How Medicare telehealth extensions impact provider compliance

Read this if you are interested in grant compliance in healthcare. 

This is a companion article to the podcast, Mitigating the compliance and revenue integrity risk of grant funded healthcare programs.

The BerryDunn Healthcare Practice Group boasts professionals who have expertise all across the spectrum of healthcare, including regulatory, revenue, integrity, general compliance, and risk management issues. This article covers the very specific arena of grant compliance affecting many of BerryDunn’s healthcare, not-for-profit, and government clients.

After starting as a newly minted MBA financial analyst with an academic medical center in Northern New England, I (Markes) worked my way into the world of grants and contracts supported by my interest in federal regulations and the non-clinical revenue streams. Fascinated to navigate through waters where it seemed no one was the expert, or really had the time or patience to figure things out, I worked to stand up a grant office in finance on the hospital side, separate from the medical school which was the usual repository for grant funding. We moved this direction because hospital leadership realized grant funding was tipping toward the clinical setting and was less focused on bench or clinical research. Put another way, less NIH and more CDC, HRSA, and CMS.

BerryDunn Senior Manager Regina Mathieson advises, “wherever there is complexity, there is compliance risk.” Whether from a federal agency like HHS, HRSA, NIH, or CDC, a state Medicaid program, foundation, or private source, grants always come with requirements, typically very specific requirements. Because the dollars are being ‘given’, those requirements for how the funds are used may be much more restrictive than loans.

Like other areas of regulatory compliance, it is reasonable to assume that grant programs often have compliance gaps that go unnoticed. For many of our clients, both in healthcare and not-for-profit, and in the government space, grant revenue has become a significant source of funding. Any kind of healthcare delivery organization, including academic medical centers, federally qualified health centers, community hospitals, behavioral health service organizations, home health providers, visiting nurse associations, and others can end up with significant portions of their income for the year being sourced by federal grants.

Grant compliance categories

We all can’t be experts in every domain of regulatory compliance, and grant compliance has a lot of breadth. Thankfully, at BerryDunn, we have a team of grant experts who work collaboratively across practice groups. When I was working on setting up the grant office and establishing a proprietary clinical FTE reporting process and system earlier in my career, I would have greatly benefited from the perspectives of other experts at the table.

When we think about grant compliance, four categories are helpful to keep in mind:

1. Restricted funding
2. Single audit
3. Indirect rate
4. Time and effort

Restricted funding

Firstly, and most universally understood and applied is that grant monies are, pretty much by definition, restricted. Aside from very specific and rare instances of monies being granted to beneficiaries who have no responsibility, all grant funding is awarded with the expectation that the funds will be expended in a specific way. 

Any funder, from the federal government to your local community organization like the Lions Club or the VFW, will likely require individuals and entities awarded a grant must promise to use the funds only for the purpose laid out in the award and proposal. Compliance with grant terms typically includes following the requested reporting requirements of that funder as well. Though this category may sound obvious, it's actually pretty far-reaching, as it usually affects sub-recipients (those entities who are partnered with the direct recipient to accomplish the grant purpose). For example, where the money goes after the initial awardee receives it, or rules about who can do the work, what type of organization, how you choose a vendor, etc.—all sorts of categories.

It should be noted that many of these grant award requirements are not dissimilar from work we already do in the healthcare compliance space to assist our clients in avoiding anti-kickback statutes and Stark risks. This is because grant compliance is grounded in the same basic concepts—no favoritism, no bribes or shady deals, and avoiding fraud, waste, and abuse. Especially if you're spending federal monies, you need to prove that you choose the vendor based on verifiable best practices, and consideration was afforded to organizations owned by women, veterans, and minorities.

Single audit 

The second category, Single Audit, is applicable to all federal funding of $750,000 or more annually. My colleague from BerryDunn’s Not-for-Profit practice group, Katie Balukas, explains: 

"The federal Single Audit Act is a requirement for entities to undergo an independent financial and compliance audit when the entity has expended over $750,000 in federal awards. These audits are conducted following guidance issued through the Governmental Auditing Standards and the United States Office of Management and Budgets' Uniform Guidance. The main focus of the compliance audit is to assess the entity's compliance with the requirements set forth by the federal agency that administered the grant funds. That includes, but is not limited to determining if the funds were utilized for allowable costs and activities and expanded within the proper grant period and that the reporting and performance objectives were met."

