CMS Announces 2021 Ambulance Inflation Factor
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Author: Brian Werfel
Brian S. Werfel, Esq. is a partner in Werfel & Werfel, PLLC, a New York based law firm specializing in Medicare issues related to the ambulance industry. Brian is a Medicare Consultant to the American Ambulance Association, and has authored numerous articles on Medicare reimbursement, most recently on issues such as the beneficiary signature requirement, repeat admissions and interrupted stays. He is a frequent lecturer on issues of ambulance coverage and reimbursement. Brian is co-author of the AAA’s Medicare Reference Manual for Ambulance, as well as the author of the AAA’s HIPAA Reference Manual. Brian is a graduate of the University of Pennsylvania and the Columbia School of Law. Prior to joining the firm in 2005, he specialized in mergers & acquisitions and commercial real estate at a prominent New York law firm. Werfel & Werfel, PLLC was founded by David M. Werfel, who has been the Medicare Consultant to the American Ambulance Association for over 20 years.
CMS: Revised Repayment Terms for Medicare Accelerated Payments
On October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP). These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.
Background
On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns. Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments. These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.
CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act. CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.
Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds. The program also called for a 100% offset until all advanced funds had been repaid.
Revised Payment Terms
Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment. Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments. The schedule for such repayments will be as follows:
- 25% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next eleven (5) months; and
- 50% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next six (6) months
To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance. The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full. To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.
Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.
CMS: COVID Testing and Screening Guidance for SNF and Long-Term Care Facilities
On August 25, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule with a comment period titled “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” The interim final rule sets forth a number of new requirements designed to limit the COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.
Specifically, the interim final rule requires skilled nursing and other long-term care facilities to test residents and staff for COVID-19. The frequency of such testing is based on the positivity rate in which the facility is located, and can require COVID-19 testing as frequently as twice per week. Regardless of the frequency of required COVID-19 tests, facilities must also screen all staff, residents, and persons entering the facility for the signs and symptoms of COVID-19.
These requirements extend to individuals that provide services to nursing homes under arrangements, including health care personnel rendering care to residents within the facility. In subsequent guidance, CMS clarified that these testing and screening requirements apply to EMS personnel and other health care providers that render care to residents within the facility. However, in that same guidance, CMS indicated that EMS personnel must be permitted to enter the facility provided that: (1) they are not subject to a work exclusion as a result of to an exposure to COVID-19 or (2) showing signs or symptoms of COVID-19 after being screened.” CMS further indicated that “EMS personnel do not need to be screened so they can attend to an emergency without delay.”
In plain terms, CMS has created an affirmative obligation on nursing homes to ensure that any individual that provides services under a contractual arrangement with the nursing home comply with these testing and screening requirements. CMS has expressly waived the screening requirements for EMS personnel responding to medical emergencies at a nursing home. However, CMS has not specifically addressed the testing and screening requirements applicable to EMS personnel responding to nursing homes in non-emergency situations.
The A.A.A. is aware that a handful of State Health Agencies have issued their own guidance on this issue. The A.A.A. is also aware that individual nursing homes have started to require proof that EMS personnel have been tested for COVID-19 prior to allowing these individuals to enter the nursing home in a non-emergency situation.
EMS agencies may already be subject to state and local testing mandates. EMS agencies may also have their own internal policies that require employees to be periodically tested for COVID-19. As a result, there exists the potential for conflict where these existing testing policies conflict with the testing requirements of your local nursing homes.
The A.A.A. has been engaged in an ongoing conversation with CMS on these issues since the issuance of the interim final rule in August. As part of that conversation, the A.A.A. pushed for the exclusion of EMS personnel from the screening requirement when responding to medical emergencies, which was included in the recent CMS guidance document. The A.A.A. also continues to push for additional funding for COVID-19 testing for EMS agencies. CMS has recognized that the frequent testing of health care workers is essential to reducing the spread of the novel coronavirus. CMS has allocated funding for these purposes to other industries, including hospitals and nursing homes. As front-line health care workers, EMS agencies should have similar access to testing funds. The A.A.A. will continue to push for funding equity for the EMS industry.
In the interim, we strongly encourage our members to work with their state associations and other stakeholders to advocate for reasonable rules related to testing on the state and local levels. To the extent the applicable state or local agency has determined the appropriate frequency for the testing of EMS personnel responding to medical emergencies, those rules should also apply to EMS personnel responding to scheduled transports and other non-emergencies that start or end at a nursing home. Requiring more frequent testing in these situations would impose an undue burden on EMS agencies that provide these services. More frequent testing may also prove counterproductive, as it may discourage EMS agencies that cannot meet these higher requirements from responding in these situations. We also encourage our members to continue to push for state and local funding for the testing of their employees.
U.S. House of Representatives Approves Continuing Resolution
On September 22, 2020, the U.S. House of Representatives approved a continuing resolution to keep the government funded through December 11, 2020. Under current law, government funding is set to expire at midnight on September 30, 2020.
The House resolution is a stopgap measure that would maintain funding for most government programs at their current Fiscal Year 2020 levels. However, the Continuing Resolution omits $30 billion in agricultural aid sought by the Trump Administration and Senate Republicans. As of last week, it appeared that a compromise had been struck between the Administration and Speaker Pelosi under which the agricultural aid would be tied to the extension of special food benefits to recipients of free or reduced-price school lunches authorized by the Families First Coronavirus Response Act. The Continuing Resolution also does not include new spending on economic aid for those impacted by the coronavirus.
The Continuing Resolution will now go to the U.S. Senate for consideration.
