CMS Directs Expansion of Telehealth Services to Medicare Beneficiaries

On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued another round of sweeping regulatory waivers and rule changes to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system during the COVID-19 pandemic. These changes include CMS’s efforts to expand beneficiaries’ access to telehealth services so that doctors and other providers can deliver a wider range of care to Medicare and Medicaid beneficiaries in their homes.

CMS issued a press release detailing the expansion of telehealth services and highlighting other additional waivers and rule changes.

Read the CMS press release.

Please contact YYMBC with any questions and for practice guidance during this pandemic.

The information contained in this post may not reflect the most current developments, as the subject matter is extremely fluid and constantly changing. Please continue to monitor Yeo & Yeo’s COVID-19 Resource Center for ongoing developments. Readers are also cautioned against taking any action based on information contained herein without first seeking professional advice.

A second wave of relief payments totaling $20 billion is on its way to healthcare providers. Take note: To access and keep the relief funds, providers must verify their 2018 payment receipts with the federal government.

The new cash infusion follows the earlier release of $30 billion to healthcare providers that the Department of Health and Human Services (HHS) began distributing in mid-April. Both series of payments are part of the broader $100 billion CARES Act Provider Relief Fund.

This time, however, the funds are targeted to providers across the board, not only those who treat a bulk of the Medicare population. Whereas the initial release of $30 billion was tied to historical Medicare payments, the new funds are based on a percentage of all-payer data.

This second release is part of HHS’ promise to supply funds to providers that may have missed out on large cash receipts from the initial disbursement. In this release, HHS is basing the share of relief payments on the revenue data providers submit in Centers for Medicare & Medicaid Services (CMS) cost reports.

The HHS began distributing payments to providers from this $20 billion on April 24. Payments will go out weekly, as information is validated. Payments are calculated so that a provider’s allocation from the entire $50 billion general distribution will be in proportion to such provider’s 2018 net patient revenue. Total revenues of Medicare facilities and providers in 2018 is estimated to be $2.5 trillion. Providers can estimate their expected general revenue distribution through the following formula:

(Individual Provider 2018 Revenue/$2.5 Trillion) X $50 Billion = Expected General Distribution

• Providers that previously provided CMS with 2018 cost reports will receive their portion of the funds automatically, but they will have to complete an attestation through the HHS Payment Portal and agree to the terms and conditions.
• Providers that have not shared their 2018 revenue information will have to submit that information to HHS through the General Distribution Portal before they will be eligible.

All payments may only be used to prevent, prepare for and respond to coronavirus, and the payment should reimburse the recipient only for healthcare-related expenses or lost revenues that are attributable to the coronavirus. If a recipient does not have lost revenues or increased expenses due to COVID-19 equal to the amount received, the recipient must return the funds.

For more information, read the HHS’ General Distribution Portal FAQs. Call your Yeo & Yeo Medical Billing & Consulting professional for assistance.

The information contained in this post may not reflect the most current developments, as the subject matter is extremely fluid and constantly changing. Please continue to monitor Yeo & Yeo’s COVID-19 Resource Center for ongoing developments. Readers are also cautioned against taking any action based on information contained herein without first seeking professional advice.

The Department of Health and Human Services (HHS) is beginning the delivery of the initial $30 billion in relief funding to providers in support of the national response to COVID-19. This is part of the distribution of the $100 billion Provider Relief Fund provided for in the Coronavirus Aid, Relief, and Economic Security (CARES) Act recently passed by Congress and signed by President Trump.

All facilities and providers that received Medicare fee-for-service (FFS) reimbursements in 2019 are eligible to receive relief funds. Payments will arrive at these providers via direct deposit beginning April 10, 2020. These are payments, not loans, to healthcare providers, and will not need to be repaid.

How Funds Will be Paid

HHS has partnered with UnitedHealth Group (UHG) to provide rapid payment to eligible providers.

• Providers will be paid via Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS).
• Automatic payments will come to providers via Optum Bank with “HHSPAYMENT” as the payment description.
• Providers who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well, within the next few weeks.
• All relief payments are made to the billing organization according to its Taxpayer Identification Number (TIN).
• Payments to practices that are part of larger medical groups will be sent to the group’s central billing office.

What You Have to Do

• As a condition to receiving these funds, providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.
• Within 30 days of receiving the payment, providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13, 2020, and will be linked on the HHS website page: https://www.hhs.gov/provider-relief/index.html.