It is important to note that adequate, appropriately scaled internal resources are essential for any organization receiving grants and even more so with larger grants. Though the phrase has been overused, it really does “take a village”. Grant management isn't something an organization should do on the side, assigning grant accounting to someone who already has a full-time role, but unfortunately this is common and also unfortunate because under resourcing tends to lead to compliance concerns, as well as just plain old poor funding management. 

Indirect rate

Speaking of funding, the third type of grant compliance is very focused on a component of the grant world that really has a life of its own: The indirect rate. Though there is an accounting definition of ‘indirect’, the way it is defined regarding grant funding is pretty specific, and there is an entire body of work organizations undertake to get a federally approved indirect rate.

There's an awful lot to think about with the indirect rate. On the one hand, you could say it's pretty simple. For example, a lot of foundation funders and even some federal funders will offer you a 5% or 10% indirect rate without any need to make a calculation. That's because they know that if you take time to do the math, you'll come up with a number much higher than 5% or 10%. When it comes to federal grants and healthcare services organizations, the indirect rate is dependent on how an organization measures costs. For hospitals, of course, the method of measurement is driven by the Medicare cost report, and that's where we would do the fancy math to derive the indirect rate. But the reality is far from simple or straightforward. 

Time and effort

The fourth and final area of grant compliance, time and effort, is also the one I'm actually most passionate about and is probably the most minimized, or at the very least, misapplied. 

In one way, “time & effort” is exactly what it sounds like. Much of granted dollars, especially from the federal government, get appropriately spent on program staff. The challenge is to match time and effort to those dollars, but that isn't as clear as it sounds, because the standard way of measuring staff time is usually in a payroll system of some sort, which can't prove how time was spent.

Most payroll systems can be programmed to account for FTE (full-time equivalent) allocations; however, there is often a breakdown between theory and practice. Putting allocations into payroll, usually done without employee interaction, may show how an employee “should” spend their time, but it is really no guarantee that that's actually how they're spending their time.

So how does the organization typically go about assuring that? Now, I don't want to speak for everyone, but let's just say I happen to know that there's a place for two or three (or maybe 10,000) that basically put allocations into payroll, and then, unfortunately, often well after the fact and/or more than once, send that allocation to the employee to sign off on without really any option to disagree, or even to modify. We all know that is not compliant…but in the organization's defense, there really haven't been very good alternatives to that kind of woeful and frustrating process, at least none that have been widely shared or understood.

As often is the case in the compliance world, rules are not followed because there is no perceived risk, but that is not a winning strategy.

Though many people involved in grant management do not have any experience or even knowledge of time and effort violations meeting with any consequences, organization interest and grant compliance have more implications than just preventing front page news. What I find in the conversations with organizations, both large and small, is that loose time and effort management costs the organization in two major ways. 

Firstly, it is inefficient to scramble around at the close of each federal grant to fix time and effort allocations. The extra time spent by grant staff, project coordinators, managers, and the finance team to sort things out because they didn't get them right the first time is the worst kind of inefficient—poor use of time with an equally poor outcome. 

Secondly, loose time and effort is costly in direct salary dollars. Most grant staff are not dedicated to one project, so we need to consider the value of their other work. Whether that is on other grants or, for example, seeing patients in the clinic as many principal investigators in healthcare do, having inaccurate or fluctuating understandings of their ability costs the organization directly in wasted salary dollars or indirectly as the opportunity cost of those providers (or other roles in other organizations). 

Digging in and fixing these issues is the work I really enjoy. It's relatively simple to build a compliant model, whether that requires very little payroll redo and is just a simple recurring attestation process in built in Excel, or more complex integrated models with triggered attestations in PDF format in a database that manages the overall FTE of principal investigators. It might even drive the available clinical provider time. It can all be done. We just need to know what the goal is. 

Working in this space so rewarding, because like so much of compliance, it's about doing something better—not just being compliant—but setting organizations up to better meet their goals and fulfill their mission.

The compliance or accounting professional might still ask, “But why aren’t payroll allocations sufficient for meeting Uniform Guidance?” The truth is, when UG came into effect and superseded the A-110, 122, 133, and others, the bar was effectively lowered. Historically, organizations abiding by the old OMB circulars had to make an attestation at least twice a year, which doesn’t really seem helpful, as who can accurately allocate their time from 5 or 6 months ago? So UG did away with the timeframe reference, relying on the idea that the payroll allocations and distributions would be all that would be needed, and in the absence of those, a monthly ‘look back’ by professional staff would be in order.

