AAA Task Force to Address Balance Billing Challenges
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Oregon | President Baird Joins OHA COVID-19 Vaccine Advisory Committee
From the Oregon Department of Human Services on December 31
OHA completes recruitment for COVID-19 Vaccine Advisory Committee
27-member group to create sequencing for COVID-19 immunizations
PORTLAND, Ore. — Oregon Health Authority has completed recruitment for its Vaccine Advisory Committee (VAC) that will determine the sequence in which new COVID-19 vaccines are distributed around the state.
The 27-member committee will advise OHA on vaccine sequencing for phases 1b, 1c and 2 of the state’s vaccine distribution plan, with the goal of prioritizing communities most affected by COVID-19. The COVID-19 Vaccine Advisory Committee will be grounded in OHA’s definition of health equity, which—as cited in this excerpt—is a health system where “all people can reach their full health potential and well-being and are not disadvantaged by their race, ethnicity, language, disability, gender, gender identity, sexual orientation, social class, intersections among these communities or identities, or other socially determined circumstances.”
To advance health equity, and counter unjust COVID-19 inequities, the COVID-19 VAC will:
- Advise OHA on the ethical principles that should guide decisions on sequencing of COVID-19 vaccines.
- Review data on COVID-19 and immunization inequities.
- Advise OHA on which workers, high-risk groups or critical populations should be sequenced at what time, taking into consideration where they are located across the state.
The committee roster is as follows:
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Aileen Duldulao |
Oregon Pacific Islander Coalition |
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Cherity Bloom-Miller |
Siletz Community Health Clinic |
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Christine Sanders |
Rockwood Community Development Corp. |
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Daysi Bedolla Sotelo |
Pineros y Campesinos Unidos del Noroeste |
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DeLeesa Meashintubby |
Volunteers in Medicine |
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Debra Whitefoot |
Nch’i Wana Housing |
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Derick Du Vivier |
Oregon Health & Science University |
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Dolores Martinez |
Euvalcree |
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George Conway |
Deschutes County Health Services |
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Kalani Raphael |
Oregon Pacific Islander Coalition |
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Kelly Gonzales |
Portland State University |
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Kristin Milligan |
Community Volunteer Network |
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Laurie Skokan |
Providence Health & Services |
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Leslie Sutton |
Oregon Council on Developmental Disabilities |
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Maleka Taylor |
The Miracles Club |
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Maria Loredo |
Virginia Garcia Memorial Health Center |
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Marin Arreola |
Interface Network |
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Muriel DeLaVergne-Brown |
Crook County Health Department |
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Musse Olol |
Somali American Council of Oregon |
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Nannette Carter-Jafri |
SEIU Local 503 Indigenous People’s Caucus |
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Ruth Gulyas |
LeadingAge Oregon |
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Safina Koreishi |
Columbia Pacific CCO |
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Sandra McDonough |
Oregon Business & Industry |
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Shawn Baird |
Metro West Ambulance Service |
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Sue Steward |
Northwest Portland Area Indian Health Board |
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Tsering Sherpa |
The Rosewood Initiative |
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Zhenya Abbruzzese |
Adventist Health |
“The COVID-19 Vaccine Advisory Committee brings tremendous lived and professional experience to guide OHA’s decisions about vaccine sequencing in a way that upholds OHA’s goal to eliminate health inequities by 2030,” said Cara Biddlecom, OHA deputy public health director.
“Members of this committee represent communities that have been unjustly impacted by COVID-19, including tribal communities and communities of color, and OHA is committed to involving community members in the decision-making processes that affect their lives.”
The committee’s first public meeting is Thursday, Jan. 7, from 9 a.m. to noon. The meeting can be accessed via conference line at 669-254-5252; meeting ID: 160 583 9896.
For more information about the committee, visit the Vaccine Advisory Committee information page. Comments or questions can be emailed to covid.vaccineadvisory@dhsoha.state.or.us.
Stay informed about COVID-19:
Oregon response: The Oregon Health Authority leads the state response.
United States response: The Centers for Disease Control and Prevention leads the US response.
Global response: The World Health Organization guides the global response.
