How to build a strong healthcare coding compliance audit plan

Read this if you are a CFO, CEO, COO, or CLO at a financial institution.

The preparation of financial statements by financial institutions involves a number of accounting estimates, some of which can be quite complex. As these estimates are often a significant focus of audits of those financial statements, financial institution personnel affected by the audit process might benefit from a discussion of the rules auditors need to follow when auditing estimates.

Accounting estimates

Across all industries, there are financial statement items that require a degree of estimation because they cannot be measured precisely. These amounts, called accounting estimates, are determined using a wide array of information available to management. In using such information to arrive at the estimates, a degree of estimation uncertainty exists, which has a direct effect on the risks of material misstatement of the resulting accounting estimates. For financial institutions, common examples of accounting estimates include the allowance for loan losses, valuation of investment securities, allocation of the purchase price in a bank or branch acquisition, and depreciation and amortization of premises and equipment, in addition to intangibles and goodwill. 

For entities other than public companies, the auditing rules are established by the American Institute of Certified Public Accountants’ Auditing Standards Board (ASB). Under these requirements a financial statement auditor has a responsibility to assess the risks of material misstatement for accounting estimates by obtaining an understanding of the following items: 

• The requirements of generally accepted accounting principles (GAAP) relevant to accounting estimates, including related disclosures. 
• How management identifies those transactions, events, and conditions that may give rise to the need for accounting estimates to be recognized or disclosed in the financial statements. In obtaining this understanding, the auditor should make inquiries of management about changes in circumstances that may give rise to new, or the need to revise existing, accounting estimates. 
• How management makes the accounting estimates and the data on which they are based. 

This final item—determining how management has calculated the accounting estimate in question—includes the following specific aspects for the auditor to address:

• the method(s), including, when applicable, the model, used in making the accounting estimate; 
• relevant controls; 
• whether management has used a specialist; 
• the assumptions underlying the accounting estimates; 
• whether there has been or ought to have been a change from the prior period in the method(s) or assumption(s) for making the accounting estimates, and if so, why; and 
• if so, how management has assessed the effects of estimation uncertainty. 

Professional skepticism

When analyzing management’s assessment of the effects of estimation uncertainty, the auditor needs to apply professional skepticism to the accounting estimate by considering whether management considered alternative assumptions, and, if a range of assumptions was reasonable, how they determined the amount chosen was the most appropriate. If estimation uncertainty is determined to be high, this is one indicator to the auditor that estimation uncertainty may pose a significant risk of material misstatement. An identified significant risk requires the auditor to perform a test of controls and/or details during the audit; in other words, analytical procedures and testing performed in previous audits will not suffice. 

CECL considerations

For audits of financial institutions, including those that have implemented the FASB CECL standard as well as those still using the incurred loss method, the allowance for loan losses will likely be deemed a significant risk due to its materiality, estimation uncertainty, complexity, and sensitivity from a user’s perspective.   

Additional factors the auditor needs to consider include whether management performed a sensitivity analysis as part of its consideration of estimation uncertainty as described above, and whether management performed a lookback analysis to evaluate the previous process used. Auditors of accounting estimates are required to do at least a high-level lookback analysis to gain an understanding of any differences between previous estimates and actual results, and to assess the reliability of management’s process. 

Auditing estimate procedures

Procedures for auditing estimates include an evaluation of subsequent events, tests of management’s methodology, tests of controls, and, in some instances, preparation of an independent estimate by the auditor. Tests of management’s method and tests of controls, including auditing the design and implementation of controls, are the most practical and likely procedures to apply to audits of the allowance for loan losses at financial institutions, both under the current guidance and following adoption of the current expected credit loss (CECL) method under Financial Accounting Standards Board (FASB) Accounting Standards Update No. 2016-13, Financial Instruments – Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments. As FASB has not prescribed a specific model, auditors must be prepared to tailor their procedures to address the facts and circumstances in place at each respective financial institution. 

In addition to auditing management’s estimate, auditors have the responsibility to audit related disclosures, including information about management’s methods and the model used, assumptions used in developing the estimate, and any other disclosures required by GAAP or necessary for a fair presentation of the financial statements. Throughout the audit process, auditors need to continue to exercise professional skepticism to consider what could have gone wrong during management’s process and to assess indicators of management bias, if any. 