I say all this, because as a result, the interpretation of ‘payroll allocations’ then becomes the standard and we have forgotten about the other elements spoken of in the regulation. Remember, for anyone salaried (the vast majority of physicians and most of the higher level grant personnel), the ‘payroll allocation’ doesn’t pass muster. It is a static allocation that has no mooring in actual activity. This is why UG calls for monthly “current and reasonable estimates” of time and effort.

So what can organizations do in response? They need to seek a solution, a process, and a method that will both pass audit muster, as well as help the organization properly manage their resources. Almost every organization manages their productivity and finances on a regular basis: monthly! That’s why the same standard should apply to grant time and effort management. It's much more reasonable to ask you how you spent your effort this month, asking you to make a reasonable estimate of your time allocations to the different efforts you worked on.

So to summarize, the four key areas of grant compliance are (1) grants are restricted funding, (2) single audit requirement for federal funding over $750,000 annually, (3) the indirect rate and related agreement, and (4) time and effort.

Of course, I would be remiss to not point out that undergirding all this is the organization’s approach to policy. Any organization that considers grant funding a regular piece of their annual income needs to have dedicated grant management policies, covering all of the above topics, with particular focus on those arenas that are unique to the world of federal funding, and being mindful to follow or otherwise update for changes in processes and/or regulations.

Final takeaways: 

• First, what grant focused infrastructure do you have in place? If you are subject to a single audit, there should be dedicated administrative grant staff. And I don’t mean the programmatic people actually working on the grant, but people outside the grant funding—also why you have an indirect rate. 
• Second, how are you handling time and effort? If the process relies on any long after-the-fact attestations or payroll-generated reporting, it is unlikely to be truly following the spirit…or the letter…of Uniform Guidance. 
• Third, review your policies regarding grants. You may not actually have policies focused on grant activities, leaving them under ‘general finance’. That isn’t sufficient to cover federal funding requirements. Many have grant policies in place, but are they actually being followed through the lifecycle of your grant programs? 
• Lastly, the grant world is a whole ball game unto itself. BerryDunn has some great resources internally to offer assistance in all phases of grant management and administration. 

Read this if you are at a public health agency.

As public health workforce challenges worsen through retirements, burnout, and added need for public health workers highlighted by the COVID-19 pandemic, funding levels for public health remain increased for the time being. This provides opportunities for states to leverage federal programs and funding streams to help ensure a strong and capable public health workforce to meet the needs of all communities. An important consideration for states is the level of cultural competence among their public health workforce.

Cultural competence: Definition and benefits

Cultural competence refers to the capacity to function effectively, both as an individual and an organization, in relation to community members’ cultural beliefs, behaviors, and needs. It allows public health professionals to provide more effective public health services to individuals and communities with cultures different from their own—through awareness, respect, and willingness to learn about cultural differences. The necessity of cultural competence in public health is especially timely due to new and existing disparities that have been highlighted by COVID-19 outcomes and the ripple effects of the pandemic.

Benefits of a culturally competent public health workforce include greater public trust in the public health system, more equitable and effective public health services, improved understanding of existing barriers and community health status, and the potential to reduce disparities and improve both healthcare access and health outcomes in historically marginalized communities.

As many states face significant workforce gaps and challenges in recruiting, training, and retaining staff, it is important to leverage best practices and key indicators of success to inform a sustainable and effective approach for workforce development. States may benefit from assessing gaps in cultural competence and related skills, and by identifying specific cultural competency areas and abilities they aim to achieve in the workforce. A strategic approach is necessary for maximizing the sustainability and long-term benefit of federal funding opportunities, such as those for public health workforce development in rural areas. 

Strategies and best practices for developing a culturally competent public health workforce 

There are many steps you can take toward building cultural competence in your agency. Some of them include:

• Develop and implement a periodic assessment of workforce cultural competence, and training to measure improvement and incorporate up-to-date best practices
• Recruit diverse staff to reflect the culture and demographics of communities, including the provision of linguistic support
• Create and improve pipeline training programs by collaborating with local colleges, universities, and schools of public health and identifying existing gaps in the workforce and in public health educational opportunities 
• Support inter-professional education and teams for community-based interventions, to foster collaboration between public health and healthcare professionals in the community to better meet needs 

Important first steps to improve and foster cultural competence in the public health workforce include setting goals related to building community partnerships and what those partnerships will achieve. 

