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:

  1. 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);
  2. The provider relief funds may not be used, in whole or in part, to advocate or promote gun control;
  3. The provider relief funds may not be used, in whole or in part, for lobbying activities;
  4. The provider relief funds may not be used to fund abortions (subject to certain exceptions);
  5. The provider relief funds may not be used for embryo research;
  6. The provider relief funds may not be used for the promotion of the legalization of controlled substances;
  7. 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;
  8. 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;
  9. 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.

 

 

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:

  1. 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,
  2. 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.

2020 Medicare Reference Manual & Medicare Update Webinar

The 2020 Medicare Reference Manual and the 2020 Medicare Update Webinar are both available for purchase. Please see details below!

2020 Medicare Update Webinar

Thursday, April 30, 2020 | 2:00pm EST
Presenter: Brian Werfel, Esq.
$99 for AAA-Members | $198 for Non-Members

Join A.A.A. Medicare Consultant Brian S. Werfel, Esq. for an update on recent changes to Medicare’s coverage of ambulance services. This webinar coincides with the American Ambulance Association’s release of its 2020 Medicare Reference Manual. Brian will discuss recent changes in Medicare policy, including changes to the rules governing the enforcement of fraud and abuse, the appeals process, etc. We will also discuss Medicare’s proposed plan for the ET3 Program, the national expansion of the prior authorization model for scheduled non-emergency transports, and much more.

Of course, we will also discuss Medicare’s coverage of ambulance services during the current COVID-19 process. This will include a frank discussion of the issues related to medical necessity for the transportation of known or suspected COVID-19 patients, the coverage of transports to field hospitals and other alternative destinations, the current status of certain administrative rules like the Medicare patient signature requirement and the Notice of Privacy Practices, etc.

The session will include an extended Q&A period to address any and all questions from attendees. Purchase Webinar► 

*2020 Medicare Reference Manual Sold Separately* 

 

2020 Medicare Reference Manual 

$200 for AAA-Members | $400 for Non-Members
By David Werfel, Esq & Brian Werfel, Esq

The American Ambulance Association’s 2020 Medicare Reference Manual is a must-have for ambulance services that bill Medicare for transports.

2% Payment Adjustment Suspended (Sequestration)

Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)

Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.

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.

COVID-19 Relief Payments Begin Today

AAA ADVOCATES FOR COVID-19 RELIEF FOR AMBULANCE SERVICES

COVID-19 Relief Payments Begin Today

Beginning today, ambulance service suppliers and providers should start automatically receiving an allocation of payments from the Public Health and Social Emergency Fund. According to the Department of Health and Human Services (HHS), an initial distribution of $30 billion of the funds appropriated through the CARES Act will be distributed to Medicare providers and suppliers over the next week. The Fund was appropriated at $100 billion but not all the funds will be distributed as direct payments to providers and suppliers.

HHS is determining the amount of individual payments based on the proportion of the 2019 Medicare payments to the provider or supplier compared to total outlays for Medicare fee-for-service that year of $484 billion. The AAA estimates a total of approximately $265 million will be distributed to ground ambulance services in the initial round of payments. While the initial payments are a good start, the AAA is pushing for ambulance services to receive ten times that amount in initial relief.

The AAA had advocated for funding in the CARES Act for ambulance services and on April 6, the AAA sent HHS Secretary Azar a letter requesting that ambulance service providers and suppliers receive $48,000 per registered ambulance for financial relief from the impact of the COVID-19 pandemic. The AAA is pushing for a similar amount within future economic stimulus packages as well as several other proposals for legislative and regulatory relief.

On Monday, the AAA will be issuing a Call To Action to its members focusing on four of the provisions on our below list.