For public companies, the Public Company Accounting Oversight Board (PCAOB) specifies auditors must evaluate both evidence that corroborates and evidence that contradicts management’s financial statement assertions in order to avoid confirmation bias. When considering the assessment of risks, as risk increases, the level of evidence obtained by the auditor should increase. As with audits of private companies, the auditor needs to consider whether the data is accurate, complete, and sufficiently precise and detailed to be used as audit evidence.

An added consideration under PCAOB rules is that the auditor is typically opining on the institution’s internal controls as well as its financial statements. This may restrict the results of control testing performed by parties independent of the function being tested from being used as audit evidence from a financial statement audit perspective. For financial institutions, this is often the case with independent loan review, since the loan review is considered part of the institution’s internal control upon which the auditor is opining. 

Supporting evidence

As with the incurred loss method, PCAOB auditing standards will require the auditor consider how much evidence is necessary to support the allowance for loan losses under CECL. All significant components of management’s allowance for loan losses estimate, including qualitative factors, will need to be supported by institution-specific data. If such data is unavailable (for example, because the institution introduces a new type of loan offering), the FASB standard indicates appropriate peer data may be acceptable. In such cases, management and the auditor may need to understand the controls in place at the vendor providing the peer data to determine its reliability. You may provide this information in the form of System and Organization Controls (commonly know as SOC1) reports of the vendor’s system.  

Recently, the International Auditing and Assurance Standards Board revised its auditing rules for estimates, with a goal of enhancing guidance regarding application of the basic audit risk model in the context of auditing estimates. The revised rules require that auditors must separately assess inherent and control risk when obtaining an understanding of controls, identifying and assessing risks, and designing and performing further audit procedures. The ASB seeks convergence of rules both internationally and domestically, and has therefore proposed changes to its requirements for auditing estimates to align with the IAASB revised rules. The ASB’s proposal on these changes indicated they would be effective beginning with audits of fiscal year ending December 31, 2022; the final effective date will be determined in conjunction with its issuance of the final rules.

The best CECL approach 

The best approach to take? Management should discuss planned changes to estimate the process with your auditors to get their perspective on best practices under CECL. Key areas to review in the discussion include documenting the decision-making process, key players involved, and the resulting review and approval process (especially for changes to methods or assumptions). Always retain copies of your final documentation for auditor review. If you would like more information, or have a specific question about your situation, please contact the team. We’re here to help. 

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

Leveraging Medicaid to support and fund state efforts
In infectious disease control and prevention, contact tracing is the process of identifying people who may have come into contact with an infected person and tracking with whom the infected person has been in contact. The intent is to halt the chain of transmission. State Medicaid Agencies (SMAs) may be able to leverage the Medicaid program to support state efforts with systems, training, and reimbursement for contact tracing. 

What is contact tracing?
Tracing the contacts of infected individuals throughout a community, testing their contacts for infection, and treating and quarantining the disease when it is found is a long-standing practice to address infectious diseases. While contact tracing may not be a service that is reimbursable by Medicaid, it may be possible for Medicaid to cover a broader package of services designed to slow the spread of COVID-19.

Contact tracing has three major components:

1. Contact identification—Confirmation of an individual’s infection is the first step. Once identified, it is essential to identify any additional people with whom that person came into contact, including family, co-workers, community members, etc.
2. Contact tracing—After conducting a complete review of the individual's contacts, outreach begins to inform them of their contact status and discuss critical next steps, starting with testing.
3. Contact follow-up—Continued follow-up with identified contacts helps prevent the spread of infection by monitoring spread and/or additional symptoms.

Public health experts maintain that contact tracing is one of the tools needed to manage the pandemic. Medicaid can play a key role in supporting systems, training, and reimbursement for contact tracing. This is enabled through Medicaid’s unique role as a significant payer in the healthcare system, along with its role as a government partnership between federal and state governments. In addition, acting to implement contact tracing may offer an opportunity to increase employment at a time when the economy has shed countless jobs. 