Impact on Repayment of Medicare Accelerated and Advance Payments
In response to the COVID-19 pandemic, CMS announced that it would be opening the Medicare Accelerated and Advance Payment Program (AAPP) to all health care providers and suppliers that were impacted financially by the pandemic. Under the AAPP, Medicare-enrolled providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments. These advances were structured as “loans,” and were required to be repaid through the offset of future Medicare payments. CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act. CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.
Under the existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds. The program also called for a 100% offset until all advanced funds had been repaid.
The American Ambulance Association, the American Hospital Association, the Association of American Medical Colleges, and numerous other advocacy groups have advocated that the AAPP be revised to give health care providers and suppliers greater flexibility to repay the advanced funds. The AAA and others argued that these changes were necessary to avoid a financial crisis when CMS began offsetting Medicare payments to repay the advanced funds. A copy of the AAA’s letter to CMS Administrator Seema Verma can be viewed by clicking here.
In the Continuing Resolution, the House addressed this issue by making the following changes to the AAPP:
- Hospitals and Other Part A Providers: Upon request of the hospital or other Part A provider: (1) provide for 1 year before claims are offset to recoup the advanced funds, (2) limit the offset to not more than 25% of the payment on a future claim for the first 11 months during which offsets are required, (3) limit the offset to not more than 50% during the next 6 months, (4) provide for up to 29 months (from the date the advanced payments were first received) before requiring that the outstanding balance be paid-in-full, and (5) limit the interest charged on the unpaid principal balance of any advanced funds to 4%.
- Part B Suppliers: Upon request of the supplier: (1) provide for 1 year before claims are offset to recoup the advanced funds, (2) limit the offset to not more than 25% of the payment on a future claim for the first 11 months during which offsets are required, (3) limit the offset to not more than 50% during the next 6 months, (4) provide for up to 29 months (from the date the advanced payments were first received) before requiring that the outstanding balance be paid-in-full, and (5) limit the interest charged on the unpaid principal balance of any advanced funds to 4%.
The Continuing Resolution would require the HHS Secretary to post within 2 weeks of enactment (and updated every 2 weeks thereafter) the following information related to the AAPP on the CMS website:
- The total amount of such payments under each part of the program, including the specific percentage of such payments made out of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Insurance Trust Fund;
- The total amount of payments under each part of the program, by industry type;
- The CMS identifier and the amounts received by each health care provider or supplier.
HHS would also be required to post periodic reports, starting in July 2021 and every six months thereafter until all AAPP amounts have been repaid, that contain the following:
- The total amounts yet to be repaid;
- The total amounts yet to be repaid, by industry type;
- The total amounts repaid under each program, including the specific percentage of such repayments deposited back to the Federal Hospital Insurance Trust Fund or the Federal Supplementary Insurance Trust Fund; and
- The total interest collected on all repayments
The Senate will most likely approve the House CR before the September 30, 2020 deadline.
Preliminary Calculation of 2020 Ambulance Inflation Update
Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2020, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 0.646%.
Cautionary Note Regarding CPI-U. Members should be advised that the BLS’ calculations of the CPI-U are preliminary, and may be subject to later adjustment. Therefore, it is possible that these numbers may change.
CMS has yet to release its estimate for the MFP for calendar year 2021. Since its inception, this number has fluctuated between 0.3% and 1.2%. For calendar year 2020, the MFP was 0.7%. Under normal circumstances, it would be reasonable to expect the 2021 MFP to be within a percentage point or two of the 2020 MFP. However, the economic impact of the COVID-19 pandemic makes predictions on the MFP difficult at this point.
Accordingly, the AAA is not in a position to confidently project the 2021 Ambulance Inflation Factor at this point in time. However, the relative low increase in the CPI-U strongly suggests that the 2021 Ambulance Inflation Factor will be significantly lower than last year’s increase of 0.9%.
The AAA will notify members once CMS issues a transmittal setting forth the official 2021 Ambulance Inflation Factor.
Werfel | Quick Take on HHS Provider Relief Fund
American Ambulance Association Medicare Consultant Brian Werfel, Esq provides a brief update on the HHS COVID-19 Provider Relief Fund.
Department of Health and Human Services Extends Deadline to Apply for Provider Relief Funds
The Department of Health and Human Services (HHS) recently announced that it would be extending the deadline for health care providers to apply to receive general distribution funding from the HHS Provider Relief Fund. The deadline to apply for these funds was previously June 3, 2020.
Relevant Background
On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, bringing the total “Provider Relief Fund” up to $175 billion. This $175 billion will be distributed to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.
HHS ultimately elected to allocate these funds through a $50 billion “general allocation,” and multiple smaller “targeted allocations.”
Under its general allocation program, HHS intended to provide health care providers with funds roughly equal to 2% of the provider’s 2018 “net patient revenue,” i.e., the provider’s total revenues from patient care minus provisions for bad debt, contractual write-offs, and certain other adjustments. This general allocation was made in two tranches, with the first tranche being distributed to all providers in mid-April. This first tranche was made based on provider’s 2019 Medicare revenues. As a result, any provider that received payments from the Medicare Fee-for-Service Program in 2019 automatically received an initial relief payment. However, HHS required providers to submit an application to receive relief funding as part of the second tranche. The deadline for applying for the second tranche of relief funding was June 3, 2020.
Scope of New Extension
HHS indicated that the new extension is limited to health care providers that missed the June 3, 2020 deadline to apply for the second tranche of relief funding. The extension also applies to providers that were ineligible for the first tranche of relief funding due to a recent change of ownership. The specific situations that HHS indicated would meet the requirements for the extension include:
- Health care providers who were ineligible for the first tranche of relief funding because: (1) they underwent a change in ownership in calendar year 2019 or 2020 under Medicare Part A and (2) did not have Medicare Fee-for-Service revenues in calendar year 2019;
- Health care providers who received a payment in the first tranche of funding but: (1) missed the June 3, 2020 deadline to submit revenue information or (2) did not receive funds in the first tranche that total approximately 2% of their net patient revenue; or
- Health care providers who received a payment in the first tranche of funding, but who ultimately elected to refund that payment (e.g., because they did not believe they met the eligibility requirements), and who are now interested in reapplying.