Other steps for building cultural competence 

Additionally, collecting diversity data and demographic characteristics of the public health workforce, measuring and evaluating performance of the public health workforce and public health services, and reflecting community diversity within the workforce are necessary for developing a workforce that supports community cohesion and trust of community members. These steps can help you assess where you can strengthen services and how communities can be better reflected in the public health services they receive. Effective communication and language access are also critical steps to improve and foster cultural competence in the public health workforce.

BerryDunn can provide state public health and human services agencies with strategic policy and programmatic guidance and management support to maximize the benefits of federal programs to facilitate public health workforce development. 

If you have any questions about your specific situation, or would like more information, please contact our Public Health Consulting team. We’re here to help.

Read this is if you are at a healthcare organization and considering telehealth options. 

Given the COVID-19 emergency declaration, telehealth service regulations have been greatly modified to provide flexibility and payment. The guidance on telehealth is very dispersed and can be difficult to navigate. Here are some FAQs based on the many questions we have received. If you have questions related to your specific situation, please contact us. We're here to help.

UPDATED: Are RHCs and FQHCs now eligible as distant site providers for telehealth services? If so, how will they be paid by Medicare?
Yes, the CARES Act includes RHCs and FQHCs as distant sites during the COVID-19 Public Health Emergency (PHE). Distant site telehealth services can be provided by any health care practitioner of the RHC or FQHC within their scope of practice. The practitioners can provide any distant site telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS) and from any location, including from the practitioner’s home. CMS has approved an interim payment rate of $92 for RHCs and FQHCs for these services. The rate is based on the average payment for all PFS telehealth services, weighted by the volume of those services paid under the PFS. This rate will apply for services furnished between January 27, 2020 and June 30, 2020. Modifier “95” must be included on the claim. In July 2020, these claims will be automatically reprocessed and be paid at the RHC all-inclusive rate (AIR) and the FQHC prospective payment system (PPS) rate. Reprocessing will begin when the Medicare claims processing system is updated for the new payment rate.

For telehealth distant site services furnished between July 1, 2020 and the end of the COVID-19 PHE, RHCs and FQHCs will need to use RHC/FQHC specific G code, G2025, for services provided via telehealth. These claims will be paid at the $92 rate, not the AIR or PPS rates. If the COVID-19 PHE continues beyond December 31, 2020, the $92 will be updated based on the 2021 PFS average payment rate for these services, again weighted by the volume of those services.

For services in which the coinsurance is waived, RHCs and FQHCs must put the “CS” modifier on the service line. RHC and FQHC claims with the “CS” modifier will be paid with the coinsurance applied, and the Medicare Administrative Contractor (MAC) will automatically reprocess these claims beginning on July 1. Coinsurance should not be collected from beneficiaries if the coinsurance is waived.

UPDATED: Will telehealth visits of any kind affect my FQHC or RHC encounter rate?
Costs associated with telehealth will not affect the prospective payment system rate for FQHCs or the all-inclusive rate calculation for RHCs, but the costs will need to be reported on the cost report. Costs of originating and distant site telehealth services will be reported as follows:

• Form CMS-222-17 on line 79 (Cost Other Than RHC Services) of Worksheet A for RHCs
• Form CMS-224-14 on line 66 (Other FQHC Services) of Worksheet A for FQHCs.

What is telehealth versus telemedicine?
Telemedicine refers to a remote clinical service while telehealth is a broader term that embodies a consumer-based approach to medical care, incorporating both delivery of care and education of patients.

UPDATED: What types of service levels are available?
There are three main types of Medicare virtual services with different payment levels. Here are the key things to know for each type:

Telehealth visits

1. These are considered the same as in-person visits and paid at the same PFS rates as regular, in-person visits.
2. Pre-existing patient relationship requirements have been waived.
3. The patient originating site can be any healthcare facility or the patient’s home.

