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April 30, 2020

Don’t Blink! Changes to Financial Support Options Happening Non-stop!

I’ll be frank: I’m finding these blogs harder and harder to write as the COVID-19 pandemic continues. It seems that as soon as I write a blog, it becomes outdated. For example, the Department of Health and Human Services (HHS) is constantly making changes to the financial support options you and your group may be relying on during this difficult time—many times without any warning or notice at all!

Let’s recap what has happened in the past week. However, before doing so, I want to provide an update from my last blog on the terms and conditions associated with the Provider Relief Fund -- a now $175 billion pot of funding appropriated by Congress to help health care providers with health care related expenses or lost revenues due to COVID-19. Last week, I highlighted our outstanding questions on the terms and conditions that we posed in a letter to HHS, and HHS still has not answered any of them—including those related to the balance billing prohibition. Despite the lack of responses from HHS, I do now have greater clarity on our question about the executive compensation condition (thanks to a little help from my colleagues in the emergency medicine community).

As a reminder, one of the conditions associated with this funding is that none of the funds can be used to pay the salary of an individual at a rate in excess of Executive Level II ($197,300). Most emergency physicians who have extensive training and are board-certified in emergency medicine have annual incomes above this arbitrary threshold. There is a Health Resources & Services Administration (HRSA) document dated February 7, 2020 that appears to clarify this condition. The HRSA document says:

An individual’s institutional base salary is not constrained by the legislative provision for a limitation of salary. The rate limitation simply limits the amount that may be awarded and charged to HRSA awards. For individuals whose salary rates are in excess of Executive Level II, the non-federal entity may pay the excess from non-federal funds.

We at ACEP believe this means that you can use federal funding to pay a salary of an employee up to the federal limit of $197,300 and can use non-federal funds to pay the excess.

Now on to the updates.

HHS outlines steps you must take to receive payments from the Provider Relief Fund

As alluded to in my last blog, HHS released additional details about the second “tranche” of funding from the Provider Relief Fund. Beyond the initial $30 billion that HHS released a couple weeks ago, HHS is now distributing an additional $20 billion as part of a “general allocation” to health care providers.

However, HHS wasn’t about to make receiving this money easy! Late last week, HHS outlined detailed steps that providers have to go through to receive these funds. While hospitals and other facilities with cost reports automatically received their share of the $20 billion, you or your group are required to actively provide financial information to HHS to receive funds (hospitals are still required to verify financial information). HHS also made it clear that there will be heavy auditing and enforcement of the terms and conditions (there are multiple sets of terms and conditions that are each slightly different). So please, if you or your group want to proceed, I strongly recommend that a financial expert in your group and/or your accountant review all the instructions extremely carefully, enter the required financial information into the portal, and review and attest to all of the terms and conditions.

I have outlined the steps you need to take to receive these funds here. I also strongly recommend that you carefully review the information in the following links:

Lastly, if you do want the funds, I would act fast. While HHS says that access to this funding is not on a first come first serve basis, it is sending out waves of payments every Wednesday, and over half of the allocated $20 billion has already been distributed.

HHS opens up registration for reimbursement program for uninsured patients

As you may know, HHS is also using the Provider Relief Fund to reimburse certain claims for the uninsured at Medicare rates. You can go here to register for the program now and start submitting eligible claims on Wednesday, May 6.

However, once again things are not that simple. You must adhere to two separate sets of terms and conditions (one for treatment services and one for testing services). It is also not entirely clear which services you will be reimbursed for. The complicating factor that we are still sorting through has to do with “treatment” services provided to COVID-19 patients. HHS states that to receive reimbursement for treatment services, you must list a COVID-19 diagnosis code (B97.29 or U07.1) as the primary diagnosis on the claim. Obviously, this is challenging in an emergency department (ED) setting, as you often do not know if your patient has a confirmed case of COVID-19 during the ED visit. Many times, a patient won’t receive test results until days after the initial ED visit—making it impossible to include a COVID-19 diagnosis code on the claim for the ED visit.

Fortunately, I do believe that at least some of the services you provide will be reimbursable under the program. HHS is also covering “testing-related visits,” including ED visits. These visits must have one of the three following diagnosis codes:

Z03.818

  • Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)

Z20.828

  • Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)

Z11.59

  • Encounter for screening for other viral diseases (asymptomatic)

Therefore, while not explicitly confirmed by HHS, it appears that if you evaluate a patient who may potentially have COVID-19, this evaluation and management (E/M) service would be covered.

I recommend you review the information in the registration portal, the program’s home page, and frequently asked questions (FAQs). It is unclear how much funding HHS will end up allocating to this program, so if you are interested, I would register now and start submitting claims next Wednesday.

CMS (temporarily?) suspends the Medicare Advance Payment Program

Last Sunday, without any prior warning, the Centers for Medicare & Medicaid Services (CMS) announced it was suspending the Medicare Advanced Payment Program. This program provides loans to Medicare providers that must be paid back. Since the start of the program a few weeks ago, CMS had already distributed around $100 billion to physicians, hospitals, and other Medicare professionals and facilities. CMS said it suspended the program in light of the “historical” direct payments from the $175 billion Provider Relief Fund—which don’t need to be repaid.

So, what do I think of this announcement?

  • Of all the available financial support programs, the Medicare Advance Payment Program is definitely the weakest. If you receive a loan from this program, you are required to pay it back within 210 days (which may be impossible since many of your ED volumes have reduced significantly and may not have sufficiently increased by then). If you do not pay back the loan in time, you are subject to an enormous 10.25 percent interest rate. That being said, ACEP, the American Medical Association, and others have made Congress aware of these issues , and lawmakers are considering making some necessary changes in the next COVID-19 legislative package.

  • The reason CMS gives for suspending the program is insufficient. As stated above, CMS claimed that it was suspending the program due to the availability of the Provider Relief Fund. While the Provider Relief Fund does have the advantage in that it is a direct payment (grant) program rather than a loan program, it is far from perfect. As you know from this blog and my previous blogs, the Provider Relief Fund includes a web of complicated, convoluted terms and conditions and application processes that only a financial expert (and perhaps even a lawyer) can successfully navigate through. Further, most of the money in the Provider Relief Fund is being distributed to hospitals. According to my very rough calculations , only a small fraction is being allocated to physician groups.

  • In all, physicians still need additional support. I strongly believe that HHS, including CMS, should be creating new options for financial relief, not eliminating current ones. It is still unclear whether CMS has instituted a permanent or temporary suspension to the program, and it will be interesting to see what CMS decides to do as individual physicians and physician groups continue to struggle during this crisis. I hope CMS will ultimately restart the program and that Congress steps in to create more favorable programmatic parameters.

As you can see, things are shifting quickly—and often with little to no notice. So, please stay tuned…and don’t blink or you may miss another important update! Given all that has happened in a week, it makes me wonder what next week has in store for us (spoiler alert: CMS is releasing another COVID-19 regulation any day now)!

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs!

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