For more information on the CARES Act Provider Relief Fund, how payments are calculated and how this applies to the various types of providers, visit the HHS website at https://www.hhs.gov/provider-relief/index.html.

Yeo & Yeo Medical Billing & Consulting is pleased to announce that Denise Garrett has been appointed to the American Academy of Professional Coders Chapter Association (AAPCCA) national board of directors. She will serve for a three-year term.

The AAPCCA is the governing board for local chapters of the American Academy of Professional Coders (AAPC). Garrett will act as a liaison between AAPCCA and the local chapter officers, serving Region 6, the Great Lakes region, including Wisconsin, Minnesota, Illinois, Indiana, Michigan and Ohio. She will also serve on the board’s Chapter Development Committee. Locally, she will also continue to serve as treasurer for the AAPC Bay City chapter during 2020.

The AAPC elevates the standards of medical coding by providing training, professional certification, ongoing education and networking opportunities for medical coders. The organization has more than 190,000 members worldwide.

Garrett is an account manager with more than 20 years of medical billing and coding experience. She is a Certified Healthcare Auditor (CHA), Certified Professional Coder (CPC), Certified Physician Practice Manager (CPPM^®), Certified Professional Compliance Officer (CPCO™), Certified Professional Medical Auditor (CPMA^®), and a Certified Foot & Ankle Surgical Coder (CFASC), with expertise in the coding of diagnoses, services, and procedures for physician practices. She is also a member of the American Medical Billers Association and the American Institute of Healthcare Compliance.

Yeo & Yeo Medical Billing & Consulting, an affiliate of Yeo & Yeo CPAs & Business Consultants, is pleased to announce April Nesbitt and Ariel Porath have earned the Certified Professional Coder Apprentice credential from the American Academy of Professional Coders.

Nesbitt is a medical billing representative and is vice president of the American Academy of Professional Coders (AAPC) Bay City Chapter. She also represents Yeo & Yeo Medical Billing & Consulting employees as a member of the Yeo & Yeo Foundation Grants Committee.

Porath is a medical billing and coding specialist and has a Certified Billing and Coding Specialist credential from the National Health Career Association. She also holds an Ophthalmic Coding Specialist credential through the American Academy of Ophthalmology.

The CPC-A credential allows Nesbitt and Porath to serve clients as a certified coder while working toward full certification.

The Department of Health and Human Services (HHS) announced proposed changes to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the “Stark Law”) and the Federal Anti-Kickback Statute.

The proposed rules provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.

The proposed rules are part of HHS’s Regulatory Sprint to Coordinated Care, which seeks to promote value-based care by examining federal regulations that impede efforts among providers to better coordinate care for patients.

“President Trump has promised American patients a healthcare system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number. But too often, government regulations have stood in the way of delivering that kind of care,” said HHS Secretary Alex Azar. “Regulatory reform has been a key piece of President Trump’s agenda not just for faster innovation and economic growth, but also better, higher-value healthcare. Our proposed rules would be an unprecedented opportunity for providers to work together to deliver the kind of high-value, coordinated care that patients deserve.”

“These proposed rules would be a historic reform of how healthcare is regulated in America,” said HHS Deputy Secretary Eric Hargan. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system, while maintaining the important protections patients need. Here at HHS, CMS and the Office of Inspector General recognized the need for reform and have acted to produce serious and thoughtful sets of proposals.”

The Stark Law’s new value-based exceptions, under the proposed rule issued by the Centers for Medicare & Medicaid Services (CMS), acknowledge that incentives are different in a healthcare system that pays for value, rather than the volume, of services provided. They include proper safeguards that ensure the Stark Law will continue to provide meaningful protection against overutilization and other harms, while giving physicians and other healthcare providers added flexibility to improve the quality of care for their patients.

“We serve patients poorly when government regulations gather dust in the attic: they become ever more stale and liable to wreak havoc throughout the healthcare system,” said CMS Administrator Seema Verma. “Administrative costs are driving up the cost of healthcare in America – to the tune of hundreds of billions of dollars. The Stark proposed rule is an important next step in President Trump’s healthcare agenda for Americans. We are updating our antiquated regulations to decrease burden for providers and helping bring down these increasingly escalating costs.”

The proposed changes to the regulations related to the Federal Anti-Kickback Statute and the Civil Monetary Penalties Law issued by the Office of Inspector General (OIG) would, if finalized, address the longstanding concern these laws unnecessarily limit the ways in which healthcare providers can coordinate care for patients. The changes would offer flexibility for beneficial innovation and improved coordinated care through, for example, outcome-based payment arrangements that reward improvements in patient health. The changes would also make it easier for physicians and other healthcare providers to ensure they are complying with the law by offering specific safe harbors for these arrangements.