Priority Access for EMS to PPE and COVID-19 Testing

  • Recognition by FEMA, HHS (USPHS), CDC of need for priority access to personal protection equipment (PPE) and COVID-19 testing for EMS
  • Non-governmental EMS being eligible to apply directly to FEMA for PPE under the Public Assistance Grants and waive applicant match for all emergency response providers

EMS Services Coverage and Reimbursement for COVID-19 Response

  • Waiver for Medicare coverage of treatment in place and loosing of signature requirements
  • 20% increase, similar to hospitals, for emergency and non-emergency ambulance services in treating and transporting COVID-19 patients
  • SCT reimbursement level for COVID-19 transports and waive hospital-to-hospital limitation on SCT

EMS System Financial Sustainability in Response to COVID-19

  • Grant program under HHS specific to EMS for reimbursement of costs resulting from response to COVID-19 and lost revenue. Payment of $48,000 per registered ambulance to each ambulance service provider and supplier.
  • Expand Paycheck Protection Program to ambulance service organizations with 500 or more employees
  • Fuel tax relief for ground ambulance services

The AAA greatly appreciates the work of our members on the front lines of treating, transporting and testing patients with COVID-19 and we will continue to push for help for you.

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.

Accelerated Payment Program Highlights

CMS announced at the end of last week that it is expanding its Accelerated Payment Program.  The goal of the program is to address cash flow problems arising from the public health emergency.  The program functions as a short-term loan with no interest.

To qualify for advance/accelerated payments the provider/supplier must: (1) Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form; (2) Not be in bankruptcy; (3) Not be under active medical review or program integrity investigation; and (4) Not have any outstanding delinquent Medicare overpayments.

Qualified providers/suppliers will be asked to request a specific amount using an Accelerated or Advance Payment Request form provided on each MAC’s website. Most providers and suppliers will be able to request up to 100% of the Medicare payment amount for a three-month period. All non-hospital Part A providers and Part B suppliers will have 210 days from the date of the accelerated or advance payment was made to repay the balance.

The provider/supplier can continue to submit claims as usual after the issuance of the accelerated or advance payment; however, recoupment will not begin for 120 days. Providers/ suppliers will receive full payments for their claims during the 120-day delay period. At the end of the 120-day period, the recoupment process will begin and every claim submitted by the provider/supplier will be offset from the new claims to repay the accelerated/advanced payment. Thus, instead of receiving payment for newly submitted claims, the provider’s/supplier’s outstanding accelerated/advance payment balance is reduced by the claim payment amount. This process is automatic.

Trump Administration Provides Financial Relief for Medicare Providers

FOR IMMEDIATE RELEASE
March 28, 2020

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

Trump Administration Provides Financial Relief for Medicare Providers

Action comes to aid providers and suppliers facing challenges in responding to COVID-19 pandemic

Under the President’s leadership, the Centers for Medicare & Medicaid Services (CMS) is announcing an expansion of its accelerated and advance payment program for Medicare participating health care providers and suppliers, to ensure they have the resources needed to combat the 2019 Novel Coronavirus (COVID-19). This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act, is one way that CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic, and ensures the nation’s providers can focus on patient care. There has been significant disruption to the healthcare industry, with providers being asked to delay non-essential surgeries and procedures, other healthcare staff unable to work due to childcare demands, and disruption to billing, among the challenges related to the pandemic.

“With our nation’s health care providers on the front lines in the fight against COVID-19, dollars and cents shouldn’t be adding to their worries,” said CMS Administrator Seema Verma. “Unfortunately, the major disruptions to the healthcare system caused by COVID-19 are a significant financial burden on providers. Today’s action will ensure that they have the resources they need to maintain their all-important focus on patient care during the pandemic.”

Medicare provides coverage for 37.4 million beneficiaries in its Fee for Service (FFS) program, and made $414.7 billion in direct payments to providers during 2019.  This effort is part of the Trump Administration’s White House Coronavirus Task Force effort to combat the spread of COVID-19 through a whole-of-America approach, with a focus on strengthening and leveraging public-private relationships.