2020 Post-Election Outlook
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America First Healthcare Executive Order on Surprise Coverage
President Trump’s “An America-First Healthcare Plan” Executive Order on Surprise Billing Policy
by Kathy Lester, J.D., M.P.H.
As the American Ambulance Association (AAA) reported yesterday, President Trump issued an Executive Order (EO) “An America-First Healthcare Plan.” The EO includes several provisions, including related to drug importation generally and for insulin specifically. It also includes statements that indicate if the Congress does not act before the end of the year, the President will have the Department of Health and Human Services (HHS) “take administrative action to prevent a patient from receiving a bill for out-of-pocket expenses that the patient could not have reasonably foreseen.” It does not mention ground ambulances.
In addition to suggesting action if the Congress does not pass legislation, the EO also states that within 180 days, the Secretary will update the Medicare.gov Hospital Compare website to inform beneficiaries of hospital billing quality, including:
- Whether the hospital is in compliance with the Hospital Price Transparency Final Rule;
- Whether, upon discharge, the hospital provides patients with a receipt that includes a list of itemized services received during a hospital stay; and
- How often the hospital pursues legal action against patients, including to garnish wages, to place a lien on a patient’s home, or to withdraw money from a patient’s income tax refund.
The narrative related to balance billing (surprise coverage) reads as follows:
My Administration is transforming the black-box hospital and insurance pricing systems to be transparent about price and quality. Regardless of health-insurance coverage, two‑thirds of adults in America still worry about the threat of unexpected medical bills. This fear is the result of a system under which individuals and employers are unable to see how insurance companies, pharmacy benefit managers, insurance brokers, and providers are or will be paid. One major culprit is the practice of “surprise billing,” in which a patient receives unexpected bills at highly inflated prices from providers who are not part of the patient’s insurance network, even if the patient was treated at a hospital that was part of the patient’s network. Patients can receive these bills despite having no opportunity to select around an out-of-network provider in advance.
On May 9, 2019, I announced four principles to guide congressional efforts to prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, the Congress has failed to act, and patients remain vulnerable to surprise billing.
In the absence of congressional action, my Administration has already taken strong and decisive action to make healthcare prices more transparent. On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care. Beginning January 1, 2021, hospitals will be required to publish their real price for every service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that are able to be shopped for in advance.
We have also taken some concrete steps to eliminate surprise out‑of-network bills. For example, on April 10, 2020, my Administration required providers to certify, as a condition of receiving supplemental COVID-19 funding, that they would not seek to collect out-of-pocket expenses from a patient for treatment related to COVID-19 in an amount greater than what the patient would have otherwise been required to pay for care by an in-network provider. These initiatives have made important progress, although additional efforts are necessary.
Not all hospitals allow for surprise bills. But many do. Unfortunately, surprise billing has become sufficiently pervasive that the fear of receiving a surprise bill may dissuade patients from seeking appropriate care. And research suggests a correlation between hospitals that frequently allow surprise billing and increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physical harm and threatens the long-term financial sustainability of Medicare.
Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they work would correspondingly streamline the ability of patients to receive care and reduce time spent on billing disputes.
The AAA will continue to advocate for the resources necessary to sustain life-saving mobile healthcare.
CMS Expands Prior Authorization Model
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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/#/.
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.
July 22 | EMS Advocacy Facebook Livestream
July 22, 2020 | 14:00 ET | Register Now for a Reminder!
Join AAA advocacy experts for a fast-paced informal dialogue on Facebook Live! Learn first-hand about EMS advocacy initiatives in the face of COVID-19.
Register to receive a reminder email one hour in advance of the live broadcast on the American Ambulance Association Facebook page!
