Modeling Medicare

cost-based

reimbursement for Critical Access Hospitals

Medicare has released final and proposed rules for FY 2022 for payment and fee schedules. We have read through them and provided quick summaries for your review. If you have any questions, please contact us. Click on the the corresponding link below to access the information for FY 2022.

Medicare Final Rule for FY 2022: Inpatient Psychiatric Facility (IPF) Prospective Payment System

Medicare Final Rule for FY 2022: Inpatient Rehabilitation Facility (IRF) Prospective Payment (PPS)

Medicare Final Rule for FY 2022: Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates 

Medicare Proposed Rule for CY 2022: Physician Fee Schedule

Medicare Proposed Rule for FY 2022: Outpatient Prospective Payment System (OPPS)

Read this if your facility or organization has received Provider Relief Funds.

The rules over the use of the HHS Provider Relief Funds (PRF) have been in a constant state of flux and interpretation since the funds started to show up in your bank accounts back in April. Here is a summary of where we are as of June 14, 2021 on HHS’ reporting requirements. Key highlights:

These requirements apply to:

• PRF General and Targeted Distributions
• the Skilled Nursing Facilities (SNF) and Nursing Home Infection Control Distribution
• and exclude:
  • the Rural Health Clinic COVID-19 Testing Program
  • claims reimbursements from HRSA COVID-19 Uninsured Program and the HRSA COVID-19 Coverage Assistance Fund (CAF)

This notice supersedes the January 15, 2021 reporting requirements.
Deadline for Use of Funds:

Recipients who received one or more payments exceeding $10,000 in the aggregate during each Payment Received Period above (rather than the previous $10,000 cumulative across all PRF payments) are subject to the above reporting requirements 

Responsibility for reporting:

• The Reporting Entity is the entity that registers its Tax Identification Number (TIN) and reports payments received by that TIN and its subsidiary TINs.
• For Targeted Distributions, the Reporting Entity is always the original recipient; a parent entity cannot report on the subsidiary’s behalf and regardless of transfer of payment.

Steps for reporting use of funds:

1. Interest earned on PRF payments
2. Other assistance received
3. Use of SNF and Nursing Home Control Distribution Payments if applicable (any interest earned reported here instead), with expenses by CY quarter
4. Use of General and Other Targeted Distribution Payments, with expenses by CY quarter
5. Net unreimbursed expenses attributable to Coronavirus, net after other assistance and PRF payments by quarter
6. Lost revenues reimbursement (not applicable to PRF recipients that received only SNF and Nursing Home Infection Control Distribution payments)

PORTAL WILL OPEN ON JULY 1, 2021!

Access the full update from HHS: Provider Post-Payment Notice of Reporting Requirements.

Read this if you are a hospital or healthcare organization that has received Provider Relief Funds. 

The long-awaited Provider Relief Fund (PRF) Reporting Portal (the Portal) opened to providers on January 15, 2021. Unfortunately, the Portal is currently only open for the registration of providers. The home page for the Portal has information on what documentation is needed for registration as well as other frequently asked questions.

We recommend taking the time to review what is needed and register as soon as possible. Health Resources & Services Administration (HRSA) has suggested the registration process will take approximately 20 minutes and must be completed in one session. The good news is providers will not need to keep checking the Portal to see when additional data can be entered as the Portal home page states that registered providers will be notified when they should re-enter the portal to report on the use of PRF funds.

Access the portal

The Provider Relief Fund (PRF) Reporting Portal is only compatible with the most current stable version of Edge, Chrome and Mozilla Firefox.

Read this if you are at a rural health clinic or are considering developing one.

Section 130 of H.R. 133, the Consolidated Appropriations Act of 2021 (Covid Relief Package) has become law. The law includes the most comprehensive reforms of the Medicare RHC payment methodology since the mid-1990s. Aimed at providing a payment increase to capped RHCs (freestanding and provider-based RHCs attached to hospitals greater than 50 beds), the provisions will simultaneously narrow the payment gap between capped and non-capped RHCs.

This will not obtain full “site neutrality” in payment, a goal of CMS and the Trump administration, but the new provisions will help maintain budget neutrality with savings derived from previously uncapped RHCs funding the increase to capped providers and other Medicare payment mechanisms.

Highlights of the Section 130 provision:

• The limit paid to freestanding RHCs and those attached to hospitals greater than 50 beds will increase to $100 beginning April 1, 2021 and escalate to $190 by 2028.
• Any RHC, both freestanding and provider-based, will be deemed “new” if certified after 12/31/19 and subject to the new per-visit cap.
• Grandfathering would be in place for uncapped provider-based RHCs in existence as of 12/31/19. These providers would receive their current All-Inclusive Rate (AIR) adjusted annually for MEI (Medicare Economic Index) or their actual costs for the year.

If you have any questions about your specific situation, please contact us. We’re here to help.

The COVID-19 emergency has caused CMS (Centers for Medicare & Medicaid Services) to expand eligibility for expedited payments to Medicare providers and suppliers for the duration of the public health emergency.

