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Medicare Home Health Notice of Admission Proposed Rule CY2021 and its cash flow impact

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Rachael is a member of BerryDunn’s Home Health and Hospice Practice Area. Rachael oversees the preparation of all third-party home care and hospice cost reports, as well as the ongoing compilation of key operating metrics of our home health and hospice client base. Rachael interprets the health of client operations through the use of these key metrics, telling the story behind the numbers and helping clients understand and identify financial opportunities.

Rachael Blehm
09.21.20

Read this if you are a home health agency (HHA).

The Centers for Medicare & Medicaid Services (CMS) proposed rule, CY2021, was published on June 30, 2020. The proposed rule indicates that the Request for Advance Payment (RAP) currently permitted will be eliminated for all 30-day home health periods beginning on or after January 1, 2021. If adopted, this proposed rule will impact the timing of cash flow for HHAs. HHAs will no longer receive an advanced payment, but rather will not be paid until approximately 45-60 days after the period of care has begun. The change in timing of the payment should be considered as part of your HHA’s cash flow forecasting.

Note: Although the RAP payment has been eliminated, HHAs will still be required to submit a zero dollar RAP bill at the beginning of each 30-day period to establish home health services. 

Also included in the proposed rule is a transition from a RAP to a Notice of Admission (NOA) in 2022. This is similar to the Notice of Election under the hospice benefit, since there will no longer be a RAP. It is proposed that HHAs would submit a one-time NOA that establishes care in place of the RAP for the patient until discharged. 

There will be a payment penalty if either the zero dollar RAP in CY2021 or NOA in 2022 is not submitted within five calendar days from the start of care. The penalty is proposed to be a payment reduction of 1/30th to the wage and case-mix adjusted 30-day period of care reimbursement for each day late until submitted, reducing the total reimbursement for patient care. HHAs should be monitoring the timeliness of RAP submissions to be prepared for this proposed change and avoid potential reimbursement reduction if this proposed rule is passed. Read the entire proposed rule.

Please contact a BerryDunn Home Health team member to assist you with evaluating the cash flow impact these proposed changes may have to your organization. 

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Read this if you are a member of a State Medicaid Agency’s leadership team or Program Integrity (PI) unit. 

In March 2020, the Centers for Medicare and Medicaid Services (CMS) suspended PERM cycle activities in response to Secretary Azar’s public health emergency (PHE) declaration. The suspension of the PERM cycle activities provided states with an opportunity to direct resources to the state’s PHE response. In August 2020, CMS released the suspension of PERM cycle activities to allow CMS and states to complete the PERM cycles that were either in progress or in the process of starting up.

While the PERM cycle suspension was in place, CMS released an updated PERM Manual in May 2020. You can access the updated PERM Manual here. The update primarily consists of the addition of guidelines related to the return of the eligibility reviews to the PERM cycle, as defined in the PERM Final Rule published by CMS in July 2017. The manual updates include adding regulation on the CMS Eligibility Review Contractor (ERC) to perform the eligibility reviews. 

Another topic receiving significant updates in the manual was the sample guidelines. Some of the updates included:

  • Sampling units related to Third-Party Liability (TPL)
  • CMS and its contractors must be granted systems access for the review process
  • Sampling timeframes updated for each cycle

There are more updates in the manual, which states will not want to miss. BerryDunn has prepared a summary of the updates included in CMS’ May 2020 release of the PERM manual. View the summary.

While state resources are busy addressing the current PHE, the states should be tracking and documenting waiver activity, as many of the flexibilities provided by waivers will expire at the end of the PHE or soon after. Provider claims for services rendered during the PHE are eligible for the PERM cycle review, and states will need to give the PERM reviewers the flexibilities honored by the state. 

For questions or to find out more information about the PERM Cycle, contact Dawn Webb

Article
Keeping the PERM Manual update in focus during the PHE

Read this if you are an engineering or architecture firm working with government agencies reimbursing overhead established in an overhead rate schedule based on direct labor.

It seems everyone is both anxious to gain forgiveness of their PPP loans and worried about the ramifications of requesting and being granted forgiveness. There is so much you need to consider to understand the potential impact forgiveness may have on your future cash flow and revenues. Let’s focus, though, on your overhead rate.

Some things to consider:

  • PPP loan forgiveness may significantly reduce your overhead rate. As a result, future contracts and related revenues from federal, state, or local government agencies will be impacted. 

    Federal Acquisition Regulation (FAR) 31.201-5 dictates that the applicable portion of any income, rebate, allowance, or other credit relating to any allowable cost and received by the contractor shall be credited to the government. If the credit will be used to reduce the indirect labor costs and rent, some of the largest costs of A/E firms, the overhead rate might be reduced by as much as 25% to 30%. 
  • Guidance on the timing of credit offset is still unclear.