Systems and training: Medicaid support for health IT system
To support contact tracing, Medicaid agencies can leverage 75% or 90% federal match or Federal Financial Participation (FFP) for the systems, training, and equipment. This match is applicable for the Medicaid population, while the remainder likely needs to be cost-allocated to other state programs. Activities that can qualify include:

• Design, development, and installation (DDI) of Medicaid solutions. The Centers for Medicare and Medicaid Services (CMS) may allow this funding to apply to data-tracking systems or changes to support new reimbursement models. 
• Provider outreach and training related to systems operation, such as training on claims submissions, claims processing, and eligibility inquiries related to case management and care coordination.
• Training of vendor or state personnel directly engaged in the operation of an approved system, including workers processing claims or determining eligibility.

To obtain this type of funding, states must submit an advanced planning document (APD). 

Reimbursement: Services and authority options for contact tracing
For Medicaid to support contact tracing, SMAs need to identify both state plan services and authority to provide the service. Defining a service and authority may be challenging, as contact tracing is historically a public health intervention and not a medical service that directly benefits a Medicaid member. CMS does not typically allow this type of service under Medicaid. Given the flexibility afforded under current disaster declarations, however, CMS may have more flexibility than usual. Some options for services include: 

Case management

• How it works 
  First, an individual tests positive and contact-tracing interviews occur. Then, a healthcare provider, such as a hospital, reaches out to the individual, facilitates testing and education, delivers results, and follows up for any care needed. This process applies to any Medicaid members or other individuals who have private insurance that is identified. The provider can discharge the member from case management once the individual recovers. Case management as a Medicaid service is unique in that a diagnosis requiring medical management is the impetus for providing the service.
• Federal approval rationale
  Hospitals may be a good partner for this service due to CMS’s Hospital Without Walls guidance. If the hospital partners with the Public Health Entity for contact tracing, then the case management piece could—in theory—be billed by the staff providing case management through the hospital. The hospital would also be able to bill for testing and lab, care, etc. Public Health could track where there is capacity through the medical community for treatment, especially hospital beds, ventilators, and alternative testing sites. The case manager providing coordination of care for COVID-19 testing and treatment would have access to the hospital medical record system, and the hospital could bill for the service.

Health home

• How it works
  A health home under the state plan could also serve as a vehicle for services for this population. To better care for Medicaid members with chronic conditions, the Affordable Care Act created an optional Medicaid state plan benefit to coordinate care. Health homes are designed to integrate all physical and behavioral healthcare. Participation in health homes is voluntary. In order for members to participate, they must possess at least one chronic condition (e.g., high blood pressure, asthma, obesity, diabetes, or any serious chronic condition) and be at risk for a second (e.g., COVID-19).
• Federal approval rationale
  The health home may be a good support model, as it is eligible for FFP of 90% for the first two years—likely long enough to respond to the pandemic—making it economically attractive. 

The most flexible potential authority for a Medicaid agency to use for contact tracing is the 1115 waiver. As part of the Medicaid Disaster Response Toolkit, CMS made expedited review available. In addition, State Medicaid Director Letter (SMDL) #20-002 provides guidance on a new section 1115 waiver available to assist states in addressing the COVID-19 public health emergency. 

Section 1115 demonstration waiver
The 1115 waiver is the most dynamic option available, and states can access it through the 1115 disaster waiver option under the Medicaid toolkit. The state may be able to show that providing contact tracing will result in savings for services billed under Medicaid. These savings may be able to be justified by decreasing the number of people who test positive for the virus, leading to budget neutrality. The budget neutrality model would need to show “with” and “without waiver” scenarios that demonstrate to Medicaid the cost of the spread of the virus with and without contact tracing. A challenge to this approach is the time necessary to develop the waiver and budget neutrality model and gain CMS approval. 

Recently, CMS approved one of these new section 1115 waivers for the state of Washington. While Washington did not request to cover contact tracing, the speed of approval and the fact that CMS has indicated for the pandemic 1115 requests states will not be required to submit budget neutrality calculations, is a positive indicator for states to consider in envisioning creative models for leveraging Medicaid to minimize the impacts of COVID-19. 