Health care providers that meet one of the requirements listed above will have until August 28, 2020 to submit an application for additional relief funds. This deadline aligns with the extended deadline for other eligible Phase 2 providers, such as Medicaid, Medicaid Managed Care, CHIP, and dental providers.
Applications should be submitted through the CARES Provider Relief Fund webpage, which can be found at: https://cares.linkhealth.com/#/.
CMS Announces Resumption of Program Integrity Functions
On July 7, 2020, CMS updated its Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). As part of this update, CMS indicated that it would resume several program integrity functions, starting on August 3, 2020. This includes pre-payment and post-payment medical reviews by its Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), and the Recovery Audit Contractors (RACs). This also includes the resumption of the Prior Authorization Model for scheduled, repetitive non-emergency ambulance transports. These programs had been suspended by CMS in March in response to the COVID-19 pandemic.
Resumption of Medicare Fee-For-Service Medical Reviews
CMS suspended most Medicare FFS medical reviews on March 30, 2020. This included pre-payment medical reviews conducted by its MACs under the Targeted Probe and Educate program, as well as post-payment reviews by its MACs, the SMRC, and the RACs. CMS indicated that, given the importance of medical review activities to CMS’ program integrity efforts, it expects to discontinue its “enforcement discretion” beginning on August 3, 2020.
CMS indicated that providers selected for review should discuss any COVID-related hardships that might affect the provider’s ability to respond to the audit in a timely fashion with their contractor.
CMS further indicated that its contractors will be required to consider any waivers and flexibilities in place at the time of the dates of service of claims selected for future review.
Resumption of Prior Authorization Model
Under the Repetitive, Scheduled, Non-Emergent Ambulance Transport Prior Authorization Model, ground ambulance providers in affected states are required to seek and obtain prior authorization for the transportation of repetitive patients beyond the third round-trip in a 30-day period. The Prior Authorization Model is currently in place in Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia.
On March 29, 2020, CMS suspended certain claims processing requirements under the Prior Authorization Model. During this “pause,” claims for repetitive, scheduled, non-emergency transports were not be stopped for pre-payment review to the extent prior authorization had not been requested prior to the fourth round trip in a 30-day period. However, CMS continued to permit ambulance providers to submit prior authorization requests to their MACs.
CMS indicated that full model operations and pre-payment review would resume for repetitive, scheduled non-emergent ambulance transportation submitted in the model states on or after August 3, 2020. CMS stated that the MACs will be required to conduct postpayment review on claims that were subject to the model, and which were submitted and paid during the pause. CMS further indicated that it would work with the affected providers to develop a schedule for postpayment reviews that does not significantly increase the burden on providers.
CMS stated that claims that received a provision affirmation prior authorization review decision, and which were submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from most future medical review.
IRS Guidance on Taxation of HHS Provider Relief Funds
On July 7, 2020, the Internal Revenue Service published a series of Frequently Asked Questions that address the taxation of payments to health care providers under the HHS Provider Relief Fund.
As part of the Coronavirus Aid, Relief and Economic Security Act (CARES Act), Congress appropriated $100 billion to reimburse eligible health care providers for health care-related expenses and/or lost revenue attributable to the COVID-19 pandemic. The Paycheck Protection Program and Health Care Enhancement Act appropriated an additional $75 billion to the Provider Relief Fund.
The first FAQ addressed the issue of taxation for for-profit health care providers. Specifically, the IRS was asked whether a for-profit health care provider is required to include HHS Provider Relief Fund payments in its calculation of “gross income” under Section 61 of the Internal Revenue Code (Code), or whether such payments were excluded from gross income as “qualified disaster relief payments” under Section 139 of the Code.
The IRS indicated that payment from the Provider Relief Fund do not qualify as qualified disaster relief payments under Section 139 of the Code. As a result, these payments are includible in the gross income of the entity. The IRS further indicated that this holds true even for businesses organized as sole proprietorships.
The second FAQ addressed the issue of taxation for tax-exempt organizations. The IRS indicated that health care providers that are exempt from federal income taxation under Section 501(a) would normally not be subject to tax on payments from the Provider Relief Fund. Notwithstanding this general rule, the IRS indicated that the payment may be subject to tax under Section 511 of the Code to the extent the payment is used to reimburse the provider for expenses or lost revenue attributable to an unrelated trade or business as defined in Section 513 of the Code.
The IRS FAQ can be viewed in its entirety by clicking here. Members are advised to discuss the issue of potential taxation of any relief funding they received with their tax professionals.
CMS Issues Additional Staffing and Licensing Waivers
On May 1, 2020, CMS updated its “COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.” The full document can be viewed by clicking here.
In the updated FAQ, CMS answers three important questions related to ambulance vehicle and staffing requirements:
- Expired Ambulance Operating Licenses. CMS was asked whether a ground ambulance vehicle operating under an expired license could nevertheless satisfy the Medicare regulations related to vehicle licensing. CMS indicated that the ground ambulance would remain in compliance with Medicare Program rules to the extent it was permitted to operate without a renewed license under a valid state or local law, regulation, or legally adequate waiver. It is important to note that this is not a “waiver” of CMS rules per se. Rather, CMS correctly noted that additional flexibility being provided is based on the state waiving or relaxing its existing rules related to licensures.
