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Telehealth FAQs

04.23.20

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. 

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Read this if your organization is required to report on Provider Relief Funds.

On October 27, 2022, HRSA released an update to its Post-Payment Notice of Reporting Requirements for Provider Relief Funds (PRF) and American Rescue Plan (ARP) funds, the first update since June 11, 2021. Although many of the updates are used to add the additional reporting periods for PRF (Periods 5 through 7) and incorporate ARP into the reporting requirements, there are several things you can do to prepare and understand the nuances of Period 4 reporting. By way of a reminder, here are the remaining reporting time periods: 

Be aware. Did you know?

Before we provide a refresher on the data elements you need to prepare your portal submission, here are some very important elements to be aware of:

  1. Phase 4 and ARP payments are required to be maintained in interest-bearing accounts.
  2. ARP monies must be utilized before any unspent general PRF distributions. 
  3. ARP distributions cannot be transferred or allocated to another recipient, because distributions were determined specific to the historical claims data of the qualifying recipient. If reporting is performed at the parent level, parent entities can still report on the ARP payments received by their subsidiaries.
  4. PRF and ARP monies can be used for lost revenues only through the end of the quarter in which the Public Health Emergency (PHE) ends. Currently, the PHE has been extended through April 11, 2023.
  5. Reporting through the HRSA portal will be on a cumulative basis. This may provide you the opportunity to change your option election for lost revenue (for the cumulative period) or correct for previous reporting errors.

Steps for reporting the required data elements

As a result of changes in requirements and the ARP distribution, the steps for reporting have morphed. Data will be entered in the following order:

  1. Interest earned on PRF payments prior to Phase 4
  2. Interest earned on Phase 4 and ARP payments 
  3. Other assistance received
  4. Use of ARP payments for eligible expenses
  5. Use of ARP payments for lost revenues 
  6. Use of Nursing Home Infection Control (NHIC) Distribution payments
  7. Use of General and Targeted Distribution payments for eligible expenses
  8. Use of General and Targeted Distribution payments for lost revenues
  9. Net unreimbursed expenses attributable to COVID-19

Although PRF and ARP funds have similar utilization, it is important to review the Terms and Conditions associated with each distribution to help ensure compliance that the funds are used appropriately.  

Data elements you will need

The following is a category overview of the data elements that will be requested as you complete your portal submission:

  1. Reporting entity identifying information
  2. Associated subsidiary questionnaire—TIN(s), total PRF Targeted Distributions
  3. ARP subsidiary attestation
  4. Acquired or divested subsidiary information
  5. Interest earned on PRF and ARP payments
  6. Tax status and Single Audit information 
  7. Other assistance received, broken down by quarters:
    a.   Department of the Treasury or SBA
    b.   FEMA
    c.   HHS COVID Testing
    d.   Local, state, and tribal government assistance
    e.   Business insurance
    f.    Other
  8. Use of ARP payments (and related earned interest) on eligible expenses
  9. Use of ARP payments (and related earned interest) on lost revenues attributed to COVID 
  10. Use of NHIC Distribution payments
  11. Use of PRF General and Targeted Distribution payments (and related earned interest) on eligible expenses
  12. Use of PRF General and Targeted Distribution payments (and related earned interest) on lost revenues attributed to COVID
  13. Net unreimbursed expenses
  14. Personnel, patient, and facility metrics
  15. Survey

Two reminders for reporting expenses and lost revenues:

  1. Recipients with qualifying expenses of $500,000 or more will need to report expenses in greater detail. As a refresher, the expanded categories are as follows:

    General and Administrative (G&A) expense categories: Mortgage/rent, insurance, personnel, fringe benefits, lease payments, utilities/operations, and other G&A

    Healthcare related expense categories: Supplies, equipment, IT, facilities, and other health care related expenses
  2. Patient service revenue must be reported at net and broken down by payor (Medicare Part A & B, Medicare Part C, Medicaid/CHIP, commercial, self-pay, and other)

The final step in the portal is to complete the required survey, which often catches recipients off-guard as they grow weary toward the end of rigors of the submission and ready to cross the finish line. Be prepared to respond to questions on the impact the PRF and ARP payments have made for your organization, whether the benefits have been overall operations, solvency, staff retention, COVID operations, etc.

HRSA audits—next steps

In addition to a federal Single Audit requirement when a recipient expends more than $750,000 of federal funding in one year (regardless of whether those federally sourced funds came directly from the federal government or were passed from a state or local government), HRSA may also perform its own audits of recipients. These audits will address the data used by the recipients to report on their usage of PRF and ARP monies. Recipients will need to provide support for lost revenue and expenses that justify the use of the funds that they received.

The HRSA is going to drill down on the revenue numbers, specifically looking at the general ledger (GL) and other select revenue tests. On the expenses side, they are going to review the GL, invoice dates, payments and more.

To complete this audit, HRSA will require a significant amount of supporting documentation. Ideally, most of these documents should already have been copied and set aside as support in anticipation of financial reporting requirements. Below is a partial list of items that could be requested during the audit:

  • GL details
  • Listing of expenses reimbursed with PRF and ARP payments grouped into specified categories
  • Listing of patient care revenue by payor
  • Listing of other sources of assistance
  • Listing of expenses reimbursed with the other assistance received
  • Detailed inventory listing of IT supplies
  • Budget attestation from CEO or CFO and board minutes showing ratification of the budget before March 27, 2020
  • Documentation of lost revenue methodologies
  • Audited financial statements
  • CMS cost reports for Medicare and Medicaid
  • Other supporting documentation

If certain documentation isn’t available, recipients will need to request copies from their vendors. Missing documentation may make it difficult to justify the use of funds and may result in recipients having to repay a portion or all of their provider relief funding.