Next steps

• Check in with your CMS contacts. COVID-19 is new, and America’s response continues to evolve. Check in with your CMS contact for input on the latest guidance that may be applicable to your agency. 
• Develop an APD. Develop your state’s APD to help fund the technology needs for tracking COVID-19, along with training for your SMA team and providers. 
• Determine services. In partnership with CMS, determine if case management, a health home, or other service makes the most sense for your state to help trace contacts, reduce the spread of COVID-19, and encourage employment in this important work. 
• Submit your waiver for state plan amendment. After working with CMS to determine the service that makes sense for your state, develop and submit the request to provide this service through a 1115 waiver, 1135 waiver, or if necessary, emergency state plan amendment. 

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 Medicaid consulting team. 

Read this if you are a leader at a state Medicaid agency, Long-Term Care Hospital, Rural Health Clinic, Federally Qualified Health Center, or intermediate care facility.

New toolkit launches to help states navigate COVID-19 health workforce challenges 

In order to maximize workforce flexibility to help confront COVID-19, CMS and the Assistant Secretary of Preparedness and Response (ASPR) have released a new toolkit to assist state and local healthcare decision makers. The toolkits are available as a set of resource collections including:

• COVID-19 Federal Regulatory and Funding Flexibilities 
• COVID-19 Healthcare Workforce Training Resources 
• COVID-19 Licensure 
• COVID-19 Liability Protections 
• COVID-19 Matching Volunteer Workforce Needs 
• COVID-19 Pre-Hospital/Emergency Medical Services (EMS) Resources 
• COVID-19 Scope of Practice Expansions 
• COVID-19 State, Territorial, and Local Resources 
• COVID-19 Workforce Protection Resources 
• COVID-19 Workforce Resilience/Sustainability Resources 
• COVID-19 Additional Healthcare Planning Resources

Our team will be taking a closer look at these resource collections in the coming week and plan to have detailed information on the opportunities within.

Compliance flexibilities announced for implementation of interoperability final rules due to COVID-19

CMS and the Office of the National Coordinator for Health IT (ONC), in conjunction with the Health and Human Services (HHS) Office of Inspector General (OIG), have announced a policy of enforcement discretion to allow compliance flexibilities regarding the implementation of the interoperability final rules previously announced on March 9, 2020.

• Announced in March, the Interoperability and Patient Access final rule (CMS-9115-F) is focused on the pursuit of interoperability and patient access to health information.
• CMS-regulated payers, including Medicaid Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP FFS programs, and CHIP managed care entities are required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1) API that allows members access their claims and encounter information, as well as provider directory information available through third-party applications of their choice.
• Due to the public health emergency posed by COVID-19, CMS is exercising the “enforcement discretion” to adopt a temporary policy of relaxed enforcement for the final rule.

CMS releases additional blanket waivers for Long-Term Care Hospitals (LTCHs), Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs) and intermediate care facilities

CMS is providing additional blanket waivers related to care for patients in LTCHs, temporary expansion locations of RHCs and FQHCs, staffing and training modifications in intermediate care facilities for individuals with intellectual disabilities, and the limit for substitute billing arrangements (locum tenens).

• The new flexibilities do not require a waiver or any requests be sent to CMS electronically or any other notification to CMS regional offices.
• The guidance includes flexibilities related to provider location, staffing, reporting requirements, discharge, patient rights and other areas regulated by CMS.
• The blanket waiver authority exercised by CMS in this case applies only to federal requirements and does not apply to state requirements for licensure or conditions of participation.

State of Washington COVID-19-related section 1115(a) demonstration approval

Washington’s approval is the first section 1115(a) demonstration specifically intended to combat the effects of COVID-19 in a state.

• CMS authorized a time-limited approval for several of the requests in Washington’s March 24, 2020 section 1115(a) demonstration with a retroactive effective date of March 1, 2020 through 60 days after the public health emergency declaration.
• CMS approved two waiver authority requests, as well as six expenditure authority requests from Washington’s section 1115(a) demonstration. 
• CMS did not require the state to submit budget neutrality calculations for the Washington COVID-19 section 1115(a) demonstration. 