Virtual check-ins

1. These are brief communications in a variety of technology-based manners.
2. They do require the patient to initiate and consent to the check-in.
3. It cannot be preceded by a medical visit within the previous 7 days and cannot lead to a medical visit within the next 24 hours. 
4. A pre-existing relationship with the patient is required.
5. Common billing codes include HCPCS code G2012 (telephone) and G2010 (captured video or images).

E-visits:

1. These also need to be initiated by the patient in order to be billable and would be conducted using online patient portals (no face-to-face), for example.
2. A pre-existing relationship with the patient is required.
3. Common billing codes include CPT codes 99421-99423 and HCPCS codes G2061-G2063. 

The payment rate for these services will be $24.76 beginning March 1, 2020, through the end of the PHE, instead of the CY 2020 rate of $13.53, and should be billed using code G0071. MACs will automatically reprocess any claims with G00771 furnished on or after March 1, 2020, that were not paid at the new rate.

What codes can be billed as telehealth services?
Here is the listing effective as of March 1, 2020. 

Since this time, 85 additional codes have been added. Click here for the list. 

Do we need to request an 1135 waiver or are these changes covered by a blanket waiver from CMS?
A blanket waiver is in effect, retroactive to March 1, 2020 though the end of the emergency declaration. 

Is patient consent required?
Yes, patients must verbally consent to services. This includes brief telecommunications (which currently have a cost share for Medicare). We recommend it for all payers as a best practice.

Is there additional information expected from Medicare?
Yes, Medicare, Medicaid, and other payers are continually updating their guidance. 

What can we bill for telehealth services for Medicaid and insurance carriers?
This is the most problematic to track as it is continually evolving and every state and carrier is different. Providers must understand each payor’s requirements around audio and video, allowable CPT/HCPCS codes, modifiers, and place of service codes. As you have questions, please reach out to us so we can be sure to provide the most current answer.

Resources
Given how quickly information related to telehealth is changing, please feel free to contact us for the latest resources. 

Read this if you are an administrator, manager, or director at a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).

CMS just released an article outlining new and expanded flexibilities for RHCs and FQHCs during the COVID-19 public health emergency (PHE). The article includes the following information:

• Payment rate for telehealth services
• How to bill for telehealth services
• Expanded virtual communications services

Payment for telehealth health services during the PHE (from January 27, 2020 through the end of the PHE) is $92. Billing for telehealth is segmented into two periods:

1. January 27, 2020 – June 30, 2020, bill using the 95 modifier
2. July 1, 2020 – end of PHE, bill using code G2025

The article further outlines that for telehealth services billed through June 30, they will be paid at the PPS rate. The claims will then be automatically reprocessed in July and a recoupment will occur for the difference between the $92 and your PPS rate. 

It will be important for you to keep track of the telehealth visits paid at your PPS rate and what the recoupment by Medicare will be so that when it occurs you will not be caught unawares.

Virtual communication services have been expanded to include digital evaluation and management services. Online digital evaluation and management services are non-face-to-face, patient initiated, digital communications using a secure patient portal. 

Additionally, the payment rate for these services will be $24.76 beginning March 1, 2020 through the end of the PHE instead of the CY 2020 rate of $13.53, and should bill using code G0071. 

Consider how the medical records component of your system interfaces with the billing component to ensure you capture these services for billing.

The full article can be accessed here: MLN Matters Special Edition Article 20016.
 

Read this if you are considering adding telehealth services, or enhancing your your current telehealth services.

Consumer and provider’s perceptions and adoption of telehealth in the US have been mixed at best. The current COVID-19 pandemic has necessitated and supported broader use of non-face-to-face provider interactions. Payor changes will likely continue post-pandemic, and the communities we serve may expect more virtual care options.    

The regulatory changes necessitated by the pandemic provide new flexibility and options to serve our patients remotely and generate revenue. Leveraging this opportunity demands:

• understanding each payor’s requirements, 
• educating providers, 
• creating revenue cycle processes, and
• ensuring compliance with payor requirements. 

Providers need to understand the “flavors” of non-face-to-face visits, the payor requirements, and the significant payment differences. Simple documentation, modifier, and/or claim form omissions can mean the difference between being paid for a face-to-face office visit versus a non-chargeable service. The effort in getting it right today will have immediate benefits that should extend into post-pandemic operations.