    Do you offset 2020 expenses for forgiveness not settled until 2021 to better match cash flows and credit expenses relevant to forgiveness? Or reflect the forgiveness in the Schedule during the period forgiveness was formally received?
  • The IRS is currently communicating that the costs incurred to gain PPP loan forgiveness will not be deductible expenses, thus increasing 2020 taxable income.

    If your company is in a taxable position, federal income taxes will increase as a result and impact cash flows. And remember, federal income taxes are unallowable costs in overhead rate schedules under FAR Part 31.201-41.

Depending on the concentration of your contracts with federal agencies, the significance of overhead rate reimbursement on contract revenues and expectations for growth, it may actually be more beneficial to pay the loan back instead of asking for forgiveness.

The Department of Defense (DOD) weighs in:

Often the first agency to establish policy or make changes, the DOD has issued guidance in the form of answers to FAQs about CARES Act impacts on DOD pricing and contracting. Q23 specifically addresses the issue of PPP loan forgiveness. It states, “to the extent that PPP credits are allocable to costs allowable under contract, the Government should receive a credit or a reduction in billing for any PPP loans or loan payments that are forgiven.” You can read that and other CARES Act credit guidance here. Even if you don’t directly work with DoD, other federal agencies and state DOT’s generally adopt DoD’s guidance. 

What if we apply forgiveness credit against direct labor? 

You might wonder, why not just apply the credit against direct and indirect labor in proportion to the actual payroll paid during the PPP loan covered period? If this was possible, the overhead rate might actually increase. Unfortunately, billing the government for direct labor costs offset on the overhead rate schedule with the credit of PPP loan forgiveness would violate FAR Part 31 cost principles. Since you can’t bill for credited costs, revenues for contracts with government agencies would be further reduced. 

We advise a wait and see approach.

The best action plan to do right now is to wait for better and clearer guidance. Industry associations such as ACEC are advocating for more favorable PPP loan forgiveness treatment. Furthermore, there are still quite a few unanswered questions by the SBA. 

If you have any questions related to your overhead rate and the impact of PPP loan forgiveness on your revenue from contracts with government agencies, please contact us. We’re here to help. 


 

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PPP loan forgiveness will likely impact your overhead rate!

Read this if your organization, business, or institution is receiving financial assistance as a direct result of the COVID-19 pandemic.

Updated: September 8, 2020

We expect to receive guidance on how to determine what qualifies as lost revenue sometime in the fall, and will post additional information when that becomes available. If you would like the information sent to you directly, please contact Grant Ballantyne.

New information continues to surface about the reporting requirements of the CARES Act Provider Relief Funds (PRFs). The most recent news published by the Health Resources and Services Administration (HRSA) states the funds will be subject to the Single Audit Act requirements. What does this mean and how does it impact your organization? Here’s a brief synopsis. 

A Single Audit (often referred to as a Uniform Guidance audit) is required when total federal grant expenditures for an organization exceed $750,000 in a fiscal year. It is important to note that while an organization may have received funds exceeding the threshold, it is the expenditure of these funds that counts toward the Single Audit threshold.  

PRFs help with healthcare-related expenses or lost revenue attributable to COVID-19. Guidance on what qualifies as a healthcare-related expense or lost revenue is still in process, and regular updates are posted on the FAQs of the US Department of Health & Human Services website.

You may remember, there were originally quarterly reporting requirements related to PRFs. On June 13, 2020 HHS updated their FAQ document to reflect a change in quarterly reporting requirements related to PRFs. According to the updated language, “Recipients of Provider Relief Fund payments do not need to submit a separate quarterly report to HHS or the Pandemic Response Accountability Committee. HHS will develop a report containing all information necessary for recipients of Provider Relief Fund payments to comply with this provision.”

Organizations that receive more than $150,000 in PRFs must still submit reports to ensure compliance with the conditions of the relief funds, but the content of the reports and dates on which these are due is yet to be determined (as of August 4, 2020). The key distinction to remember here is that this limit is based on total funds received, regardless of whether or not expenditures have been made. 

As more information comes out, we will update our website. At the moment the main takeaways are:

  • Expending $750,000 of combined relief funds and other federal awards will trigger a Single Audit
  • Receiving $150,000 of PRFs will cause reporting requirements, on a to-be-determined basis
  • Tracking PRF expenditures throughout the fiscal year will be essential for the dual purpose of reporting expenditures and accumulating any potential Single Audit support

If you would like to speak with a BerryDunn professional about reporting under the Single Audit Act, please contact a member of our Single Audit Team.

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Provider Relief Funds Single Audit

Read this if your organization, business, or institution is receiving financial assistance as a direct result of the COVID-19 pandemic.