Accelerated and advance Medicare payments provide emergency funding and addresses cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. These expedited payments are typically offered in natural disasters to accelerate cash flow to the impacted health care providers and suppliers. In this situation, CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19.  The payments can be requested by hospitals, doctors, durable medical equipment suppliers and other Medicare Part A and Part B providers and suppliers.

To qualify for accelerated or advance payments, the provider or supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/ supplier’s request form,
  • Not be in bankruptcy,
  • Not be under active medical review or program integrity investigation, and
  • Not have any outstanding delinquent Medicare overpayments.

Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.

An informational fact sheet on the accelerated/advance payment process and how to submit a request can be found here: www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf

This action, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.

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Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS@CMSgov, and @CMSgovPress. 

Webinar Materials & FAQ: Claims Guidance for COVID-19

Webinar: How to Best Document and Track Claims Related to COVID-19

Recorded: Thursday, March 26th | 12:00pm Eastern
View On-Demand Recording
View PPT Slides

FAQ of unanswered webinar questions:

  1. Is the idea that the ET3 model will be pushed to all ambulance companies or only previously selected participants?

The request into CMS and leadership during the declared public health emergency is to allow all ambulance providers and suppliers to transport patients or treat in place based upon the concepts outlined in the Emergency Triage, Treatment and Transport model as defined by CMMI’s release last year.

  1. While we wait for finalization of the ET3 protocols, will billing be allowed retroactively?

If CMS follows other waiver provisions that they have been approving, then we would expect the waiver to be retroactive. However, that will be clearly identified when and if the final waiver is approved.

  1. Asbel spoke about Telehealth medical necessity, which we assume applies to the QHP.  Neither CMS nor the MAC has provided any guidance regarding MN guidance for the ambulance that is facilitating the telehealth.  CMS ET3 FAQ provides a non-answer. Can you advise?

You will need to understand the nuances around telehealth and what Medicare requires as a covered benefit for telehealth. Please see attached resources below

  1. Do we need to file an application for TIP?

That is unclear at this time. The AAA has been advocating for national policy that would not include an application process during this public health emergency. If CMS accepts our proposal, then we do not expect an application process.

  1. Will Medicare pay for signs and symptoms such as a cough that is not on our LCD list?

The Centers for Disease Control and Prevention (CDC) has established new codes related to COVID-19.  They are available in this link:  https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf

  1. How can we bill for lift assists and basically public assist? For example, we are seeing increased med alarm pulls because in some of the senior assisted living or independent with aide service, the aide staff is not showing up or is late.  We are getting 911 calls for help getting dressed, move me from my chair to bed at night, etc. (We have one building with many PACE participants, so many Medicare primary)

Yes, you can bill for any response. I am assuming you are looking to understand who the payer source will be for those responses. Currently, Medicare does not pay for an ambulance response without a subsequent medically necessary transport to a covered destination.

The lift assist and public assist responses may be billed to whoever the caller source is if there is no state or local law that prohibits this practice.

Suggestion: You could work with your state legislature or local governing body to codify in statute or local ordinance the responsibility for these false alarms, or public assists are the responsibility of the requestor and invoke penalties if not paid. There are many local jurisdictions that codify this in law with prescribed penalties to try and deter this abuse.

  1. How does this impact the patients who typically are transported by sedan cars or gurney vans to dialysis, but now are confirmed COVID-19 or suspected and still need to be transported to Dialysis? Gurney Van or Sedan cars don’t have the isolation precautions to transfer those patients. Can those patients now be transported by BLS Non-Emergency ambulance?

Medicare has not changed its requirements for transporting beneficiaries to/from dialysis facilities.  We understand that some MACs recognize as a primary reason for ambulance transport patients who have a communicable disease or hazardous material exposure and must be isolated from the public or whose medical condition must be protected from public exposure.  Some MACs do not view this condition as a primary reason to transport a patient, however.  The AAA is seeking clarification from CMS to try to align MACs around the view that patients who require isolation because of a communicable disease or hazardous material exposure can be transported by ground ambulances.