The first step is researching and documenting each payor’s requirements. The rules and regulations are not the same for RHCs, FQHCs, Method II billing, and the different provider types such as physical therapists and MDs. Providers need to understand documentation, CPT/HCPC, modifier, place-of-service, video requirements versus audio only, and other nuances. Simplification of each payor’s rules into an easy-to-digest grid creates an invaluable tool for everyone involved. Below is an example of a payor grid:

Other questions on payor requirements that may prove worth tracking:

• Will cost shares be waived?
• Is payor reimbursing at face-to-face rates?
• Are telehealth services limited to established patients?
• Are requirements around follow-up appointments bundled or not?
• For organizations with multiple provider types, what claim type is required?

Every member of the revenue cycle must be involved to optimize telehealth services. Do not overlook the importance of registration, IT/system configuration (from a documentation and billing perspective), and physician education. Providers should consider simple flow charts to assist in operationalizing the rules by payor. For example (click to expand):   

The government relaxed HIPAA rules allowing providers many more options for telehealth technology (such as using Web-Ex, Skype, Zoom, and other readily available services). These options are of no value if not available and/or adopted by providers and patients. In terms of payment, the lack of a video component is often the difference between billing and being paid at the face-to-face in office rate versus a non-chargeable or minimal payment service. Some payors are allowing and paying audio-only visits at the office rate, which further highlights the need to understand the rules.  

Here is an example from Medicare showing the potential payment difference between an audio-only and video-enabled service:

In this example, the physician time is about 15 minutes with the patient. However, if video were used the payment would be 177 percent more. When you account for the number of physicians in your organization that are providing these visits every day times the payment difference, the delta is substantial. The payment difference is even more significant for other codes and payor rates (and further exacerbated by payers that do not pay for audio-only visits).

There are significant payment difference between the different codes that can be billed for telehealth visits by payor. These are difficult financial times for providers and every dollar counts. BerryDunn is available to help if you have questions around rules, regulations, and/or best practice processes around billing for these services. You can e-mail Denny Roberge or call 603.518.2623 with any questions or for assistance optimizing your telehealth program.

Read this if you are an IT Leader, CMO, CNO, CFO, or COO in a healthcare setting that may be looking at offering telehealth services.

Adopting telehealth technology is happening rapidly in response to social distancing and the strain that COVID-19 is putting on health systems. In response to this strain and with focus on "flattening the curve" by improving access amid a torrent of temporarily closed provider offices, some state and federal restrictions on telehealth have been lifted with the passage of the CARES Act.  

So, now, the question is not if your organization should implement telehealth services but how do you do it rapidly, effectively, holistically, and with an eye on wide-spread adoption?  

Telehealth is a bit more complex than other services, because it requires a patient to be able to use technology and follow through on provider advice―without physical discussion and interaction. Taking the time with your clinicians to increase their comfort using the technology can help put your patients at ease during this uncertain time while maintaining the clinician-patient relationship. Here are things to consider to become effective with telehealth programs:

1. Identify purpose and goals. Do you want to expand access, support more patients, improve outcomes, support social distancing, or have further geographic reach? All of the above? 
2. Choose an approach. Use existing technology within your EHR or use a third party solution.
3. Test the solution. Check connectivity, devices (iPhone vs Android), and patient skill level.
4. Camera placement is important. Making sure the patient can see the provider will be important for patients.
5. Practice with a colleague and an open mind. Develop confidence and help foster patient trust. 
6. Be adaptable to this being different. As this is new for all parties, showing patience and maintaining calm goes a long way to help ease patient worry.
7. Consider and plan for the patient’s technical ability, or lack thereof. Be prepared to help troubleshoot minor technical barriers or utilize alternative processes without hampering the clinical encounter. 
8. Look directly into the camera. Helps establish and maintain the patient-provider relationship. 
9. Document in real time. Complete good notes, as the volume of telehealth visits and lack of physical proximity to the patient will make it more challenging to remember details later. 
10. Develop “how to” content for your staff. This will help front line staff explain what the patient should expect before the visit and will outline clear follow up procedures, should there be any technical issues.

Once you have the more technical pieces planned, the keys to success will be testing technology and workflow and embracing the change. As we know, it doesn’t take much for a vulnerable patient to lose ground. Now is the time to expand your reach, lower costs, improve outcomes, improve relationships, show adaptability, sustain progress, and send healthcare directly into the home.

We are here to help
If you have any questions about your specific needs, please contact the healthcare consulting team.