Updated: August 5, 2020

Many for-profit and not-for-profit organizations are receiving financial assistance as a direct result of the COVID-19 pandemic. While there has been some guidance, there are still many unanswered questions. One unanswered question has been whether or not any of this financial assistance will be subject to the Single Audit Act. Good news―there’s finally some guidance:

  • For organizations receiving financial assistance through the Small Business Administration (SBA) Payroll Protection Program (PPP), the SBA made the determination that financial assistance is not subject to the Single Audit.
  • The other common type of financial assistance through the SBA is the Emergency Injury Disaster Loan (EIDL) program. The SBA has made the determination that as these are direct loans with the federal government, they will be subject to the Single Audit. 

It is unlikely there will be guidance within the 2020 Office of Management and Budget (OMB) Compliance Supplement related to testing the EIDL program, as the Compliance Supplement anticipated in June 2020 will not have any specific information relative to COVID-19. The OMB announced they will likely be issuing an addendum to the June supplement information specific to COVID-19 by September 2020.

Small- and medium-sized for-profit organizations, and now not-for-profit organizations, are able to access funds through the Main Street Lending Program, which is comprised of the Main Street New Loan Facility, the Main Street Priority Loan Facility, the Main Street Expanded Loan Facility, the Nonprofit Organization New Loan Facility, and the Nonprofit Organization Expanded Loan Facility. We do not currently know how, or if, the Single Audit Act will apply to these loans. Term sheets and frequently asked questions can be accessed on the Federal Reserve web page for the Main Street Lending Program.

Not-for-profits have also received additional financial assistance to help during the COVID-19 pandemic, through Medicare and Medicaid, and through the Higher Education Emergency Relief Fund (HEERF). While no definitive guidance has been received, HEERF funds, which are distributed through the Department of Education’s Education Stabilization Fund, have been assigned numbers in the Catalog of Federal Domestic Assistance, which seems to indicate they will be subject to audit. We are currently awaiting guidance if these programs will be subject to the Single Audit Act and will update this blog as that information becomes available.

Healthcare providers are able to access Provider Relief Funds (PRF) through the US Department of Health & Human Services. PRF help with healthcare-related expenses or lost revenue attributable to COVID-19. Guidance on what qualifies as a healthcare-related expense or lost revenue is still in process, and regular updates are posted on the FAQs of the US Department of Health & Human Services website. According to the Health Resources and Services Administration (HRSA), PRF funds will be subject to the Single Audit Act requirements. It is important to note that while an organization may have received funds exceeding the threshold, it is the expenditure of these funds that counts toward the Single Audit threshold.

If you have questions about accounting for, or reporting on, funds that you have received as a result of the COVID-19 pandemic, please contact a member of our Single Audit Team. We’re here to help.

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COVID-19: Single audit and uniform guidance clarifications

Read this if your company is considering outsourced information technology services.

For management, it’s the perennial question: Keep things in-house or outsource?

For management, it’s the perennial question: Keep things in-house or outsource? Most companies or organizations have outsourcing opportunities, from revenue cycle to payment processing to IT security. When deciding whether to outsource, you weigh the trade-offs and benefits by considering variables such as cost, internal expertise, cross coverage, and organizational risk.

In IT services, outsourcing may win out as technology becomes more complex. Maintaining expertise and depth for all the IT components in an environment can be resource-intensive.

Outsourced solutions allow IT teams to shift some of their focus from maintaining infrastructure to getting more value out of existing systems, increasing data analytics, and better linking technology to business objectives. The same can be applied to revenue cycle outsourcing, shifting the focus from getting clean bills out and cash coming in, to looking at the financial health of the organization, analyzing service lines, patient experience, or advancing projects.  

Once you’ve decided, there’s another question you need to ask
Lost sometimes in the discussion of whether to use outsourced services is how. Even after you’ve done your due diligence and chosen a great vendor, you need to stay involved. It can be easy to think, “Vendor XYZ is monitoring our servers or our days in AR, so we should be all set. I can stop worrying at night about our system reliability or our cash flow.” Not true.

You may be outsourcing a component of your technology environment or collections, but you are not outsourcing the accountability for it—from an internal administrative standpoint or (in many cases) from a legal standpoint.

Beware of a false state of confidence
No matter how clear the expectations and rules of engagement with your vendor at the onset of a partnership, circumstances can change—regulatory updates, technology advancements, and old-fashioned vendor neglect. In hiring the vendor, you are accountable for oversight of the partnership. Be actively engaged in the ongoing execution of the services. Also, periodically revisit the contract, make sure the vendor is following all terms, and confirm (with an outside audit, when appropriate) that you are getting the services you need.

Take, for example, server monitoring, which applies to every organization or company, large or small, with data on a server. When a managed service vendor wants to contract with you to provide monitoring services, the vendor’s salesperson will likely assure you that you need not worry about the stability of your server infrastructure, that the monitoring will catch issues before they occur, and that any issues that do arise will be resolved before the end user is impacted. Ideally, this is true, but you need to confirm.