- Modified Staffing Requirements. CMS was asked whether an ambulance service that staffs its vehicles with personnel that fall below the previously required levels of certification would be in compliance with Medicare Program rules. The Medicare regulations at 42 C.F.R. §410.41(b) set forth the requirements for vehicle staffing. These regulations largely defer to state and local laws. However, they do require a certain minimum level of staffing. Specifically, the Medicare regulations require that: (i) BLS vehicles be staffed with at least two people, at least one of whom must be certified as an EMT and (ii) ALS vehicles be staffed by at least two people, at least one of whom must be certified as a paramedic or an EMT that is permitted to perform one or more ALS services (e.g., an EMT-Intermediate). CMS is indicating that it is waiving this minimum staffing requirement under its 1135 Waiver Authority for the duration of the Public Health Emergency. Under this waiver, CMS will consider the vehicle staffing requirement to be met to the extent state or local law, regulation, or waiver permits an alternative staffing arrangement. CMS specifically cited examples where the state or locality would permit BLS vehicles to be staffed with EMRs instead of EMT-Basics, or ALS vehicles staffed with RNs instead of paramedics. Note: claims submitted in reliance upon this waiver should be submitted using the “CR” modifier after the origin/destination modifiers.
- Ambulance Services Rendered Across State Lines. CMS was asked whether an ambulance service that provides care across state lines, in a state where it is not certified to provider services or in which its personnel are not licensed, would be in compliance with Medicare Program rules. CMS indicated that it is using its 1135 Waiver Authority to waive the requirement under 42 C.F.R. 410.41(b) that vehicle personnel be licensed in the state in which they are furnishing services to the extent that: (i) they have an equivalent licensing or certification in another state and (ii) they are not affirmatively excluded from practicing in that state or any other state. Please note that this waiver only applies to the Medicare certification requirements. CMS lacks the authority to waive the licensing requirements of the other state or locality. Thus, for this waiver to apply, you must be permitted to operate in the other state pursuant to that state’s laws, regulations, and/or validly issued waiver. Note: claims submitted in reliance upon this waiver should be submitted using the “CR” modifier after the origin/destination modifiers.
COVID-19 Uninsured Program Now Includes Air, Water
HHS Updates Guidance on Provider Relief Funding for Uninsured to include Air and Water Ambulance
The Department of Health and Human Services recently updated its guidance on the disbursement of provider relief funds under the CARES Act for the testing and treatment of the uninsured. Previously, HHS indicated that this allocation was only available for the reimbursement of emergency and non-emergency ground ambulance transportation. However, in its most recent update, HHS has removed the restriction that limited participation to ground ambulance providers and suppliers. The new guidance indicates that the relief funds are now available for all emergency ambulance transportation and non-emergency patient transfers via ambulance.
Thus, it appears that air and water ambulance providers and suppliers are now eligible to receive funding for the treatment of COVID-19 patients.
Is there anything my air or water ambulance organization needs to do to claim reimbursement for treatment of uninsured COVID patients?
Yes. In order to be eligible for payments for the treatment of uninsured COVID patients, you must enroll as a participant in the program. Enrollment must be done through an online portal that can be accessed at: http://www.coviduninsuredclaim.hrsa.gov.
Once my organization enrolls, when can we start submitting claims for reimbursement for treatment of uninsured COVID patients?
HHS has indicated that it will begin to accept claims for reimbursement for treatment of the uninsured on May 6, 2020.
FUNDING FOR TREATMENT OF UNINSURED COVID PATIENTS IS SUBJECTED TO AVAILABLE FUNDING, AND IS THEREFORE ON A FIRST-COME, FIRST-SERVED BASIS. IT IS EXPECTED THAT THESE FUNDS WILL BE EXHAUSTED IN FAIRLY SHORT ORDER.
UPDATED: What to Do for Round 2 of HHS Provider Relief
UPDATED: HHS Opens Portal for Healthcare Providers and Suppliers to Apply for Second Tranche of CARES Act Provider Relief Funding
Updated April 24, 2020 at 9:40 pm | Register for AAA’s 4/27 webinar on this topic►
At 5 p.m. on Friday, April 24, 2020, the Department of Health and Human Services opened the online portal that health care providers and suppliers must use to submit their revenue information. This is a requirement to access the second $20 billion tranche of general allocation funding. Access the online portal►
In order to provide the required information, you will need the following information/documentation:
- Your Tax Identification Number (TIN)
- The bank account to which the first tranche of provider relief funding
- You will need access to the email account that you are using to apply for funds (to accept and provide back a security verification code)
- A PDF copy of your most recent tax return
The portal will ask a series of questions to verify your identity and the identity of your organization. These include providing your TIN and the last six digits of the bank account to which the original tranche of relief funding was provided.
After completing the verification process, you will be asked to complete an attestation that you received the initial tranche of relief funding.
You will then be prompted to complete a short questionnaire that is used to apply for additional funding. The steps for completing that questionnaire are as follows:
- Step 1: You will be asked to provide basic information about your organization. This information is similar to the information that you would use to complete a federal W-9 form.
- Step 2: You will be asked to provide your gross receipts or sales as reported on your most recent tax filing.
- Step 3: You will be asked to provide an estimate of your lost revenue for March 2020 and April 2020. Note: HHS provided little guidance on how you should go about estimating your lost revenues. The AAA believes that there are several possible approaches that you can use to provide these estimates. To help members answer this question, the AAA anticipates that it will be issuing a Financial Impact Calculator on Monday, April 27, 2020.
- Step 4: The final step will be for you to upload a copy of your latest tax return.