Read this if you are a leader at a state Medicaid agency.

Here is a summary of information we have gleaned from the Center for Medicare and Medicaid Services (CMS) Administrator Verma’s recent call.

CMS is implementing new rules and waivers that increase provider flexibility and free up resources to deal with a surge in COVID-19 patients. CMS is working with the provider community to provide clarity around specific changes that impact their operations.

• The rulemaking process has been dramatically expedited to accommodate recent and forthcoming regulatory changes
• CMS is in the process of working out details to administer CARES Act provisions, including further regulatory flexibilities, expansion of accelerated payment program, and $100 billion appropriated to reimburse eligible health care providers
• CMS clarifies that the 3-Day Rule Waiver for skilled nursing facilities applies throughout the country and to all patients, regardless of their COVID-19 status

Medicaid Substance Use Disorder Treatment via Telehealth, and Rural Health Care and Medicaid Telehealth Flexibilities Guidance

This informational bulletin is composed of two parts: Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder Treatment via Telehealth.

• The informational bulletin identifies opportunities for telehealth delivery for services to increase access to Medicaid services. It is composed of two parts, Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder (SUD) Treatment Services Furnished via Telehealth
• The bulletin provides SUD guidance around Medication Assisted Treatment (MAT), counseling, high risk populations, and other areas critical to providing SUD services.

Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

CMS is issuing an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities.

• The toolkit includes electronic links to sources of information regarding telehealth and telemedicine, including the changes made by CMS over the last week in response to the national health emergency.
• Much of the toolkit’s information is intended for providers who may wish to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well.
• There are specific documents identified that may be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. 

CMS makes regulatory changes to help US healthcare system address COVID-19 patient surge

CMS has issued a number of temporary regulatory waivers and new rules to assist the nation’s healthcare system with improved flexibility.

• Increased hospital capacity. CMS will allow communities to take advantage of local ambulatory surgery centers that have canceled elective surgeries, per federal recommendations.
• Healthcare workforce expansion. CMS’s temporary requirements allow hospitals and healthcare systems to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules.
• Paperwork requirements. CMS is temporarily eliminating paperwork requirements.
• Telehealth in Medicare. CMS will now allow for more than 80 additional services to be furnished via telehealth.

Additional COVID-19 FAQs for state Medicaid and Children's Health Insurance Program (CHIP) agencies

CMS released an update to the COVID-19 FAQs posted on March 18, 2020 related to emergency preparedness and response, eligibility and enrollment flexibilities, benefit flexibilities, cost sharing flexibilities, financial flexibilities, managed care flexibilities, fair hearing flexibilities, health information exchange flexibilities, and COVID-19 T-MSIS coding guidance. Notably:

• States that have CHIP disaster provisions in their state plans can activate these provisions. CMS considers a significant outbreak of an infectious disease to be a disaster. CMS also recommends that states that do not have disaster relief provisions in their CHIP state plans include language that a federal- or governor-declared emergency is considered an event that can trigger the disaster provisions.

States may not suspend use of their AVS, however CMS reminds states that they can rely on self-attestation of assets and verify financial assets using their AVS post-enrollment in Medicaid.

• CMS can help provide technical assistance regarding approaches states can use to rapidly scale telehealth technologies.
• CMS clarified and provided COVID-19 T-MSIS coding guidance.

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Read this if you are a director, manager, or administrator at a Federally Qualified Health Centers (FQHC) or Rural Health Clinic (RHC).

The latest COVID-19 bill, the Coronavirus Aid, Relief, and Economic Security (CARES) Act included enhancing Medicare telehealth services for FQHCs and RHCs. This legislation waives the Section 1834(m) restriction on FQHCs and RHCs that prohibits them from serving as distant sites. This means during the COVID-19 State of Emergency, FQHCs and RHCs will be able to serve as distant sites to provide telehealth services to patients in their homes and other eligible locations. The legislation will reimburse FQHCs and RHCs at a rate that is similar to payment for comparable telehealth services under the physician fee schedule (Medicare Part B). FQHCs and RHCs will not be paid the Medicare PPS rate for these services.