Panelists
- Randy Strozyk, Secretary, AAA
- Jamie Pafford-Gresham, Chair, AAA Government Affairs Committee
- Asbel Montes, Chair, AAA Payment Reform Committee
- Rob Lawrence, Chair, AAA Communications Committee
- Maria Bianchi, AAA Executive Director
- Tristan North, AAA SVP of Government Affairs
- Mercury Group Public Affairs
Updated CMS FAQs on the Ambulance Data Collection
Updated CMS FAQs on the Ambulance Data Collection System and Reporting Requirement Delay
As we recently reported, CMS announced that it will be delaying the implementation of the statutorily mandated ambulance data collection system. CMS has released a new set of Frequently Asked Questions (FAQs) clarifying the delay. In sum, ambulance organizations selected to provide cost data for 2020 will now be required to report 2021 data in Year 2. CMS will also add a new set of ambulance organizations for Year 2 reporting as well. This means that twice as many ambulance organizations will be reporting 2021 data in Year 2 and there will be no data reported for 2020. Any organization selected that does not report data will be subject to the 10 percent penalty, unless an exception applies. In addition to addressing concerns about reporting during the pandemic, the FAQs suggest that CMS is concerned that 2020 data “may not be reflective of typical costs and revenue associated with providing ground ambulance services.”
The complete list of these questions, as well as previous ambulance FAQs for COVID-19 on Medicare Fee-for-Service (FFS) Billing can be found here. The new data collections are below.
Data Collection and Reporting Requirements for the Medicare Ground Ambulance Data Collection System
1. Question: CMS requires selected ground ambulance organizations to collect cost, revenue, utilization, and other information through the Medicare Ground Ambulance Data Collection System. The collected information will be provided to MedPAC, which is required to submit a report to Congress on the adequacy of Medicare payment rates for ground ambulance services and geographic variations in the cost of furnishing such services. Will the data collection and reporting requirements for the Medicare Ground Ambulance Data Collection System be delayed due to COVID-19?
Answer: Yes. CMS has issued a blanket waiver: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration- waivers.pdf due to the PHE for the COVID-19 pandemic. CMS is modifying the data collection period and data reporting period, as defined at 42 CFR §414.626(a), for ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (Year 1).
Under this modification, these ground ambulance organizations can select a new data collection period that begins between January 1, 2021, and December 31, 2021; collect the necessary data during their selected data collection period; and submit the data during the data reporting period that corresponds to their selected data collection period.
CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020–2021 so that they can focus on their operations in support of patient care.
As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under §414.626(c) to collect data beginning between January 1, 2021, and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at §414.626.
For additional information on the Medicare Ground Ambulance Data Collection System, please visit the Ambulances Services Center website at
https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.
New: 6/16/20
2. Question: Will the 10 percent payment reduction still apply to ground ambulance organizations that are now required to collect and report data under the modified data collection and reporting period but do not sufficiently report the required data?
Answer: Yes. The 10 percent payment reduction described at 42 CFR §414.610(c)(9) will still apply if a ground ambulance organization is selected to collect and report data under the modified data collection and reporting timeframe, but does not sufficiently submit the required data according to the modified timeframe and is not granted a hardship exemption. The payment reduction will be applied to payments made under the Medicare Part B Ambulance Fee Schedule for services furnished during the calendar year that begins following the date that CMS provides written notification that the ground ambulance organization did not submit the required data.
New: 6/16/20
3. Question: The modification states that the ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (year 1) can select a new continuous 12-month data collection period that begins between January 1, 2021, and December 31, 2021. Do the ground ambulance organizations that were selected in year 1 have an option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021?
Answer: No. The ground ambulance organizations that were selected for year 1 do not have an option and must select a new data collection period that begins in 2021. CMS cannot permit this option because the data collected in 2020 during the PHE may not be reflective of typical costs and revenue associated with providing ground ambulance services. New: 6/16/20
4. Question: Does the guidance mean that there will be no data reporting in 2021 and that both the ground ambulance organizations that were selected for year 1 and the ground ambulance organizations that will be selected for year 2 will collect and report data during the same time periods?
Answer: Yes. Under the modification, ground ambulance organizations that are selected for year 1 will not collect data in 2020. These ground ambulance organizations will select a new data collection period that begins in 2021 and must submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. As a result of the modification, year 1 and year 2 selected ground ambulance organizations will collect and report data during the same time periods. New: 6/16/20
Legislative hurdles check hazard pay, PSOB benefits
May 22 at 2:20 PM | EMS1 | By AAA Communications Chair Rob Lawrence
In my last EMS One-stop column, I commented on the legislative to-do list to ensure that EMS receives the federal support it deserves right now as we staff the front lines and perhaps brace ourselves for COVID-19 round two as the nation craves a return to the normality and liberty enjoyed before the lockdown.