Attention Governmental Providers
AAA is aware of an issue that may affect governmental EMS organizations. Specifically, those governmental agencies that do not file federal tax returns may not be able to complete the final stage of the application, which asks you to upload a copy of your most recent tax return. The AAA has reached out to HHS to request guidance on how governmental organizations should complete the form. We will update our members as soon as we know anything different. Register for our May 4 COVID-19 Financial Resources for Governmental Providers webinar►
Targeted Allocation for Treatment of the Uninsured
HHS indicated that it will allocate an undisclosed portion of the $29.6 billion in otherwise unallocated relief funding to reimburse healthcare providers and suppliers for COVID-related treatment of the uninsured. Please note that this allocation is only available for the reimbursement of emergency and non-emergency ground ambulance transports. Reimbursement will be available for COVID-related care furnished with dates of service on or after February 4, 2020. Payments will be made at the Medicare rates, subject to available funding. As a condition to receipt of funding, you must agree to accept HHS’ payment as payment-in-full, i.e., you may not balance bill the uninsured patient.
Is there anything my organization needs to do to claim reimbursement for treatment of uninsured COVID patients?
Yes. In order to be eligible for payments for the treatment of uninsured COVID patients, must enroll as a participant in the program. Enrollment must be done through an online portal that will open starting on April 27, 2020. Once open, the portal can be accessed at http://www.coviduninsuredclaim.hrsa.gov.
Once my organization enrolls, when can we start submitting claims for reimbursement for the treatment of uninsured COVID patients?
HHS has indicated that it will begin to accept claims for reimbursement for the treatment of the uninsured at some point in early May 2020.
FUNDING FOR TREATMENT OF UNINSURED COVID PATIENTS IS SUBJECTED TO AVAILABLE FUNDING, AND IS THEREFORE ON A FIRST-COME, FIRST-SERVED BASIS. IT IS EXPECTED THAT THESE FUNDS WILL BE EXHAUSTED IN FAIRLY SHORT ORDER.
The AAA strongly recommends that all members complete their enrollment form as soon as reasonably practicable, so that you are in a position to submit claims as soon as the claim submission window opens.
HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding
HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding
By Brian S. Werfel, Esq.
March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10. These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19. Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”
The Department of Health and Human Services (HHS) began the disbursement of the first $30 billion tranche of the CARES Act Provider Relief Funding on April 10, 2020, with full disbursement of this tranche being completed by April 17, 2020. The American Ambulance Association has issued a Frequently Asked Question that provides additional details on how the payments under this first tranche were calculated, as well as the terms and conditions that are applicable to this disbursement.
On April 22, 2020, HHS announced its plans for the disbursement of the remaining $70 billion in CARES Act Provider Relief Funding. These monies will be distributed using four broad categories:
- General Allocation. HHS indicated that it will be supplementing the initial $30 billion tranche with an additional $20 billion. Ultimately, HHS’ intent is to distribute this $50 billion to all eligible healthcare providers and suppliers (including ambulance providers and suppliers) based on the provider’s or supplier’s 2018 net patient revenue. “Net patient revenue” is a term of art in the Medicare world, and is used to describe all patient revenues (from whatever source) minus: (i) provision for bad debts, (ii) contractual adjustments, (iii) charity discounts, (iv) teaching allowances, (v) policy discounts, (vi) administrative adjustments, and (vii) other deductions from revenue. HHS indicated that it would calculate every provider’s and supplier’s proportionate share of the entire $50 billion would be using their 2018 net patient revenue. HHS would then subtract the amounts that the provider or supplier received during the first tranche, and pay the unpaid balance over the next few weeks. For institutional providers that have already submitted 2018 cost reports, these payments will go out on April 24, 2020. Providers or suppliers that do not have adequate cost report data on file will need to submit their revenue information using an online portal that will become available this week, with payments to follow on a rolling basis once a provider’s or supplier’s information has been validated. As with the first tranche, recipients of relief funding will be required to sign an attestation confirming receipt of the funds, and agreeing to the terms and conditions, including the restrictions on surprise medical billing.
- Targeted Allocations. HHS indicated that it would be setting aside an additional $20.4 billion for certain targeted segments of the health care industry. This includes: (i) $10 billion being allocated to hospitals in areas that have been particularly hard-hit by the COVID-19 outbreak, (ii) $10 billion for rural health clinics and hospitals, and (iii) $400 for the Indian Health Service.
- Reimbursement for Uninsured Patients. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse healthcare providers and suppliers for COVID-related treatment of the uninsured. This allocation is available for the reimbursement of emergency and non-emergency ground ambulance transportation furnished to uninsured COVID-19 patients; however, air and water ambulance providers are not eligible to participate. Reimbursement will be available for COVID-related care furnished with dates of service on or after February 4, 2020. Payments will be made at the Medicare rates, subject to available funding. To be eligible for reimbursement for care furnished to uninsured COVID-19 patients, ambulance providers and suppliers will need to enroll as a provider participant, which can be done starting on April 27, 2020. Claims will be accepted starting in early May 2020. As a condition to receiving reimbursement for the care of uninsured COVID-19 patients, you will be required to accept HHS’ payment as payment-in-full, i.e., you will not be permitted to balance bill the patient. Additional information on HHS’ reimbursement for uninsured COVID-19 patients can be found at: http://www.coviduninsuredclaim.hrsa.gov.
- Reimbursement for Certain Medicaid-Only Providers. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse skilled nursing facilities, dentist, and provides that only participate in State Medicaid Programs.
Upcoming Important Dates
To participate in these future funding tranches, AAA Members will need to keep the following dates in mind:
- On or after April 23/24 – You will need to access the online portal to submit your revenue information in order to receive the second tranche of the $50 billion general allocation of provider relief funds.
- April 27, 2020 – You will need to register for the COVID-19 Uninsured Reimbursement Allocation. Once open, the online portal can be accessed from the following webpage: http://www.coviduninsuredclaim.hrsa.gov.