Accelerated payments have been available to providers/suppliers in the past due to a disruption in claims submission or claims processing, mainly due to natural disasters. Because of the COVID-19 public health emergency, CMS has expanded the accelerated payment program to provide necessary funds to eligible providers/suppliers who submit a request to their Medicare Administrative Contractor (MAC) and meet the required qualifications.

Eligibility requirements―Providers/suppliers who:

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

Amount of payment:
Eligible providers/suppliers will request a specific amount for an accelerated payment. Most providers can request up to 100% of the Medicare payment amount for a three-month period. Inpatient acute care hospitals and certain other hospitals can request up to 100% of the Medicare payment amount for a six-month period. Critical access hospitals (CAHs) can request up to 125% of the Medicare payment for a six-month period.

Processing time:
CMS has indicated that MACs will work to review and issue payment within seven calendar days of receiving the request.

Repayment, recoupment, and reconciliation:
The December 2020 Bipartisan-Bicameral Omnibus COVID Relief Deal revised the repayment, recoupment and reconciliation timeline on the Medicare Advanced and Accelerated Payment Program as identified below. 

Application:
Applications for accelerated payments can be found on each MACs' website. CMS has established COVID-19 hotlines at each MAC that are operational Monday through Friday to assist providers with accelerated or advance payment concerns. Access your designated MACs' website here.

The MAC will review the application to ensure the eligibility requirements are met. The provider/supplier will be notified of approval or denial by mail or email. If the request is approved, the MAC will issue the accelerated payment within seven calendar days from the request.

When funding is approved, the requested amount is compared to a database with amounts calculated by Medicare and provides funding at the lessor of the two amounts. The current form allows the provider to request the maximum payment amount as calculated by CMS or a lesser specified amount.

We are here to help
If you have questions or need more information about your specific situation, please contact the healthcare consulting team. We’re here to help.

Read this if your facility or organization has received provider relief funds.

The rules over the use of the provider relief funds (PRF) have been in a constant state of flux since the funds started to show up in your bank accounts back in April. Here is a summary of where we are as of November 30, 2020 with allowable uses of the funds.
 
The most recent Post-Payment Notice of Reporting Requirements is dated November 2, 2020. In accordance with the notice, PRF may be used for two purposes:

1. Healthcare-related expenses attributable to coronavirus that another source has not reimbursed and is not obligated to reimburse
2. Lost revenue, up to the amount of the difference between 2019 and 2020 actual patient care revenue

The Department of Health and Human Services (HHS) has issued FAQs as recently as November 18, 2020.  The FAQs include the following clarifications on the allowable uses:

Healthcare related expenses attributable to the coronavirus

1. PRF may be used for the marginal increased expenses or incremental expenses related to coronavirus.
2. Expenses cannot be reimbursed by another source or another source cannot be obligated to reimburse the expense.
3. Other sources include, but are not limited to, direct patient billing, commercial insurance, Medicare/Medicaid/Children’s Health Insurance Program (CHIP), or other funds received from the Federal Emergency Management Agency (FEMA), the Provider Relief Fund COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured, and the Small Business Administration (SBA) and Department of Treasury’s Paycheck Protection Program (PPP). This would also include any state and federal grants received as a result of the coronavirus.
4. Providers should apply reasonable assumptions when estimating the portion of costs that are reimbursed from other sources.
5. The examples in the FAQs for increased cost of an office visit and patient billing seem to point to only supplemental coronavirus related reimbursement needing to be offset against the increased expense.
6. PRF may be used for the full cost of equipment or facility projects if the purchase was directly related to preventing, preparing for and responding to the coronavirus; however, if you claim the full cost, you cannot also claim the depreciation for any items capitalized.
7. PRF cannot be used to pay salaries at a rate in excess of Executive Level II which is currently set at $197,300.

Lost revenues attributable to the coronavirus

1. Lost revenues attributable to coronavirus are calculated based upon a calendar year comparison of 2019 to 2020 actual revenue/net charges from patient care (prior to netting with expenses).
2. Any unexpended PRF at 12/31/20 is then eligible for use through June 30, 2021 and calculated lost revenues in 2021 are compared to January to June 2019.
3. Reported patient care revenue is net of uncollectible patient service revenue recognized as bad debts and includes 340B contract pharmacy revenue.
4. This comparison is cumulative, for example, if your net income improves in Q4, it will reduce lost revenues from Q2.
5. Retroactive cost report settlements or other payments received that are not related to care provided in 2019 or 2020 can be excluded from the calculation.

Whether you are tracking expenses or lost revenues, the accounting treatment for both is to be consistent with your normal basis of accounting (cash or accrual).
 
As a reminder, the first reporting period (through December 31, 2020) is due February 15, 2021. The reporting portal is supposed to open January 15, 2021. Any unexpended PRF at December 31, 2020 can be used from January 1, 2021 through June 30, 2021, with final reporting due July 31, 2021.

