the account that you have on file with Medicare. The goal is to deposit the funds within 10 days of submitting the required information. Although the fund is limited to $20 billion (and, as of April 24, HHS has stated that $10 billion has already been distributed), HHS claims that the remainder will not be distributed on a first come first serve basis. HHS will be processing applications in batches every Wednesday at 12:00 noon EST. HHS has stated that you must submit information at attest to the Terms and Conditions by June 3rd. 

After you receive the funds, you must log back into the CARES Act Provider Relief Fund attestation portal to confirm receipt and agree to ANOTHER set of terms and conditions. This second set of terms and conditions is similar to the first, but not identical. Both sets of terms and conditions (both for the initial $30 billion and the subsequent $20 billion) can be found here.

IMPORTANT NOTE: ACEP strongly recommends that a financial expert in your group and/or your accountant review all the instructions extremely carefully, enter the information into the portal, and review and attest to both sets of terms and conditions.

Here are some useful sources of information to review:

If you have questions, please reach out to Jeffrey Davis, ACEP’s Director of Regulatory Affairs. You may also call the provider relief hotline at (866) 569-3522.

$22 billion for Providers in Hot Spots and Rural Health Providers: On May 1, HHS announced that it had started the process of distributing $12 billion of the funding to hospitals in areas that have been particularly impacted by the COVID-19 and $10 billion to rural health clinics and hospitals. None of this funding was distributed directly to physician groups. For more information about this announcement, please go here.

$500 million for Indian Health Service (IHS) Facilities: $500 million has been distributed to the IHS and tribal hospitals, clinics, and urban health centers to support the tribal response to COVID-19.

$4.9 billion for Skilled Nursing Facilities: HHS provided nearly $4.9 billion in additional relief funds to skilled nursing facilities (SNFs).

Reimbursement for Providers Treating Uninsured COVID-19 Patients:
Every health care provider who has provided treatment for uninsured suspected or confirmed COVID-19 patients on or after February 4, 2020 can request claims reimbursement at Medicare rates, subject to available funding. Approximately $12 billion has been allocated to this program, although more could be added in the future. 

Providers can register NOW for the program here and begin submitting claims. ACEP encourages you to review the information in this registration portal. Emergency department visits that lead to an order of or administration of a test (i.e. testing related services) are covered under this program, as long as the claim includes one of three diagnosis codes: Z03.818, Z11.59, or Z20.828. These codes can appear in any position on the claim. In other words, you have the flexibility to submit a testing-related visit claim for reimbursement that includes another diagnosis code as the primary diagnosis instead of one of the three required codes.

However, for any treatment of COVID-19 positive patients, you will only receive reimbursement if the primary diagnosis on the claim is COVID-19 (diagnosis codes B97.29 and U07.1). The billing codes are found here.

The program’s website can be found here and there are two sets of frequently asked questions (set one and set two).

Finally, it is important to note that there are two sets of terms and conditions associated with this program:

On April 30, the Health Resources & Services Administration (HRSA) held a webinar to discuss the program. A summary of the webinar can be found here.

HHS also announced that some providers will receive further, separate funding, including skilled nursing facilities, dentists, and providers that solely take Medicaid. Finally, HHS has not made any decisions about how the additional $75 billion included in the Paycheck Protection Program and Health Care Enhancement Act will be allocated.

Medicare Advanced Payments

NOTE: AS OF APRIL 26, CMS WILL NO LONGER BE APPROVING NEW REQUESTS FOR FUNDING THROUGH THIS PROGRAM

On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) announced the expansion of an advanced payment program for the duration of the COVID-19 national emergency. This payment is meant to help health care practitioners with their cash flow during this emergency. Under this program:

  • Medicare-enrolled providers who have billed Medicare within the last six months and meet a few other criteria can request a specific amount up to 3 months-worth of their historical Medicare payments.
  • CMS’ Medicare Administrative Contractors will work to review and issue payments within seven calendar days of receiving the request.
  • Please note that this is NOT a grant. Health care practitioners will be required to pay back the payment over time, starting 120 days after the receipt of the payment. 
  • Specifically, after 120 days, CMS will start recoup the funding by reducing each Medicare claim billed until the full amount is repaid. Health care practitioners must pay back the entire amount by 210-day period (seven months).

More details about the program, including eligibility criteria, the application process, and the recoupment/repayment process can be found here. The American Medical Association also put together a frequently asked questions document on this program. 

While ACEP appreciates the expansion of this program and believes that it can provide a significant boost to emergency physician practices that are struggling due to decreased emergency department (ED) volumes (which we hear are as high as 50 percent in some cases), we do not support the requirement to pay back the loan in full by 210 days after receipt. It is unclear whether ED volumes will pick up by then and whether emergency physician practices can fully repay the loan. Further, it is not fair that health care practitioners who aren’t able to pay back the full amount in time will be faced with an exorbitant 10.25 percent interest rate. ACEP is currently exploring potential regulatory and legislative fixes to address these issues.

Between the time that CMS initiated the program at the end of March and suspended it at the end of April, the agency had given out over $100 billion in loans to Medicare providers, including hospitals and other facilities under Medicare Part A and physicians and other health care professionals under Medicare Part B.

Recently, CMS released a breakout of these payments by state and by provider type. Around 92 percent of the funds ($92 billion) went to hospitals and facilities and only 8 percent (8.3 billion) to physicians and other health care professionals. Health care professionals that bill under the specialty of emergency medicine received $15.9 million, or 0.016% of the total $100 billion that was distributed.

Small Business Loan Forgiveness

The CARES Act provides loan forgiveness for certain qualifying Small Business Administration (SBA) loans. The details of one such program (Section 7(a) Paycheck Protection Loans) are found below:

  • Medical and outpatient clinics are eligible for the SBA program, provided they employ less than 500 employees.
  • The maximum available loan is $10 million.
  • The loan may be used for payroll support, paid sick or medical leave, employee salaries, mortgage, and other debt obligations.
  • There are loan forgiveness programs for certain payroll costs, mortgages, rent, and utilities.
  • Loan forgiveness procedures are as follows:
    • The loan is an amount equal to the payroll costs and costs related to payment of debts for the period of March 1, 2020 through June 30, 2020.
    • The amount of loan forgiveness will be reduced by the number of employees laid off during the period of March 1, 2020 through June 30, 2020.
    • The amount of loan forgiveness will be reduced by the amount of any reduction in total salary or wages of employees during the covered period that is in excess of 25 percent. There is relief from the forgiveness reduction if the employee's wage reduction is caught up by June 30, 2020.
    • For determining forgiveness, payroll costs must exclude those employees who earn equal to or greater than $100,000 annual compensation; however, the loan forgiveness should apply to the first $100,000 of that compensation, but not to any payroll costs in excess of $100,000 per employee.

To find out more information about the SBA’s loan forgiveness programs, please click here.

On May 22, the SBA, in conjunction with the Department of Treasury, issued an interim final reg that includes some important clarifications on how to calculate certain costs for the purposes of figuring out your loan forgiveness amount.

Here are some other useful links:

The original $349 billion allocated to the Payroll Protection Program ran out, and Congress approved an additional $321 billion in the Paycheck Protection Program and Health Care Enhancement Act.

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