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Preparing your revenue cycle for the pandemic:
COVID-
19

03.12.20

Editor’s note: read this if you are a hospital or senior living facility administrator, CFO, finance director or manager, patient financial services staff, or revenue team member. 

Unless you own a working crystal ball, no one knows the true impact COVID-19 will have on our communities and our healthcare ecosystem. The very nature of being a healthcare provider demands being prepared for emergencies, crises, and pandemics. This particular pandemic highlights how critical yet fragile the healthcare system is in our country—and across the globe.

Despite differences in payment mechanisms, terminology, and cultural expectations, registration is a critical function shared with all developed health systems across the globe and must be considered when preparing for COVID-19 and other community disasters. This function is responsible for correctly identifying patients, managing where they are in the systems (arrivals, bed management, scheduling, and other functions), and accurately identifying financial responsibility for services provided.  

Insurance verification is important during crisis, but the other functions are more important, as they ensure providers have access to timely and correct medical information and can document each patient's course of treatment and transfer care to other providers. Delays and inaccuracy in upfront functions can lead to decreased patient throughput and possibly impede patient care if access to medical records is delayed.

Preparation for successful patient care

Now is a great time to assess if your system’s patient access teams are properly staffed and trained, and you have contingency plans in place for emergencies and pandemics. Many systems continue to staff their registration functions with entry level/inexperienced staff. Are they dependable and able to handle the high stress that can accompany a crisis in your community? Systems must have contingency plans and training in place before it is needed.

Patient access staffpeople are at the front end of care and we must ensure they have the training, equipment, and tools to protect themselves from sick patients (this is true every day). If there is a health emergency in your community, a high likelihood exists that your patient access staff will be impacted. What is your plan for decreased patient access staff during times of increased/unprecedented demand? Many options exist and preparation prior to a crisis is important to successfully care for patients during the crisis. Here are some options to consider:

  • Cross-train billing and coding staff to register patients
    Cross-train revenue cycle staff to improve the strength of your revenue cycle. Billers and coders that fully understand registration can problem solve and collaborate quickly during a crisis, saving valuable time and improving efficiency.
  • Develop mass registration processes
    Create forms and/or have mobile laptops and technology ready to register patients in conference rooms and other non-traditional access points. This eliminates bottlenecks at ED and other high-demand registration points, speeding up treatment.
  • Continue to invest in self-service and telehealth tools
    Telehealth and self-service registration tools can alleviate staff demands, prevent non-emergency patients from coming to the facility, and improve patient satisfaction.

Patient access assessments

Patient access has been and will continue to be the foundation of the revenue cycle. This is true during normal operations and even more so during emergency and crisis situations. When is the last time you assessed your system’s patient access emergency plans and overall performance of your patient access department?  

BerryDunn’s patient access consultants can assist in ensuring your front-end functions are performing at best-practice levels, based on registration related denials and rework, processes flows, point-of-service collections, authorizations, and other metrics. The assessment will identify financial and revenue cycle improvement opportunities dependent on your people, processes, and technology. Assessments will also review the department’s preparedness for emergencies and provide recommendations to support the needs of the community during normal operations and during a crisis.

For more information, or if you have questions or comments about your specific situation, we're here to help. Please contact our revenue cycle consultants.

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

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

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

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

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

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

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

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

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

Telehealth visits

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

Virtual check-ins

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

E-visits:

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

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

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

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

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

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

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

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

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

Article
Telehealth FAQs

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

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

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

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

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

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

Payor Sample payor 1 Sample payor 2
Video requirement waived? Yes No
Place of service 02 02 for 11
Virtual check-in/brief communication codes G2012 or G2010 G2012 or telephone E/M codes (G99441-99433)
Telehealth service codes All codes in CPT Appendix P All codes in CPT Appendix P, video required, use office POS
Modifier rules V3 required for audio only visits 95 or GT
Note Use G2012 for triage Payor notes that most appropriate level is 99212 or 99213

Other questions on payor requirements that may prove worth tracking:

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

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

Operationalize Telehealth Rules by Payor

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

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

Code Long description Medicare fee schedule rate
99442 Telephone evaluation and management service; 11-20 minutes of medical discussion. $27.82
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history, an expanded problem focused examination, and/or medical decision making of low complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
$77.15

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

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

Article
COVID-19 telehealth changes: Every charge counts

Read this if you are a Maine business or organization that has been affected by COVID-19. 

The State of Maine has released a $200 million Maine Economic Recovery Grant Program for companies and organizations affected by the COVID-19 pandemic. Here is a brief outline of the program from the state, and a list of eligibility requirements. 

“The State of Maine plans to use CARES Act relief funding to help our economy recover from the impacts of the global pandemic by supporting Maine-based businesses and non-profit organizations through an Economic Recovery Grant Program. The funding originates from the federal Coronavirus Relief Fund and will be awarded in the form of grants to directly alleviate the disruption of operations suffered by Maine’s small businesses and non-profits as a result of the COVID-19 pandemic. The Maine Department of Economic & Community Development has been working closely with affected Maine organizations since the beginning of this crisis and has gathered feedback from all sectors on the current challenges.”

Eligibility requirements for the program from the state

To qualify for a Maine Economic Recovery Grant your business/organization must: 

  • Demonstrate a need for financial relief based on lost revenues minus expenses incurred since March 1, 2020 due to COVID-19 impacts or related public health response; 
  • Employ a combined total of 50 or fewer employees and contract employees;
  • Have significant operations in Maine (business/organization headquartered in Maine or have a minimum of 50% of employees and contract employees based in Maine); 
  • Have been in operation for at least one year before August 1, 2020; 
  • Be in good standing with the Maine Department of Labor; 
  • Be current and in good standing with all Maine state payroll taxes, sales taxes, and state income taxes (as applicable) through July 31, 2020;
  • Not be in bankruptcy; 
  • Not have permanently ceased all operations; 
  • Be in consistent compliance and not be under any current or past enforcement action with COVID-19 Prevention Checklist Requirements; and 
  • Be a for-profit business or non-profit organization, except
    • Professional services 
    • 501(c)(4), 501(c)(6) organizations that lobby 
    • K-12 schools, including charter, public and private
    • Municipalities, municipal subdivisions, and other government agencies 
    • Assisted living and retirement communities 
    • Nursing homes
    • Foundations and charitable trusts 
    • Trade associations 
    • Credit unions
    • Insurance trusts
    • Scholarship funds and programs 
    • Gambling 
    • Adult entertainment 
    • Country clubs, golf clubs, other private clubs 
    • Cemetery trusts and associations 
    • Fraternal orders 
    • Hospitals, nursing facilities, institutions of higher education, and child care organizations (Alternate funding available through the Department of Education and Department of Health and Human Services for hospitals, nursing facilities, child care organizations, and institutions of higher education.)

For more information

If you feel you qualify, you can find more details and the application here. If you have questions about your eligibility, please contact us. We’re here to help. 

Article
$200 Million Maine Economic Recovery Grant Program released

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.

Article
COVID-19: Single audit and uniform guidance clarifications

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.

Article
Provider Relief Funds Single Audit