“Any patient can tell you how difficult it is to coordinate their own care. This proposed rule would help patients to focus on their health, enable providers to better coordinate high-quality healthcare, and empower both to achieve improved health outcomes,” said Acting Inspector General Joanne M. Chiedi. “We are proposing strong safeguards to protect patients from fraud and abuse by bad actors who might seek to misuse the new flexibilities.”

Below are examples involving coordinated care, value-based care, data sharing, and patient engagement activities that, depending on the facts, could currently be difficult to fit under existing protections and could potentially be protected by the Stark Law, Anti-Kickback Statute, or Civil Monetary Penalties Law proposals if all applicable conditions are met:

• In an effort to coordinate care and better manage the care of their shared patients, a specialty physician practice could share data analytics services with a primary care physician practice.
• Hospitals and physicians could work together in new ways to coordinate care for patients being discharged from the hospital. The hospital might provide the discharged patients’ physicians with care coordinators to ensure patients receive appropriate follow up care, data analytics systems to help physicians ensure that their patients are achieving better health outcomes, and remote monitoring technology to alert physicians or caregivers when a patient needs healthcare intervention to prevent unnecessary ER visits and readmissions.
• A physician practice could provide smart pillboxes to patients without charge to help them remember to take their medications on time. The practice could also provide a home health aide to teach the patient and the patient’s caregiver how to use the pillbox. The pillbox could automatically alert the physician practice and caregiver when a patient misses a dose so they could follow up promptly with the patient.
• A local hospital could improve its cybersecurity and the cybersecurity of nearby providers that it works with frequently. To do so, it could donate, for free, cybersecurity software to each physician that refers patients to its hospital. The hospital and the physicians often share information about their patients, so it is important that there are no weak links that might compromise everyone else. The software would help ensure that hackers cannot attack the physician’s computers. Improving each physician’s cybersecurity would help prevent hackers from spreading the attack to other physicians and the hospital.
• To improve health outcomes for patients with end-stage kidney disease, a nephrologist, dialysis facility, or other provider could furnish the patients with technology that is capable of monitoring the patient’s health and two-way, real-time interactive communication between the patient, facility, and physician. In addition, the facility could equip the physicians with data analytics software to help them monitor patients’ health outcomes.

Writing off patient copays may be well-intended, but this generosity can have costly consequences. Write-offs may be hurting your practice by compromising your contracts with private payers. Violating these terms of your contract may negatively affect reimbursements from those payers. You may even be found guilty of a felony if the patient is enrolled in Medicare or Medicaid. The repercussions of said felony are: up to five years in prison, criminal penalty of up to $25,000, administrative penalty of up to $50,000, triple damages, and permanent exclusion from these programs. These risks are avoidable providing you follow the proper channels to help your patients with their out-of-pocket expenses.

There are several reasons why waiving copays could be a problem. It is harder for payers to enter into contracts when practices are undervaluing their services by writing off patient copays or deductibles. Copays being a part of the contract between provider and payer, waiving them can be a breach of contract resulting in civil lawsuits, compensatory damages, and loss of additional contracts. Payers use copays to prevent overuse of services, so waiving patient charges may be seen as encouragement to use more services, effectively increasing the payers’ costs. Other possible consequences include violation of a number of statues including the Anti-Kickback Statute (AKS), Civil Monetary Penalties Law (CMPL), and Stark Law. For Medicare or Medicaid patients, you could find yourself in violation of the AKS wherein waiving copays and deductibles may be seen as bribing patients to seek your services instead of going to another practice. Violations of the AKS are penalized by $5,500 to $11,000 per claim and repayment of the funds your practice erroneously received. Your practice would be guilty of breaking the CMPL if waiving a Medicare copay induces the patient to seek specific services or medical equipment from your provider or another by your recommendation. Influencing a patient to seek services from a specialist or provider your practice is associated with by waiving out-of-pocket expenses is a violation of the Stark Law.