- Early May 2020 – You will be able to start submitting claims to the COVID-19 Uninsured Reimbursement Allocation.
FAQs – HHS CARES Act Provider Relief Funding
Frequently Asked Questions (FAQs) related to HHS CARES Act Provider Relief Funding
By Brian S. Werfel, Esq.
In March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10. These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19. Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”
On April 9, 2020, the Department of Health and Human Services (HHS) began the disbursement of the first $30 billion of this provider relief funding. This disbursement was made to all healthcare providers and suppliers that were enrolled in the Medicare Program, and who received Medicare Fee-for-Service reimbursements during Calendar Year 2019. For most ambulance providers and suppliers, these relief funds were automatically deposited into their bank accounts.
In this Frequently Asked Question (FAQ), the AAA will address some of the more common questions that have arisen with respect to the Cares Act Provider Relief Funds.
Question #1: My organization received relief funds through an ACH Transfer. Is there anything our organization needs to do?
Answer #1: Yes. Within thirty (30) days of receiving the payment, you must sign an attestation confirming your receipt of the provider relief funds. As part of that attestation, you must also agree to accept certain Terms and Conditions. The attestation can be signed electronically by clicking here.
Question #2: Am I required to accept these funds? What happens if I am not willing to accept the Terms and Conditions imposed on the receipt of these funds?
Answer #2: You are not obligated to accept the provider relief funds. The purpose of these funds was to provide healthcare providers and suppliers with an immediate cash infusion in order to assist them in paying for COVID-related expenses and/or to offset lost revenues attributable to the COVID-19 pandemic.
If you are not willing to abide by the Terms and Conditions associated with these funds, you must contact HHS within thirty (30) days of receipt of payment, and then return the full amount of the funds to HHS as instructed. The CARES Act Provider Relief Fund Payment Attestation Portal provides instructions on the steps involved in rejecting the funds. Please note that your failure to contact HHS within 30 days to arrange for the return of these funds will be deemed to be an acceptance of the Terms and Conditions.
Question #3: Our organization has elected to retain the provider relief funds. Are there any major restrictions on how we can use these funds?
Answer #3: Yes. In the Terms and Conditions, HHS has indicated that you must certify that the funds will only be used to prevent, prepare for, and respond to coronavirus. You are also required to certify that the funding will only be used for health-care related expenses and/or to offset lost revenues that are attributable to coronavirus.
You are specifically required to certify that you will not use the relief funding to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.
While the language in the Terms and Conditions are somewhat ambiguous, the AAA interprets this to mean that you must certify that your organization’s operations have been impacted, in some way, by the national response to the coronavirus. The AAA further interprets this language as requiring that, on net, the coronavirus pandemic has had an adverse impact on either your operations (in terms of added costs) or your revenues (in terms of decreased revenues). At the present time, the AAA believes that most, if not all, of our members that are currently providing services in response to the coronavirus pandemic will meet this standard.
Note: one situation where a provider may not be eligible for provider relief funding would be a situation where the provider ceased operations prior to January 31, 2020. For example, a provider that ceased operations on December 31, 2019. Because the ambulance provider was paid for Medicare FFS services furnished in 2019, it may receive provider relief funding. However, if the organization’s operations ceased prior to the onset of the current state of emergency, it would not be able to meet the requirement that it provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. In this situation, the ambulance provider would likely be obligated to reject the provider relief funding.
Question #4: Are there any other restrictions on our use of provider relief funding?
Answer #4: Yes. In addition to the restrictions discussed in Answer #3 above, you are also restricted from using the provider relief funding for any of the following purposes:
- The provider relief funds may not be used to pay the salary of an individual at a rate in excess of Executive Level II (approximately $189,600);
- The provider relief funds may not be used, in whole or in part, to advocate or promote gun control;
- The provider relief funds may not be used, in whole or in part, for lobbying activities;
- The provider relief funds may not be used to fund abortions (subject to certain exceptions);
- The provider relief funds may not be used for embryo research;
- The provider relief funds may not be used for the promotion of the legalization of controlled substances;
- The provider relief funds may not be used to maintain or establish a computer network, unless such network blocks the viewing, downloading, and exchanging of pornography;
- The provider relief funds may not be provided to the Association of Community Organizations for Reform Now (ACORN), or any of its affiliates, subsidiaries, allied organizations, or successors;
- The provider relief funds may not be used to purchase sterile needles or syringes for hypodermic injections of illegal drugs.
Question #5: How will HHS verify that the provider relief funding is being used for an appropriate purpose?
Answer #5: HHS will require all recipients of provider relief funding to submit reports “as the Secretary determines are needed to ensure compliance with the conditions imposed.” HHS indicated that it will provide future program instructions to recipients that specifies the form and content of these reports. Recipients will also be required to maintain appropriate records and cost documentation to substantiate how provider relief funds were spent, and to provide copies of such records to HHS upon request.
In addition, ambulance providers and suppliers that receive, in the aggregate, more than $150,000 in funds under the CARES Act, the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, and any other legislation that makes appropriations for coronavirus response and related activities will be required to submit a report within 10 days of the end of each calendar quarter. These reports must specify: (1) the total amount of funds received from HHS under each of these pieces of legislation, (2) the amount of funds received that was spent or obligated to be spend, and (3) a detailed list of all projects or activities for which large covered funds were expended or obligated.
Question #6: We understand that one of the conditions associated with the provider relief funding is that we agree not to balance bill patients. Is our understanding correct?
Answer #6: The Terms and Conditions do contain provisions that would likely place restrictions on your ability to balance-bill patients.
In order to understand these restrictions, it is probably helpful to understand the underlying purpose of the restriction. The actual language from the Terms and Conditions reads as follows:
“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.”