Here’s how to stay involved with your vendor
Ask lots of questions. There’s never a question too small. Here are samples of how precisely you should drill down:

  • What metrics will be monitored, specifically?
  • Why do the metrics being monitored matter to our own business objectives?
  • What thresholds must be met to notify us or produce an alert?
  • What does exceeding a threshold mean to our business?
  • Who on our team will be notified if an alert is warranted?
  • What corrective action will be taken?

Ask uncomfortable questions
Being willing to ask challenging questions of your vendors, even when you are not an expert, is critical. You may feel uncomfortable but asking vendors to explain something to you in terms you understand is very reasonable. They’re the experts; you’re not expected to already understand every detail or you wouldn’t have needed to hire them. It’s their job to explain it to you. Without asking these questions, you may end up with a fairly generic solution that does produce a service or monitor something, but not necessarily all the things you need.

Ask obvious questions
You don’t want anything to slip by simply because you or the vendor took it for granted. It is common to assume that more is being done by a vendor than actually is. By asking even obvious questions, you can avoid this trap. All too often we conduct an IT assessment and are told that a vendor is providing a service, only to discover that the tasks are not happening as expected.

You are accountable for your whole team—in-house and outsourced members
An outsourced solution is an extension of your team. Taking an active and engaged role in an outsourcing partnership remains consistent with your management responsibilities. At the end of the day, management is responsible for achieving business objectives and mission. Regularly check in to make sure that the vendor stays focused on that same mission.

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Oxymoron of the month: Outsourced accountability

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, and Governmental Accounting Standards Board (GASB) Statement No. 87, Leases, we thought the time had finally come for implementation. With the challenges that COVID-19 has brought to everyone, the FASB and GASB recognize the significant impact COVID-19 has had on commercial businesses, state and local governments, and not-for-profits and both have proposed delays in effective dates for various accounting standards, including both lease standards.

But wait, there’s more! In response to feedback FASB received during the comment period for the lease standard, the revenue recognition standard has also been extended. We didn’t see that coming, and expect that many organizations that didn’t opt for early adoption will breathe a collective sigh of relief.

FASB details and a deeper dive

On May 20, 2020, FASB voted to delay the effective date of the lease standard and the revenue recognition standard. A formal Accounting Standards Update (ASU) summarizing these changes will be released early June. Here’s what we know now:

  • Revenue recognition―for entities that have not yet issued financial statements, the effective date of the application of FASB Accounting Standards Codification (ASC) Topic 606, Revenue Recognition, has been delayed by 12 months (effective for reporting periods beginning after December 15, 2019). This does not apply to public entities or nonpublic entities that are conduit debt obligors who previously adopted this guidance.
  • Leases―for entities that have not yet adopted the guidance from ASC 842, Leases, the effective date has been extended by 12 months (effective for reporting periods beginning after December 15, 2021).
  • Early adoption of either standard is still allowed.

FASB has also provided clarity on lease concessions that are highlighted in Topic 842. 

We 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.

GASB details

On May 8, 2020, GASB issued Statement No. 95, Postponement of the Effective Dates of Certain Authoritative Guidance. GASB 95 extends the implementation dates of several pronouncements including:
•    Statement No. 84, Fiduciary Activities―extended by 12 months (effective for reporting periods beginning after December 15, 2019)
•    Statement No. 87, Leases―extended by 18 months (effective for reporting periods beginning after June 15, 2021)

More information

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.
 

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May 2020 accounting standard delay status: GASB and FASB

Read this if your organization is required to perform physician time studies.

Currently hospitals allocate physician compensation costs to Part A (provider) and Part B (professional/patient) time based on either time studies or allocation agreements. The basic instructions for periodic time studies are that they must be based on the following criteria:

  1. One full week per month of the cost reporting period
  2. Based on a full work week
  3. Use three weeks from the first week of the month, three weeks from the second week of the month, three weeks from the third week of the month and three weeks from the fourth week of the month
  4. Consecutive months cannot use the same week of the month

Per a CMS Special Edition of mlnconnects published May 15, 2020, during the COVID-19 Public Health Emergency (PHE) CMS has made the following time study options available to hospitals as follows:

  • A one-week time study every six months (two weeks per year);
  • Time studies completed prior to January 27, 2020 (the PHE effective date) for the applicable cost report period can be used with no time studies needed for 1/27/2020 – 6/30/2020; or
  • Time studies for the same period in CY 2019 (e.g., if unable to complete time studies during February through July 2020, use time studies completed February through July 2019)

If you have any questions regarding the information in this article please contact Ellen Donahue.

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Physician Time Studies during the COVID-19 Public Health Emergency