  1. There is already an “I” origin/destination modifier for the site of transfer between modes of ambulances. Wouldn’t this new “I” confuse things?

Great question. Yes. We will wait and see final direction from CMS if they approved transport to a COVID-19 testing site.

  1. Does the use of the “I” modifier include a site such as a shelter that might be set up for COVID-19 patients? Specifically I am referring to a site that maybe the state or local authority has set up and is not directly tied to a hospital.

Yes, that is the waiver that we are seeking from CMS. They could recommend a different modifier. It should be noted that States do have the authority to request a waiver to allow for this, as well. You do not have to wait on the CMS.

  1. The ICD 10 codes related to COVID19 are not effective until April 1st. Once effective, can they be used on a run that occurred before that date?

On February 20, 2020, the Centers for Disease Control and Prevention issued guidance on the ICD-10 codes that should be used. You can find this guidance at the following site:

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf

  1. Is there anything on the end user if ambulance personnel need to document differently for billing purposes?

Best practices would be to provide instruction or edits within your PCR that identifies the following: (1) COVID-19 suspected or positive patient; (2) PPE equipment used (not just a general statement); and (3) any other pertinent information related to the inability to sign any forms due to local or state mandates.

Due to circumstances surrounding this national emergency that we have not experienced before, things are constantly changing. Documentation will be the CRITICAL in helping to obtain additional federal, state and local waivers. Accurate and reliable documentation will be key in building the case retrospectively.

  1. Have there been any signature requirement changes due to COVID 19?

CMS has provided the following guidance:

“At this time, suppliers should do their best to obtain proof of delivery and should notate the file that the beneficiary declined to sign.  Where FedEx or similar delivery services have altered their delivery protocols (such as leaving packages at the home without signatures) due to the COVID-19 pandemic, CMS will consider the revised protocols if conducting review absent suspicion of deliberate gaming or attempted fraud.  Suppliers should continue providing the necessary supplies and document the proof of delivery to the best of their ability (such as a picture of the delivery and/or notation in the file). “

  1. Do any of the waivers apply to the patient signature requirement? Are there links or support for how to learn about 1135? How do we know what our state has done regarding 1135 waiver? How do we work with our state to expand services via 1135 waiver?

The link below is a great tutorial on how 1135 waivers work and tracking existing waivers.

https://www.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/

The health agency in your state would be your POC to engage regarding ambulance requests for expanded services via the 1135 waiver.

  1. Is there a specific documentation on the HCFA form’s for using the 1135 waiver?

Each payer is issuing specific claims guidance on how to bill for waived services through the 1135. You will need to check with your state Department of Insurance or Medicaid Agency. They should have resources online to assist you with identifying what specific documentation is needed.

  1. Has there been any discussion in the delay of Data Collection?

No.  At this point the program remains underway.  The first set of services required to submit were notified at the end of 2019.  CMS continues to develop the tool it will use to collect the data, which we expect to see later this summer or early fall.  However, if the pandemic continues, we will engage with CMS to determine how they view data collection.

If you have an additional questions, please email the AAA at info@ambulance.org

Presenters:

Asbel Montes
Senior Vice President of Strategic Initiatives and Innovation, Acadian Ambulance Service

Asbel has been a member of the American Ambulance Association (AAA) for eight years and has served on its Board of Directors; he currently is Chair of the Payment Reform Steering Committee. Asbel also sits on the board of the Louisiana Ambulance Alliance. He is a respected thought leader on reimbursement initiatives within the industry and is a requested speaker at many conferences. He has also been asked to testify as an expert witness before federal and state health committees regarding ambulance reimbursement.

Asbel began his employment with Acadian in May 2009. He oversees Acadian’s revenue cycle management, contract management, business office process improvements, and government relations for state and federal reimbursement policy initiatives.