As the language makes clear, HHS was not focused primarily on the practice of balance-billing. Rather, HHS’ concern was that many healthcare providers would have capacity restraints. As a result, patients may be restricted in their ability to receive care from their normal providers (who are presumably in-network with the patient’s insurer). HHS’ intent was to ensure that the patient does not suffer any adverse financial consequences as a result of seeking care for presumptive or actual cases of COVID-19. It accomplishes this goal by requiring the recipient of provider relief funds to agree not to collect from the patient out-of-pocket expenses that are greater than what the patient would have incurred has the care been provided by an in-network provider.
This is being interpreted as a ban on “balance-billing” because most commercial insurers require their contracted providers to accept the plan’s allowed amount as payment-in-full, i.e., to agree to only bill the patient for applicable copayments and deductibles.
Ambulance providers and suppliers should keep in mind that this will not impact the payment of claims from: (1) Medicare, Medicaid or other state and federal health care programs that already require you to accept the program’s allowed amount as payment-in-full, (2) commercial insurers with which the organization currently contracts, and (3) the uninsured. In other words, this requirement only impacts payments from commercial insurers with which the organization currently does not contract.
At this point in time, it is expected that non-contracted commercial insurers will process your claim and make a determination as to whether the claim is related to the treatment and care of a presumptive or actual case of COVID-19. If the plan determines that the services you furnished were COVID-related, they will likely pay you the in-network rate they have established with contracted providers in your services area. The plan will likely then issue a remittance notice that indicates that you may not bill the patient for any balance over the insurer’s payment. Note: many of the larger commercial insurers have indicated that they will waive the copayments and deductibles due from patients for COVID-related claims. If the plan waives the copayment and deductibles, they will pay these amounts to you as part of their payment of the claim. If they do not waive the copayment and deductible, you will be permitted to seek to collect these amounts from the patient. If the plan determines that the services you furnished were not COVID-related, they will continue to pay your claims using their normal claims processing, and you would be permitted to balance bill the patient to the extent otherwise permitted under state and local law.
There is still a good deal of confusion related to this aspect of the CARES Act Provider Relief Funding. It is expected that HHS will be issuing further clarification in the days to come. The AAA will update this FAQ to reflect any updated guidance from HHS.
CMS: Medical Necessity & Patient Signature Requirements During COVID-19
CMS Clarifies Medicare Requirements Related to Medical Necessity and the Patient Signature Requirement during Current National State of Emergency
By Brian S. Werfel, Esq.
On April 9, 2020, CMS updated its Frequently Asked Questions (FAQs) for billing Medicare Fee-For-Service Claims during the current national state of emergency. This document includes guidance for numerous industry types, including ambulance services. The ambulance-specific questions start on page 11.
Two of the more common questions that A.A.A. members have asked during the current crisis are:
- Whether the transportation of a patient known or suspected to be infected with the COVID-19 virus would automatically justify medical necessity for the ambulance? And,
- Whether CMS will be waiving the requirement that ambulance providers and suppliers obtain the patient’s signature (or an acceptable alternative signature) to consent to the submission of a claim?
CMS did provide some guidance on both of these issues.
CMS addressed the issue of medical necessity in its answer to Question #9 on page 13. The question posed to CMS was whether an ambulance provider/supplier could consider any COVID-19 positive patient to meet the medical necessity requirements for an ambulance. CMS responded as follows:
“Answer: The medical necessity requirements for coverage of ambulance services have not been changed. For both emergency and non-emergency ambulance transportation, Medicare pays for ground (land and water) and air ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other forms of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided for the billed services to be considered medically necessary.”
Basically, CMS declined to offer a blanket waiver of the medical necessity requirements for COVID-19 patients. In doing so, CMS seems to be suggesting that COVID-19 status, in and of itself, is not sufficient to establish Medicare coverage for an ambulance transport.
Fortunately, CMS did offer specific relief on the Medicare patient signature requirement. The question posed to CMS on page 16 (Question #14) was whether an ambulance provider/supplier could sign on the patient’s behalf to the extent the patient was known or suspected to be infected with COVID-19, and, as a result, asking the patient (or an authorized representative) to sign the Tablet would risk contaminating the device for future patients and/or ambulance personnel. CMS responded as follows:
“Answer: Yes, but only under specific, limited circumstances. CMS will accept the signature of the ambulance provider’s or supplier’s transport staff if that beneficiary or an authorized representative gives verbal consent. CMS has determined that there is good cause to accept transport staff signatures under these circumstances. See 42 CFR 424.36(e). CMS recommends that ambulance providers and suppliers follow the Centers for Disease Control’s Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States, which can be found at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. This guidance includes general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with known or suspected COVID-19. However, in cases where it would not be possible or practical (such as a difficult to clean surface) to disinfect the electronic device after being touched by a beneficiary with known or suspected COVID-19, documentation should note the verbal consent.”
Essentially, CMS is indicating that you can accept a patient’s verbal consent to the submission of a claim in lieu of a written signature. In these instances, CMS is indicating that the crew must clearly document that they have obtained the patient’s (or the authorized representative’s) verbal consent.
HHS Announces Release of Initial Tranche of CARES Act Provider Relief Funding
On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10. These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19. Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”
On April 9, 2020, the Department of Health and Human Services (HHS) indicated that it would be disbursing the first $30 billion of relief funding to eligible providers and suppliers starting on April 10, 2020. This money will be disbursed via direct deposit into eligible providers and supplier bank accounts. Please note that these are outright payments, i.e., these are not loans that will need to be repaid.
Who is Eligible to Receive Relief Fund Payments?