Despite the penalties for erroneously waiving copays, practices should not be dissuaded from assisting Medicare and Medicaid patients when situations of financial hardship arise. When you have evidence supporting a patient’s financial need, there are exceptions to the AKS and CMPL that provide proper channels for forgiving patient responsibility. Poof that the write-off is not an inducement to seek services or equipment from you or an affiliate is necessary to ensure that the write-off is legitimate. Additionally, you may need to provide evidence that your office is not waiving copays and deductibles regularly to avoid violations and penalties. Your practice should have an established policy that outlines the circumstances in which it is and is not appropriate to forgive a patient’s out-of-pocket expenses. Documentation should be kept in patient files as proof of the financial circumstances supporting your decision to waive patient responsibility per your policy. Your policy and documentation will benefit all parties, upholding your contracts, safeguarding your practice, and providing financial assistance to your patients.

CMS.gov. “Medicare Fraud & Abuse: Prevent, Detect, Report.” MLN Booklet , Centers for Medicare & Medicaid Services, Feb. 2019, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf .

NHIC, Corp. “Improper waivers.” Fraud & Abuse Guide, Centers for Medicare & Medicaid Services, 5^th ed., Oct. 2007, pp. 13-15, https://cdn.ymaws.com/www.aahcm.org/resource/resmgr/2007_fraud_policy.pdf.

Pegg, Bruce. “Know When You Can – and Cannot – Waive Patient Copays.” AAPC Knowledge Center , American Academy of Professional Coders (AAPC), 4 Sept. 2019, https://www.aapc.com48289-know-when-you-can-and-cannot-waive-patient-copays/.

HMS will begin auditing Medicare Plus Blue PPO’s reimbursed diagnosis-related group claims for clinical and coding validation, starting Sept. 1, 2019. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines, and diagnoses were supported by documentation in the medical record.

Be ready to share medical charts for review. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

The purpose of the clinical audit of the diagnosis-related group, or DRG, is to:

• Confirm compliance with national coding guidelines.
• Ensure documentation supports diagnoses and procedures reported.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payments.

HMS will be holding webinars for providers with information on the overall DRG clinical validation process and helpful tips. Schedules will be provided in a future web-DENIS message.

DRG clinical validation audits take a three-phase approach. See the scope of each phase and the data period for each phase in the chart below.

Effective Sept. 1, 2019, through Aug. 31, 2020, value-based reimbursement for the Patient-Centered Medical Home designation will increase from 110% to 115%.

The temporary change recognizes that PCMH value-based reimbursement has remained at the same level for 10 years, but the expectations have become more rigorous over time and continue to evolve.

As part of the continued evolution of the program, we encourage PCMH practices to collaborate with their physician organizations to:

• Adopt more advanced PCMH capabilities
• Use care managers or care teams and the health information exchange to improve care coordination

Value-based reimbursement for PCMH designation will return to 110%, effective Sept. 1, 2020. The additional 5% value-based reimbursement will be reallocated from PCMH to the Provider-Delivered Care Management program for primary care physicians.

We’ll be communicating about these changes in future issues of The Record.

If you have any questions about these changes, contact your PGIP physician organization.

In 2011, the Centers for Medicare & Medicaid Services (CMS) terminated their use of consultation codes. They created a crosswalk system to transition providers away from using these eliminated codes. Office/outpatient Evaluation & Management (E/M) codes 99211-99205 replaced consult codes 99241-99245. Initial hospital care codes 99221-99205 replaced 99251-99255.

This shift resulted in lower reimbursement because the Relative Value Units (RVUs) for non-consult codes are significantly lower than those of the eliminated consult codes. Other payers still accepted the consult codes, causing confusion over inpatient consult codes being replaced with initial hospital care codes. The new AI (principal physician of record) modifier created confusion as well. The AI modifier was to be appended by admitting physicians so that specialists doing consultations could report initial hospital care codes on the same day. However, many didn’t use the modifier resulting in denials for duplicate services.

Training was provided to fix these issues, but physicians still had a decision to make. They had to decide if they would continue documenting the additional information required for consult codes that other E/M codes don’t need. This additional information includes: requesting provider, reason for consult, report of results, and recommended treatment. Some providers liked these details because they help to differentiate consult and transfer of care situations. Others preferred to omit these extra details because they viewed them as more work for less reimbursement in the end.

UnitedHealth announced in March of 2019 that they would be updating fee schedules to align more with Medicare. They will be eliminating the consult codes in congruence with the CMS. Cigna announced the same in July of 2019 that they would be implementing a new reimbursement policy. Their deadline is October 19, 2019, after which CPT consultation codes will not be valid. Though claims rejected for this reason may be resubmitted with the appropriate non-consultation E/M code. This update for both UnitedHealth and Cigna reflect their private plans. Any Medicare Advantage plans eliminated consult codes back in 2011. This is a big change for practices used to commercial insurances.