In 1999, Asbel began working for an ambulance billing and consulting firm. After three years, he decided to work for a private, non‐emergency ambulance service. Since then, he has provided leadership in revenue cycle management to four ambulance agencies located throughout the Southeast.

Asbel pursued his education the non‐traditional way by attending college online while maintaining a fulltime job. He received an associate’s degree in accounting in 2007 and graduated in November 2010 with a bachelor’s degree in business management.

Asbel is married to Stephenie Haney‐Montes. He has one daughter and resides in Carencro, LA.

Kathy Lester, Esq.
Principal, Lester Health Law

Kathleen Lester provides legal and strategic advice on legislative and regulatory matters involving Medicare and Medicaid coverage and reimbursement, quality measurement (including valuebased purchasing programs), federal health care funding, health information technology, and medical and Internet privacy — including the Health Insurance Portability and Accountability Act (HIPAA) regulations, other federal and state privacy laws.

Ms. Lester practices at the intersection of health care law and public policy. She focuses her practice on finding solutions to her clients’ problems by assisting them with compliance programs and by seeking legislative or regulatory modifications. She has worked with health care providers and suppliers to modernize their payment structures within the Medicare program. She also assists non-profit organizations navigate the complex maze of federal funding and the authorization process for public health programs. She has worked with manufacturers to ensure coverage and appropriate reimbursement. She helps clients identify and resolve issues that arise from creating, collecting, maintaining, using, and disclosing personal health information. She has been deeply involved in measure development, as well as the creation and implementation of value-based purchasing programs in the Medicare program.

Ms. Lester has served a wide variety of health care providers, including physicians, dialysis facilities, hospitals, long-term care providers, home respiratory suppliers, pharmaceutical manufacturers, device companies, and patient organizations. She also has assisted with the formation and growth of industry-wide coalitions. Ms. Lester has experience in all three branches of the federal government.

Ms. Lester served as a privacy consultant in the Office of General Counsel to the U.S. Department of Health and Human Services (HHS), where she finalized the HIPAA Privacy Rule. Ms. Lester also served as law clerk to the Honorable Michael S. Kanne, Circuit Judge, U.S. Court of Appeals for the 7th Circuit and worked for Senator Richard G. Lugar (R-IN). Prior to opening her own firm, Ms. Lester was a partner in the health care group at Patton Boggs LLP.

During her time at Johns Hopkins, Ms. Lester served on a number of research and review boards, including the Human Genome Project’s Ethical, Legal, and Social Issues Working Group. She has an undergraduate degree in biology with an emphasis on microbiology and genetic research.

Ms. Lester received her J.D. from Georgetown University (cum laude), her M.P.H. from The Johns Hopkins School of Hygiene and Public Health, and her B.A. from DePauw University (magna cum laude). She is a member of the District of Columbia, Indiana, and Maryland bars and is admitted to the U.S. Court of Appeals for the 7th Circuit.

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.

CMS Grants State of Florida’s 1135 Waiver Request for Coronavirus Response

On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:

1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.

2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.

3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.

4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.

5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.

Understanding Medicare, Medicaid, and SCHIP Coverage of Ambulance Services under a Declared National State of Emergency

On March 13, 2020, President Donald J. Trump announced a national state of emergency in response to the COVID-19 pandemic. Previously, HHS Secretary Alex Azar had declared a public health emergency under Section 319 of the Public Health Service Act in response to COVID-19.

This has prompted many AAA members to ask what impact, if any, these declarations have on the coverage of ambulance services under federal health care programs?

The short answer is that these declarations give CMS the authority under Section 1135 of the Social Security Act to waive certain Medicare, Medicaid, and SCHIP Program requirements. This waiver authority includes, but is not necessarily limited to:

• Waiving certain conditions of participation and/or certification requirements;
• Waiving certain pre-approval requirements;
• Waiving the requirements that a provider or supplier be licensed in the state in which they are providing services;
• Waiving EMTALA requirements related to medical screening examinations and transfers; and
• Waiving certain limitations on payments for services provided to Medicare Advantage enrollees by out-of-network providers.