HHS indicated that any healthcare provider or supplier that received Medicare Fee-For-Service reimbursements in 2019 will be eligible for the initial allocation. Payments to practices that are part of larger medical groups will be sent to the group’s central billing office (based on Medicare enrollment information). HHS indicated that billing organizations will be identified by their Taxpayer Identification Numbers (TINs).
Are There Any Conditions to Receipt of this Funding?
Yes. As a condition to receiving relief funding, a healthcare provider or supplier must agree not to seek to collection out-of-pocket payments from COVID-19 patients that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.
How is the Amount of Relief Funding an Entity will Receive Determined?
HHS indicated that the amounts healthcare providers and suppliers will receive will be based on their pro-rata share of total Medicare FFS expenditures in 2019. HHS indicated that Medicare FFS payments totaled $484 billion in 2019.
Providers and suppliers can estimate their initial relief payment amount by dividing their 2019 Medicare FFS reimbursement by $484 billion, and then multiplying that “ratio” by $30 billion. Note: payments from Medicare Advantage plans are not included in the calculation of a provider’s/supplier’s total 2019 Medicare payments.
As an example, HHS cited a community hospital that received $121 million in Medicare payments in 2019. HHS indicated that this hospital’s ratio would be 0.00025. That amount is then multiplied by $30 billion to come up with its initial relief fund payment of $7.5 million.
The AAA has created a CARES Act Provider Relief Calculator
that you can use to estimate your initial relief payment. |
USE DOWNLOADABLE EXCEL CALCULATOR►
Do I Need to do Anything to Receive Relief Funds?
No. You do not need to do anything to receive your relief funding. HHS has partnered with UnitedHealth Group (UHG) to disburse these monies using the Automated Clearing House (ACH) system. Payments will be made automatically to the ACH account information on file with UHG or CMS.
Providers and suppliers that are normally paid by CMS through paper checks will receive a check from CMS within the next few weeks.
How Will I Know if I Received My Relief Funds?
The ACH deposit will come to you via Optum Bank. The payment description will read “HHSPayment.”
Do I Need to do Anything Once I Receive My Relief Funds?
Yes. You will need to sign an attestation statement confirming relief of the funds within 30 days. These attestations will be made through a webportal that HHS anticipates opening the week of April 13, 2020. The portal will need to be accessed through the CARES Act Provider Relief Fund webpage, which can be accessed by clicking here.
You will also be required to accept the Terms and Conditions within 30 days. Providers and suppliers that do not wish to accept these terms and conditions are required to notify HHS within 30 days, and then remit full repayment of the relief funds. The Terms and Conditions can be reviewed by clicking here.
How will HHS Distribute the Remaining $70 Billion in Relief Funds?
HHS has indicated that it intends to use the remaining relief funds to make targeted distributions to providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve Medicaid populations, and providers requesting reimbursement for the treatment of uninsured Americans.
CMS Announces Delay to ET3 Start Date
On April 8, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will be delaying the start of the Emergency Triage, Treat and Transport (ET3) Model until Fall 2020. The ET3 Model was previously set to start on May 1, 2020. CMS cited the national response to the COVID-19 pandemic as the reason for this delay.
In its delay notice, CMS also reminded the EMS industry that it has issued a number of temporary regulatory waivers and new rules that are designed to give health care providers and suppliers maximum flexibility to respond to the current national emergency. This includes a number of flexibilities offered specifically to the ambulance industry.
Summary of Financial Relief Provisions Under the CARES Act
AAA Operations & Human Resources Consultant Scott Moore, Esq has developed a summary of financial relief provisions from the recent CARES Act. The resource will help your organization evaluate in which programs it may qualify to participate.
CMS “Pauses” Prior Authorization Model for Scheduled, Repetitive Non-Emergency Ambulance Transportation
CMS released published a guidance document summarizing some of the steps that it has taken to relieve the administrative burden on health care providers and suppliers during the current public health emergency. As part of that document, CMS indicated that it will be “pausing” the Prior Authorization Model for scheduled, repetitive non-emergency ambulance transports. Under this program, ambulance suppliers are required to seek and obtain prior authorization for the transportation of repetitive patients beyond the third round-trip in a 30-day period. Absent prior authorization, claims will be stopped for pre-payment review. The Prior Authorization Model is currently in place in Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia.
CMS indicated that this pause went into effect as of March 29, 2020, and will continue for as long as the current public health emergency continues. During this pause, claims for repetitive, scheduled, non-emergency transports will not be stopped for pre-payment review if the prior authorization has not been requested and obtained prior to the fourth round-trip. However, CMS indicated that claims submitted and paid during the pause without prior authorization will be subject to postpayment review.
CMS further indicated that during this period: (1) the MACs will continue to review any prior authorization requests that have previously been submitted and (2) that ambulance suppliers may continue to submit new prior authorization requests.
Ambulance suppliers in these areas will have to make a business decision on whether to continue to request prior authorization during the current crisis. Please note that there are significant benefits to obtaining prior authorization for your repetitive patient population. Specifically, claims that are submitted based on an affirmative prior authorization decision are excluded from future medical review.
The existing Prior Authorization Model is scheduled to expire on December 1, 2020. CMS has indicated that, at the present time, it does not plan an extension beyond December 1, 2020. CMS further indicated that the Prior Authorization Model will not be expanded beyond the current states and territories during the public health emergency.
CMS Releases Update Guidance on Hospital EMTALA Obligations Related to COVID-19
On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA). This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.
Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition. Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.
The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.
Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.
Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19
CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity. CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required. CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.
CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department. CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department. This redirection can even take place outside the entrance to the emergency department. Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).
CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites. Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses. However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam. Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention.
Finally, communities may set up screening clinics at sites not under the control of a hospital. These sites would not be subject to EMTALA.
EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection
To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately. CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.
Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.
CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.