It is possible that certain expenses were not allowable under PRF and ARP. However, that doesn’t necessarily mean recipients will have to repay their funds. Recipients may have other lost revenue or expenses that would be allowed under PRF and ARP—but only if they have the documentation to prove it. That’s why it’s crucial that recipients have all relevant documentation for expenses and lost revenue over the periods they received provider relief funding.

To get ready for a potential HRSA audit, there are at least three immediate steps you should take:

  • Select a responsible point person. One person should be responsible for coordinating the process to help ensure that nothing falls through the cracks or is overlooked. 
  • Keep your PRF/ARP filing reports on hand. Pull any related supporting documentation and collate it into one place if it isn’t already.
  • Identify what support is needed by doing a gap analysis. Determine where you need additional support or expertise and seek to close these gaps before the notification of any audit process.

Insufficient documentation may result in the recapture of provider relief funding by the HRSA. Fortunately, a lack of documentation is preventable with the right support and resources in place. If you would like more information or have any questions about your specific situation, please contact us. We’re here to help.

Article
Are you ready for PRF Period 4 reporting?

When we meet with hospital boards to review the results of their audit, we are most often asked to share what we are seeing in the industry—and how their hospital compares with others in our client base. As we (hopefully) emerge from the COVID-19 pandemic, I wanted to see where we are as an industry after two challenging years. In reviewing our own benchmarking data, and reading this very comprehensive CFO Outlook Survey by BDO, it reinforced that these are challenging times indeed. 

The pressures of top line sustainability, cost containment, and recruitment and retention of talent are very real. And while healthcare providers are seasoned to the continual challenges and opportunities, the difference going forward, post-pandemic, will be what this looks like for rural providers without the influx of stimulus funds and beyond the initial surge of postponed surgeries. Based on the BDO survey, 69% of healthcare organizations surveyed expect an increase in profitability. Is your organization prepared to take the steps to make it happen? What is your financial resilience outlook?

You can read the survey here. If you would like to discuss further, please contact our Hospital Consulting team. We’re here to help.
 

Article
Healthcare survey: A comprehensive look at the industry

Read this if you have not yet reported for Phase 1.

Phase 1 provider relief reporting portal

HRSA opened the Provider Relief Funds (PRF) reporting portal on July 1, 2021, for Phase 1 PRF reporting. In Phase 1, providers will be reporting on the use of PRF received prior to June 30, 2020. While Phase 1 reporting was originally due September 30, 2021, HRSA has provided a 60-day grace period for the reporting period. Providers will be considered out of compliance with the reporting requirements if they do not submit reporting by November 30, 2021. Providers can submit their reporting on the Provider Relief Fund portal. Please note:

  1. Providers must register for the reporting portal, as this is not the same portal as the application and attestation portal. The portal registration must be completed in one session. Follow the link to the Portal Registration User guide
  2. Providers can only report on eligible lost revenues and expenditures related to payments received before June 30, 2020. Providers are not yet allowed to report on payments received subsequent to June 30, 2020. See the June 11, 2021 Reporting Requirements Notice for more detail on reporting requirements.
  3. The period of availability for Phase 1 lost revenues and eligible expenditures is January 1, 2020 through June 30, 2021.
  4. It is extremely helpful to complete the HRSA provider portal worksheets prior to beginning the portal data entry. 
  5. Providers should return unused funds as soon as possible after submitting their report. All unused funds must be returned no later than 30 days after the end of the grace period. (December 31, 2021)
  6. Provider Relief Funds are considered federal awards under Assistance Listing Number (ALN) 93.948. Providers, both for-profit and not-for-profit, may be subject to a Uniform Guidance Audit if they expend more than $750,000 of federal awards during the provider’s fiscal year. 
  7. Providers are able to retrieve their data submission from the portal if a copy was not retained during the submission process.

Your BerryDunn Hospital team is here to help you navigate the Provider Relief Fund reporting and compliance requirements. Please contact us if you have any questions or would like to talk about your specific situation. 

Article
Provider Relief Funds: Highlights

Read this if you are involved with financial statement audits or use audited financial statements. 

Almost as exciting as the look of a new outfit or (completion of) a renovation project, SAS 134 brings a new design to the auditor’s report accompanying your audited financials for periods ending on or after December 31, 2021. Why the new look, you ask? 

Users spoke and the AICPA Auditing Standards Board listened. The new standard significantly changes the layout and content of the report (including management’s responsibilities) and permits communication of key audit matters (areas of higher assessed risk of material misstatement, areas involving significant judgment, or significant events or transactions during the period). Implemented changes include: 

  • The auditor’s opinion is now at the beginning of the audit report and otherwise strengthens the transparency for the auditor’s opinion.
  • The standard clarifies the responsibilities of both management and the auditors, strengthening the financial audit. 

Sample auditor’s report

The simplest way to relay the changes is with an example. The following report is a basic illustration in which an unmodified opinion was issued and the auditor was not engaged to communicate key audit matters. 

If you have questions or would like to speak to us about your specific situation, please contact us. We’re here to help.

Article
Auditor's report redesigned for better communication

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:

Payment Received Period

Deadline to Use Funds

Reporting Time Period

Period 1

4/10/20-6/30/20

6/30/21

7/1/21-9/30/21

Period 2

7/1/20-12/31/20

12/31/21

1/1/22-3/31/22

Period 3

1/1/21-6/30/21

6/30/22

7/1/22-9/30/22

Period 4

7/1/21-12/31/21

12/31/22

1/1/21-3/31/23

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.

Article
Provider Relief Funds: HHS Post-Payment Notice of Reporting Requirements

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