September 3, 2020

Advocating for Reforms to the COVID-19 Provider Relief Fund and Uninsured Program

Unfortunately, the U.S. Department of Health and Human Services (HHS) has continued to mishandle the distribution of the Provider Relief Fund (PRF), a $175 billion fund appropriated by Congress to help cover health care providers’ lost revenues and increased expenses due to COVID-19. Over the last several months, ACEP has written repeatedly to HHS outlining issues with how the Department has chosen to allocate the funds as well as expressing concerns about the PRF’s confusing terms and conditions and reporting requirements.

What remains most frustrating about the PRF distribution process is that you, as emergency physicians, have only received a fraction of the total amount you have lost due to declining revenues and increased expenses since the pandemic began. And while we have asked HHS to allocate additional funding directly to you, HHS has not responded to our request and is instead sitting on approximately $60 billion of unallocated funding from the $175 billion fund.  

I believe that there are two major reasons why HHS has struggled to get funding out the door and has bungled other aspects of the allocation process.

First, HHS decided to have its Health Resources and Services Administration (HRSA), a primarily grant-making agency with limited experience directly paying health care providers, allocate the funds (rather than the Centers for Medicare & Medicare Services, which has extensive experience paying providers). Since HRSA does not have the infrastructure in place to distribute PRF funds, it has had to contract out the work to UnitedHealthcare (UHC), a major nationwide health insurance company. Although HRSA claims that UHC has no conflicts of interest and that UHC is only using the data and information it is collecting from health care providers for the purposes of making PRF payments, HRSA has been forced to repeatedly explain and defend its use of UHC on almost every public stakeholder call.

Second, as alluded to above, the PRF has such convoluted terms and conditions and other requirements that some health care providers are simply deciding it is not worth it to accept the funds—or worse, providers believe that they are eligible for funding only to find out late in the process that they don’t meet the complicated eligibility requirements. This has become such an issue that HRSA has had to extend the deadline for applying for the latest allocation of funds—a Medicaid provider distributionmultiple times (the new deadline is now September 13). HRSA has also re-opened the application portal for providers who were eligible for earlier distributions of funding in the hopes that more providers will apply. However, it is important to note that HRSA still hasn’t increased the maximum amount it has decided to allocate to each provider (2 percent of total revenues). Therefore, if you’ve already received your allotted funding from previous PRF distributions, you aren’t eligible for more at this time.

This second issue can also help explain the difficult experience emergency physicians and other providers have had getting their claims reimbursed under the COVID-19 “Uninsured Program.” The program—also run by HRSA—is mainly funded by the PRF. While HHS had allocated $12 billion to the Uninsured Program, less than a $1 billion has actually been paid out to providers. This number is shockingly low, given that that the Kaiser Family Foundation estimates that hospital costs alone for uninsured patients during the pandemic could be between $13.9 billion to $41.8 billion.

The goal of the Uninsured Program is simple—to provide reimbursement at Medicare rates for COVID-19 treatment and testing and testing-related services delivered to patients who are uninsured. And if anyone would be well suited to take advantage of such a program, it is emergency physicians who see a higher proportion of uninsured patients than other specialists do. However, complicated and inappropriate program rules have led to numerous denials for what should be legitimate claims—and physicians are not allowed under the current rules of the program to appeal these denied claims.

Last week, ACEP wrote a letter to Administrator of HRSA requesting the agency to make fundamental changes to the Uninsured Program to address the underlying issues that are causing these denials.

Here is an overview of the issues with the program that we’ve identified and the recommended changes we outline in our letter.

Many of the eligible claims emergency physicians are submitting for reimbursement under the Uninsured Program fall under the “testing-related services” portion of the program. Individuals are coming to the emergency department (ED) with symptoms that the Centers for Disease Control and Prevention (CDC) has identified as being suspicious for COVID-19 infection and emergency physicians have to evaluate them as a possible COVID-19 case. Claims submitted for these testing-related ED visits are supposed to be eligible for reimbursement. However, buried in the terms and conditions associated with the Uninsured Program is a statement that an eligible ED visit must “result in an order for or administration of COVID-19 Testing.”

As you well know, it is not always possible or practical to test patients for COVID-19 during an ED encounter. There continues to be shortages of tests in many areas in the country leaving many patients who may be evaluated with suspicion of COVID-19 infection with no definitive testing resources available. Further, the billing code for the test itself usually appears on the facility claim that the hospital submits, not the professional claim that emergency physicians submit for reimbursement. Therefore, even if a test is ordered or administered, the emergency physician has no way of providing the appropriate documentation to HRSA to prove that either was done.

Beyond this issue with testing-related services, many providers are also concerned with the definition of “treatment services” under the Uninsured Program. The fundamental flaw with how HRSA has chosen to reimburse claims for the treatment of COVID-19 was actually the subject of a recent article from The New York Times. Under the program, claims for the treatment of COVID-19 can only be reimbursed if COVID-19 is listed as the primary diagnosis on the claim. However, this simply does not reflect current practice realities. Emergency physicians and other providers are treating numerous patients with COVID-like symptoms (as defined by the CDC), where the patient either tests negative, or the results from the test aren’t available until after the patient encounter. ACEP, along with many others, believe the program should reimburse for treatment services provided to patients with COVID-like symptoms, regardless of whether a diagnosis of COVID-19 is ultimately included on the claim.

In all, we requested that HRSA make the following changes to administration of the Uninsured Program:

  • Provide reimbursement for testing-related services when patients with COVID-like symptoms are evaluated in the ED regardless of whether a COVID-19 test was performed or information about the test is included on the professional claim.
  • Provide reimbursement—including for treatment—for all ED visits where the patient presented with symptoms and/or a diagnosis consistent with “COVID-like symptoms” as defined by the CDC.

We strongly believe that making these programmatic changes will allow emergency physicians and other frontline providers to appropriately receive reimbursement for otherwise legitimate claims, affording them with necessary financial relief during this difficult time.

For more information on the PRF, please click here—and to stay up-to-date on the latest federal announcements and guidance related to COVID-19, please click here. You can also always reach out to me with any questions. Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.

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