CMS issues guidance allowing Independent Freestanding Emergency Departments (IFEDs) to provide care to Medicare and Medicaid beneficiaries during the COVID-19 Public Health Emergency

CMS issued guidance On April 21, 2020 which allows licensed IFEDs in the states of Colorado, Delaware, Rhode Island, and Texas to temporarily provide care to Medicare and Medicaid patients to address any surge.

• IFEDs generally offer a range of services including basic imaging services, computed tomography (CT) scans, ultrasound, and basic on-site laboratory services. During this public health emergency these entities can temporarily bill Medicare and Medicaid as a certified hospital.
• CMS is waiving certain conditions of participation for hospital operations to maximize patient care capabilities during this public health emergency. IFEDs may participate in Medicare and Medicaid in one of three ways: 
   
  • Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 emergency waiver; 
  • Participating in Medicaid under the clinic benefit if permitted by the state; or
  • Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services.

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 your organization, business, or institution has leases and you’ve been eagerly awaiting and planning for the implementation of the new lease standards.

Ready? Set? Not yet. As we have prepared for and experienced delays related to Financial Accounting Standards Board (FASB) Accounting Standards Codification Topic 842, Leases, we thought the time had finally come for implementation. With the challenges that COVID-19 has brought to everyone, the FASB recognizes the significant impact COVID-19 has brought to commercial businesses and not-for-profits and is proposing a one-year delay in implementation, as described in this article posted to the Journal of Accountancy: FASB effective date delay proposals to include private company lease accounting.

But what about lease concessions? We all recognize many lessors are making concessions due to the pandemic. Under current guidance in Topics 840 and 842, changes to lease contracts that were not included in the original lease are generally accounted for as lease modifications and, therefore, a separate contract. This would require remeasurement of the new lease contract and related right-of-use asset. FASB recognized this issue and has published a FASB Staff Questions and Answers (Q&A) Document,  Topic 842 and Topic 840: Accounting for Lease Concessions Related to the Effects of the COVID-19 Pandemic. Under this new guidance, if lease concessions are made relating to COVID-19, entities do not need to analyze each contract to determine if a new contract has been entered into, and will have the option to apply, or not to apply, the lease modification provisions of Topics 840 and 842.

Implementation of the lease accounting standard will most likely be delayed for Governmental Accounting Standards Board (GASB) entities as well. On April 15, 2020, the GASB issued an exposure draft that would delay most GASB statements and implementation guides due to be implemented for fiscal years 2019 and later. Most notably, this includes Statement 84, Fiduciary Activities, and Statement 87, Leases. Comments on the proposal will be accepted through April 30, and the board plans to consider a final statement for issuance on May 8. More information may be found in this article from the Journal of Accountancy: GASB proposes postponing effective dates due to pandemic.

More information

Whether you are a FASB or GASB entity, you can expect a delay in the implementation of the lease standard. If you have questions, please contact a member of our financial statement audit team. For other COVID-19 related resources, please refer to BerryDunn’s COVID-19 Resources Page.

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

CMS has delivered nearly  $34 billion, later updated to $51 billion, in the past week to the healthcare providers on the frontlines battling the 2019 novel coronavirus

• The process in which CMS is implementing requests has reduced times of an accelerated or advance payment to four to six days. Previously the timeframe was three to four weeks. 
• To date, CMS has received over 25,000 requests from providers and suppliers for accelerated and advance payments. Of these, CMS has approved over 17,000 requests in the past week. 
• It should be noted that this funding is separate and distinct from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

CMS issues new wave of infection control guidance based on CDC guidelines to protect patients and healthcare workers 

CMS has issued a series of updated guidance documents focused on infection control to prevent the spread of COVID-19 in a variety of inpatient and outpatient care settings.

• The updated guidance includes a number of updates, notably the option of providing home dialysis training and support services. These are designed to help some dialysis patients stay home during the pandemic.
• In particular, the guidance includes the establishment of Special Purpose Renal Dialysis Facilities (SPRDFs), which can allow dialysis facilities to isolate vulnerable or infected patients.
• For hospitals, psychiatric hospitals and CAHs, the updated guidance provides recommendations on screening and visitation restrictions, discharge to subsequent care locations, as well as staff screening and testing.

CMS acts to ensure US healthcare facilities can maximize frontline workforces to confront COVID-19 crisis 

CMS has temporarily suspended a number of rules in order for hospitals, clinics, and other healthcare facilities to boost their frontline medical staffs.