The guidance continues to change rapidly and new FAQs are issued each week. Please check back here for any updates, or contact Mary Dowes for more information.

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. 

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. 

CARES Act update:

As anticipated, the House of Representatives approved the CARES Act on March 27, 2020, and the President has signed the measure. The provisions highlighted in our prior summary remain intact in the final measure. 

So…how are the emergency relief funds in the legislation accessed by healthcare providers?

• Public Health & Social Services Emergency Fund (PHSSEF): The guidance on how hospitals will access the $100 billion in PHSSEF funds to offset “COVID-19 related expenses and lost revenue” is expected to be released shortly. Keep an eye on this space for further updates as information becomes available.
• Medicare Advanced Lump Sum or Periodic Interim Payments: Application is made through the Fiscal Intermediary (FI). It should be noted that healthcare organizations do not qualify if they are in bankruptcy, under active medical review or program integrity investigation, or have outstanding, delinquent Medicare overpayments.
• SBA Paycheck Protection Program (PPP): This application process begins with your local lender. Do not hesitate—contact your lender immediately as it is anticipated that application volume will be tremendous. For more specifics on this program compiled by BerryDunn experts, visit our blog.

We will continue to provide updates as more information becomes available. In the meantime, please feel free to contact the hospital consulting team. Despite the current circumstances we remain available to support your needs. 

On March 25, 2020 the US Senate unanimously approved the $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act (The “Act”). The White House has signaled that it will sign the measure as approved by the Senate. 

Major provisions of the proposed legislation include:

• $100 billion for hospital “COVID-19 related expenses and lost revenue”
• $275 million for rural hospitals, telehealth, poison control centers, and HIV/AIDS programs
• $250 million for hospital capacity expansion and response
• $150 million for modifications of existing hospital, nursing home, and “domiciliary facilities” undertaken as part of COVID-19 response

The CARES Act also includes the following targeted relief and payment modifications under the Medicare and Medicaid programs:

• The Medicare 2% sequester will be suspended from May 1, 2020 through December 31, 2020. 
• “Through the duration of the COVID-19 emergency period”, the Act will increase by 20% hospital payments for the treatment of patients admitted with COVID-19. The add-on applies to hospitals paid through the Inpatient Prospective Payment System.
• $4 billion in scheduled cuts to Medicaid Disproportionate Share Hospital payments will be further delayed from May 22, 2020 to November 30, 2020.
• Certain hospitals, including those designated as rural or frontier, have the option to request up to a six month advanced lump sum or periodic interim payments from Medicare. The payments will:
  1. Be based upon net payments represented by unbilled discharges or unpaid bills,
  2. Equal up to 100% of prior period payments, 125% for Critical Access Hospitals
  3. In terms of paying down the “no interest loans”, hospitals will be given a four month grace period to begin making payments and at least 12 months to fully liquidate the obligation.

Non-financing provisions contained in the Act that will impact hospital operations include:

• Providing acute care hospitals the option to transfer patients out of their facilities and into alternative care settings to "prioritize resources needed to treat COVID-19 cases." That flexibility will come through the waiver of the Inpatient Rehabilitation Facility (IRF) three-hour rule, which requires patients to need at least three hours of intensive rehabilitation at least five days per week to be admitted to an IRF.
• Allowing Long-Term Care Hospitals (LTCH) to maintain their designation even if more than 50% of their cases are less intensive and would temporarily pause LTCH site-neutral payments.
• Suspending scheduled Medicare payment cuts for durable medical equipment during the length of the COVID-19 emergency period, to help patients transition from hospital to home.
• Disallow Medicare beneficiary cost-sharing payments for any COVID-19 vaccine.
• Ensuring that uninsured individuals could receive free COVID-19 tests "and related service" through any state Medicaid program that elects to enroll them.

Other emergency-period provisions that directly affect other entities but have implications for hospitals:

• Affording $150 billion to states, territories, and tribal governments to cover their costs for responding to the coronavirus public health emergency.
• Physician assistants, nurse practitioners, and other professionals will be allowed to order home health services for Medicare beneficiaries, to increase "beneficiary access to care in the safety of their home."
• Requiring HHS to clarify guidance encouraging the use of telecommunications systems, including remote patient monitoring, for home health services.
• Allowing qualified providers to use telehealth technologies to fulfill the hospice face-to-face recertification requirement.
• Eliminating the requirement that a nephrologist conduct some of the required periodic evaluations of a home-dialysis patient face-to-face.
• Allowing federally qualified health centers and rural health clinics to serve as a distant site for telehealth consultations.
• Eliminating the telehealth requirement that physicians or other professionals have treated a patient in the past three years.
• Allowing high-deductible health plans with a health savings account (HSA) to cover telehealth services before a patient reaches the deductible.
• Allowing patients to use HSA and flexible spending accounts to buy over-the-counter medical products without a prescription.

For more information
If you have questions or need more information about your specific situation, please contact the hospital consulting team. We’re here to help.