On May 15, 2020, the much talked about HEROES Act narrowly passed from the U.S. House of Representatives by a 208 to 199 vote to the Republican-controlled Senate. The HEROES Act proposed $3 trillion in tax cuts and spending to address the negative health and financial impacts of the COVID-19 pandemic. This included benefits for the public safety community, extensions to enhanced unemployment benefits, debt collection relief, direct cash payments to households and possibly even hazard pay.
CMS Modifies the Cost Data Collection System Year 1 Data Collection
CMS has issued a blanket waiver modifying the data collection period for the ground ambulance services that were selected to report in Year 1. Under the current law, these organizations would have been required to collect data beginning January 1, 2020, and through December 31, 2020. The waiver allows these organizations to select a new continuous 12-month data collection period that begins between January 1, 2021 and ends December 31, 2021. This modification means that such organizations will collect and report data during the same time period as the ground organizations that CMS will select for Year 2 of the cost collection program.
From the summary of the waiver, it appears that organizations will have the choice of submitting data in Year 1 or Year 2. CMS has not moved the timeline for any other data collection year, so there is the potential for a substantial number of organizations to report in Year 2, which would increase the amount of data available.
The AAA has supported the data collection system to make sure that CMS and the Congress have valid and reliable data to support maintaining the geographic add-ons to the Medicare Ambulance Fee Schedule and to support efforts to address the chronic underfunding of the Medicare Ambulance Fee Schedule.
The complete FAQ is below and also available at: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf (on page 29).
“CMS is modifying the data collection period and data reporting period, as defined at 42 CFR § 414.626(a), for ground ambulance organizations (as defined at 42 CFR § 414.605) that were selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2020 and December 31, 2020 (year 1) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626. Under this modification, these ground ambulance organizations can select a new continuous 12-month data collection period that begins between January 1, 2021 and December 31, 2021, collect data necessary to complete the Medicare Ground Ambulance Data Collection Instrument during their selected data collection period, and submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020- 2021 so that they can focus on their operations and patient care.”
“As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2021 and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626.”
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.
Grants and Tax Credits Toolkit
Grants and Tax Credits Toolkit
Download materials from Akin Gump including aid summaries and how-to guides on qualifying for tax credits and deferments and applying for financial assistance.
- Paycheck Protection Provision Loans Summary
- Five Steps to an SBA PPP Loan
- Five Steps to Getting a Self-Employed Paycheck Protection Plan (PPP) Loan
- Five Steps to Claim an Employee Retention Tax Credit
- Three Steps to Qualify for Deferred Payroll and Self-Employment Tax Payments
EMS1 | Wisconsin fire, EMS leaders unite in plea for funding
Wisconsin EMS and fire leaders join forces to provide an overview of EMS legislative and regulatory requests to support front line response to COVID-19
I recently reported on how the leaders of a few of our national associations united to tell the story of EMS on the front lines and to draw attention to the shortfalls we are all encountering daily from PPE to funding. EMS providers of all denominations are also coming together at a state level to tell their story and appeal for assistance and funding to ensure the continuity of operations. On Apr. 15, 2020, the Professional Ambulance Association of Wisconsin, Wisconsin EMS Association, Professional Fire Fighters of Wisconsin, and Wisconsin State Fire Chiefs Association conducted an online press conference to discuss the mobile healthcare situation in Wisconsin.
Paycheck Protection Program Funding Update
The Department of Treasury has announced that the $350 billion appropriated under the CARES Act for the Paycheck Protection Program has been exhausted. However, Congressional leaders are currently negotiating an economic stimulus package to act as a bridge between the CARES Act and the next comprehensive package stimulus package. A core provision of the bridge package is an allocation of an additional $250 billion for the Paycheck Protection Program. If your operation is in the process or plans to apply for a loan under the Paycheck Protection Program, you should move forward with your efforts. The AAA is advocating that the bridge package or next comprehensive package include more funding for ambulance services.
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.