The CMS guidance focuses on reducing supervision and certification requirements so that practitioners can both be hired rapidly and perform work to the extent of their licensure. CMS guidance allows the following:

• Doctors can now directly care for patients in certain settings without having to be physically present.
• Nurse practitioners may now perform some medical exams on Medicare patients at skilled nursing.

CMS approves additional state Medicaid waivers and amendments to give states flexibility to address coronavirus pandemic

CMS continues to deliver regulatory relief to a number of new states in the form of waivers and state plan amendments.

• In total, CMS has now approved 49 emergency 1135 waivers, 26 state amendments, seven COVID-19 related Medicaid disaster amendments and the first CHIP COVID-related disaster amendment
• The COVID-related Children’s Health Insurance Program (CHIP) disaster amendment is for the State of Maine. 
• CMS has now approved COVID-related Medicaid disaster state plan amendments for North Dakota, Rhode Island, and Wyoming.

HHS authorizes licensed pharmacists to order and administer COVID-19 tests

On April 8, HHS released new guidance under the Public Readiness and Emergency Preparedness Act that authorizes licensed pharmacists to order and administer FDA-approved COVID-19 tests.

• The guidance allows pharmacists to order and administer COVID-19 tests to their patients will provide easier access to testing and will expand testing for healthcare workers and first responders. 

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 would like a refresher of common-sense approaches to protect against fraud while working remotely.

Coronavirus (COVID-19) has imposed many challenges upon us physically, mentally, and financially. Directly or indirectly, we all are affected by the outbreak of this life-threatening disease. Anxious times like this provide perfect opportunities for fraudsters. The fraud triangle is a model commonly used to explain the three components that may cause someone to commit fraud when they occur together:

1. Financial pressure/motivation 
   In March 2020, the unemployment rate increased by 0.9 percent to 4.4 percent, and the number of unemployed persons rose by 1.4 million to 7.1 million.
2. Perceived opportunity to commit fraud 
   Many people are online all day, providing more opportunities for internet crime. People are also desperate for something, from masks and hand sanitizers to coronavirus immunization and cures, which do not yet exist. 
3. Rationalization 
   People use their physical, mental, or financial hardship to justify their unethical behaviors.

To combat the increasing coronavirus-related fraud and crime, the Department of Justice (DOJ) launched a national coronavirus fraud task force on March 23, 2020. It focuses on the detection, investigation, and prosecution of fraudulent activity, hoarding, and price gouging related to medical resources needed to respond to the coronavirus. US attorney’s offices are also forming local task forces where federal, state, and local law enforcement work together to combat the coronavirus related crimes. Things are changing fast, and the DOJ has daily updates on the task force activities. 

Increased awareness for increased threats

Given the increase in fraudulent activity during the COVID-19 outbreak, it’s important for employees now working from home to be aware of ways to protect themselves and their companies and prevent the spread of fraud. Here are some of the top COVID-19-related fraud schemes to be aware of. 

• Phishing emails regarding virus information, general financial relief, stimulus payments, and airline carrier refunds
• Fake charities requesting donations for illegitimate or non-existent organizations 
• Supply scams including fake shops, websites, social media accounts, and email addresses claiming to sell supplies in high demand but then never providing the supplies and keeping the money 
• Website and app scams that share COVID-19 related information and then insert malware that could compromise the device and your personal information
• Price gouging and hoarding of scarce products
• Robocalls or scammers asking for personal information or selling of testing, cures, and essential equipment
• Zoom bombing and teleconference hacking

If you have encountered suspicious activity listed above, please report it to the FBI’s Internet Crime Complaint Center.

Staying vigilant

To protect yourself from these threats, remember to use proper security measures and follow these tips provided by the Federal Bureau of Investigation (FBI) and DOJ:

• Verify the identity of the company, charity, or individual that attempts to contact you in regards to COVID-19.
• Do not send money to any business, charity, or individual requesting payments or donations in cash, by wire transfer, gift card, or through the mail. 
• Understand the features of your teleconference platform and utilize private meetings with a unique code or password that is not shared publicly.
• Do not open attachments or click links within emails from senders you do not recognize.
• Do not provide your username, password, date of birth, social security number, insurance information, financial data, or other personal information in response to an email or robocall.
• Always verify the web address of legitimate websites and manually type them into your browser.
• Check for misspellings or wrong domains within a link (for example, an address that should end in a ".gov" ends in .com" instead).