One situation where an 1135 waiver may be of use to an ambulance provider or supplier would be where the ambulance provider or supplier is sending vehicles and crews to a state that is outside its normal service area. The ambulance provider or supplier is unlikely to be licensed by the state in which it is responding. As a result, under normal circumstances, it would be ineligible for payment under federal health care program rules. The 1135 waiver would permit it to submit claims for the services it furnishes in the other state.

Of more immediate significance to the current national emergency, an 1135 waiver may permit hospitals and other institutional health care providers to establish an off-site treatment center for initial screenings of patients. For example, hospitals may establish triage sites in parking lots and other open spaces for the initial intake of patients suspected of being infected with the COVID-19 virus. In theory, this waiver could also extend to drive-thru testing sites to the extent they are operated by the hospital or another health care provider. When a hospital has obtained an 1135 waiver to operate an off-site treatment center, the off-site area becomes a part of the hospital for Medicare payment purposes. Therefore, ambulance transports to an approved off-site treatment area should be submitted to Medicare using the “H” modifier for the destination.

AAA Releases 2020 Medicare Rate Calculator

AAA 2020 Medicare Rate Calculator Now Available!

The American Ambulance Association is pleased to announce the release of its 2020 Medicare Rate Calculator tool. The AAA believes this is a valuable tool that can assist members in budgeting for the coming year. This calculator has been updated to account for recent changes in Medicare policies, including the 2020 Ambulance Inflation Factor (0.9%) and the continuation of the current temporary add-ons.

To access the Rate Calculator, please CLICK HERE.

2020 calculator

CMS Posts 2020 Public Use File

On December 2, 2019, CMS posted the 2020 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2020 for the various levels of ambulance service and mileage. These allowables reflect a 0.9% inflation adjustment over the 2018 rates.

The 2020 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. AAA members can access this reformatted fee schedule at the link below.

2020 Ambulance Fee Schedule▶

 

2018 National and State-Specific Medicare Data

The American Ambulance Association is pleased to announce the publication of its 2018 Medicare Payment Data Report. This report is based on the “Early Edition” of the 2018 Part B National Summary Data File (previously known as the Bess Report). The report consists of an overview of total Medicare spending nationwide, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.

For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, with the second limited to dialysis transports. Each chart is further broken down by HCPCS code. The charts provide information on the total number of allows services and the total Medicare payments for CYs 2017 and 2018. Percentage changes will allow members to view payment trends over the past year.

2018 National & State-Specific Medicare Data

Questions? Contact Brian Werfel at bwerfel@aol.com.

 

CMS Open Door Forum & Member Q&A – November 7th

The Centers for Medicare and Medicaid Services has scheduled its next Ambulance Open Door Forum for Thursday, November 7 from 2:00-3:30 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

CMS Ambulance Open Door Forum

November 7 | 2:00 PM ET
Participant Dial-In Number:  1-888-455-1397
Conference ID #: 4676500

Questions?

Have more questions? The AAA is here to help! Following the ODF the AAA will be publishing a follow up blog post going over any updates and important announcements.

AAA Follow Up Q&A

November 7 | 4:00 PM ET
1-800-250-2600
Pin: 82802314#
Speakers: AAA Senior Vice President of Government Affairs, Tristan North; AAA Healthcare Lobbyist, Kathy Lester, Esq.

CMS Announces 2020 Ambulance Inflation Factor

On October 4, 2019, CMS issued Transmittal 4407 (Change Request 11497), which announced the Medicare Ambulance Inflation Factor (AIF) for calendar year 2020.

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 2018, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased 1.6%. CMS further indicated that the CY 2020 MFP will be 0.7%. Accordingly, CMS indicated that the Ambulance Inflation Factor for calendar year 2019 will be 0.9%.