Currently, Medicare, unlike many Medicaid programs and commercial payers, still requires the video component for telehealth. Effective immediately, the Office for Civil Rights at the Department of Health and Human Services will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 State of Emergency. Providers who want to use audio or video communication technology to provide telehealth during the COVID-19 State of Emergency can use any non-public facing remote communication product that is available to communicate with patients. Examples of acceptable platforms (non-public facing) include Apple FaceTime, Google G Suite Hangouts Meet, and Skype for Business.

We would also like to remind you of the ability to bill for virtual communication services. Virtual communication services are a brief, non-face-to-face check-in with a patient via communication technology, to assess whether the patient's condition necessitates an office visit. The call must be initiated by the patient and to be billable, the call must be between the patient and a physician, nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, or clinical social worker. If the discussion is conducted by a nurse, health educator, or other clinical personnel, it is not billable as a virtual communication service. There is no video component required for virtual communication services. The check-in cannot relate to a visit with the patient during the previous seven days or result in a visit with the patient within the next 24 hours (or next available appointment). Read the FAQs from Medicare on the virtual communication services.

We continue to be here to support you. If you have any questions or concerns, please do not hesitate to reach out to any of us. 

Here is a summary of information we have gleaned from recent CMS updates and guidance. 

COVID-19 stakeholder call - March 16 

CMS held a National Stakeholder Call on March 16, 2020 to update the healthcare community on the rapidly evolving COVID-19 situation, which was declared a national emergency by President Trump on March 13, 2020.

Key takeaways:

• Administrator Verma reaffirmed the goal of reducing administrative barriers in the way of healthcare workers and agencies and to support them as best CMS is able.
• Acknowledging that there were questions on testing, Administrator Verma outlined that there will be a ramp-up in testing in conjunction with state and local governments. 
• CMS is relaxing clinician enrollment requirements for Medicare and making the same option available to states in their Medicaid programs.
• The administration has been clear that it wants agencies to focus on infection control efforts. CMS is designing a streamlined template to evaluate infection control.
• CMS sends guidance to Programs of All-Inclusive Care for the Elderly (PACE) Organizations.

On March 17, 2020, CMS issued guidance to all Programs of All-Inclusive Care for the Elderly (PACE) Organizations (POs) on accepted policies and standard procedures with respect to infection control.

Key takeaways:

• POs will need to create, apply, and sustain a documented infection control plan that involves procedures to recognize, examine, regulate, and avert infections in PACE centers
• POs will need to work to prevent infections within each participant’s place of residence, as well as implement procedures to record and develop corrective actions related to incidents of infection.
• CMS provides guidance that recognizes POs may need to undertake strategies that do not traditionally comply with CMS PACE program requirements in order to provide benefits while guarding from COVID-19. Some examples of this may include telehealth services.
• President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak.

CMS is expanding Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

• Under the new 1135 waiver, Medicare can pay for office, hospital, and other visits provided via telehealth across the country and including in patient’s place of residence starting March 6, 2020. 
• Medicare telehealth visits: These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
• Virtual check-ins: Virtual check-in services can only be reported when the billing practice has an established relationship with the member.  
• E-visits: Such services can only be reported when the billing practice has an established relationship with the patient.  

CMS coronavirus partner virtual toolkit

CMS has released a virtual toolkit to help stakeholders stay up-to-date on CMS materials available on COVID-19. Here is specific guidance from the toolkit designed for states and health plans:

• Medicaid.gov 
• Medicaid and CHIP Disaster Response Toolkit 
• Medicaid Telehealth

CMS approves first state request for 1135 Medicaid waiver in Florida and Washington

The 1135 waiver allows Florida and Washington to modify certain Medicaid program requirements, policies, operational procedures, and deadlines applicable to each state’s administration of its Medicaid program during the period of the national state of emergency to prevent further transmission of COVID-19. 

Key takeaways from Florida’s waiver

• Provider participation flexibilities for Medicaid and CHIP Waiver of Service Prior Authorization (PA) Requirements for fee-for-service delivery systems
• Waiver for Pre-Admission Screening and Annual Resident Review (PASRR) Level II Level II Assessments for 30 Days
• Waiver to allow evacuating facilities to provide services in alternative settings, such as a temporary shelter when a provider’s facility is inaccessible
• Waiver to temporarily delay scheduling for state fair hearing requests and appeal deadlines (NOTE: CMS was unable to waive all of Florida’s requested authorities in this area)

If you have questions or would like more information, we are here to help. Please contact us.