Stay aware, and stay informed. If you have specific concerns or questions, or would like more information, please contact our team. We’re here to help.
 

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. 

Per CMS, all state Medicaid agencies, including territories, are eligible for the increased Federal Medical Assistance Percentage (FMAP), provided they adhere to the conditions outlined in the Families First Coronavirus Response Act (FFCRA). 

Key takeaways:

• The increase in FMAP will be retroactive to January 1, 2020 and will be available to state Medicaid agencies through the end of the quarter in which the public health emergency for COVID-19 ends.
• This guidance answers some of the following questions for states, including:
  • How long the funding will be available and when it begins
  • What costs are matchable under the enhanced funding 
  • The specific conditions under which states are eligible to claim the funds 
  • What documentation and processes will be needed in order to gain full access to funding

Trump administration releases COVID-19 checklists and tools to accelerate relief for state Medicaid & CHIP programs

In order to assist states as part of the COVID-19 outbreak, the Trump administration has released a number of tools and checklists that constitute a federal authority toolkit to support states in applying for and receiving federal waivers and other key flexibilities for their program. 

Key takeaways:
The tools released today include:

• 1115 Waiver Opportunity and Application Checklist 
  Under this demonstration opportunity states may select from a variety of options to deliver the most effective care to their beneficiaries as a result of COVID-19.
• 1135 Waiver Checklist 
  CMS released a template that states can use to help develop their 1135 Waiver request to temporarily waive certain Medicaid program requirements.
• 1915(c) Appendix K Template 
  Appendix K is a standalone appendix that states can utilize during emergency situations to request an amendment to approved 1915(c) waivers.
• Medicaid Disaster State Plan Amendment (SPA) Template 
  CMS released a SPA template and instruction document dedicated to temporary changes to support COVID-19 response.

CMS issues FAQs on catastrophic health coverage and the coronavirus

A catastrophic health plan may not provide coverage of an essential health benefit prior to an enrollee meeting the deductible for that plan. In order to clarify treatment and coverage of COVID-19 for catastrophic health plans CMS has issued Frequently Asked Questions (FAQs).

Key takeaways:

• Catastrophic plans currently include coverage for the diagnosis and treatment of COVID-19 as they must cover the essential health benefits (EHB) as required by the Patient Protection and Affordable Care Act (PPACA).
• Issuers of catastrophic plans will be able to provide coverage for the diagnosis and treatment of COVID-19 for enrollees who have not yet met their deductible without CMS taking enforcing action.
• The FAQ document encourages states to take an enforcement approach and CMS does not “consider a state to have failed to substantially enforce section 1302(e) of the PPACA if it takes such an approach.”

Relief for clinicians, providers, hospitals, and facilities participating in quality reporting programs in response to COVID-19

CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs.  

Key takeaways:

• The exceptions include pending dates for measure reporting and data submission for related programs. 
• For data submission deadlines in April and May of 2020, submission of those data will be optional, based on the facility’s choice to report.
• 2019 data submission
  • Deadline extended from March 31, 2020 to April 30, 2020.
  • Deadlines for October 1, 2019 - December 31, 2019 (Q4) 
  • Data submission is optional for inpatient rehabilitation and hospital-acquired conditions.

CMS releases telehealth toolkits for general practitioners and End-Stage Renal Disease (ESRD) providers

CMS has released two toolkits on telehealth which follow the broadened access to Medicare telehealth services under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

• The toolkit consists of electronic links to sources of information pursuant to telehealth and telemedicine. 
• Generally directed towards providers, particularly ones who may be considering a permanent telemedicine program.
• CMS notes that most of the resources were established prior to the current COVID-19 crisis. As a result, there are likely references to rules and regulations whose requirements may have been waived for the duration of the outbreak.

Toolkits:

• General Practitioners
• End-Stage Renal Disease Providers

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. 

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.