CMS Instructs MACs to Temporarily Hold Claims Pending Congressional Action to Extend the Moratorium on 2% Medicare Sequestration Cuts
In anticipation of Congressional action to extend the moratorium on the 2% Medicare sequestration, the Centers for Medicare and Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers' cash flow. This will minimize the volume of claims the MACs must reprocess when Congress extends the moratorium.
As a reminder, last week, the Senate amended and passed legislation (H.R. 1868) to extend the moratorium on the 2% Medicare sequestration through the end of the year in addition to some technical corrections related to rural health clinics and disproportionate share hospitals. The House is expected to vote favorably on the Senate version when it returns in mid-April.
Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021
On April 1, CMS announced that it began recovering payment from all Medicare providers and suppliers who requested and received COVID-19 Accelerated and Advance Payments (CAAPs). According to CMS, it began recovering those payments as early as March 30, 2021. Repayment does not begin until one year from the date the accelerated or advance payment was issued. Beginning 1 year from the date CMS issued the CAAP and continuing for 11 months, CMS will recover the CAAP from Medicare payments due to providers and suppliers at a rate of 25%. After the end of this 11 month period, CMS will continue to recover the remaining CAAP from Medicare payments due to providers and suppliers at a rate of 50% for 6 months. After the end of the 6 month period, your Medicare Administrative Contractor (MAC) will issue you a demand letter for full repayment of any remaining balance of the CAAP. If CMS does not receive payment within 30 days, interest will accrue at the rate of 4% from the date your MAC issues you the demand letter. After that, CMS will assess interest for each full 30-day period that you fail to repay the balance.
Democratic Congressional candidate Rita Hart Concedes to Representative Mariannette Miller-Meeks, MD
On March 31, Democratic Congressional candidate Rita Hart announced she is withdrawing her challenge to the November election of Representative Mariannette Miller-Meeks, MD (R-IA), an opthalmologist. Rita Hart lost Iowa's Second Congressional District race to Representative Miller-Meeks by six votes. The announcement comes after Rita Hart filed a formal election contest with the House of Representatives asking for a recount.
ASCRS Joins the Alliance of Specialty Medicine in Request for Oversight Hearing on MACRA
On March 30, ASCRS joined the Alliance of Specialty Medicine in letters to the Senate Finance Committee, as well as the House Ways and Means Committee, and Energy and Commerce Committee requesting an oversight hearing to examine ongoing implementation issues related to physician-focused value-based care initiatives authorized under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. In the letters, we ask the committees to explore ongoing challenges with MACRA, including:
- The administrative complexity of MIPS
- Flawed value assessments
- Scoring issues
- Constantly shifting goalposts
- Unactionable and untimely performance feedback and program evaluation
- Lack of coordination within CMS
- Limited ability for specialties to develop and participate in Advanced Payment Models
While we support the goals of MACRA, we encourage Congress to provide ongoing oversight of its implementation and collaboration with the medical community to ensure meaningful engagement.
HHS Updates Provider Relief Fund FAQs
HHS recently updated its Provider Relief Fund FAQs. Modified questions are copied below. Key information highlighted below: HHS reaffirms the June 30, 2021 date for the expenditure of funds. In addition, HHS has noted that it "reserves the right to audit Provider Relief Fund recipients now or in the future." Finally, the updated FAQs add new information related to interaction with FEMA.
Does HHS intend to recoup any payments made to providers not tied to specific claims for reimbursement, such as the General or Targeted Distribution payments? (Modified 3/31/2021)
The Provider Relief Fund Terms and Conditions require that recipients be able to demonstrate that lost revenues and expenses attributable to COVID-19, excluding expenses and losses that have been reimbursed from other sources or that other sources are obligated to reimburse, meet or exceed total payments from the Provider Relief Fund. Provider Relief Fund payment amounts that have not been fully expended on health care expenses or lost revenues attributable to coronavirus by the end of the final reporting period must be returned to HHS. The Provider Relief Fund Terms and Conditions and applicable legal requirements authorize HHS to audit Provider Relief Fund recipients now or in the future to ensure that program requirements are met. Provider Relief Fund payments that were made in error, or exceed lost revenue or expenses due to COVID-19, or do not otherwise meet applicable legal and program requirements must be returned to HHS, and HHS is authorized to recoup these funds.
Is there a set period of time in which providers must use the funds to cover allowable expense or lost revenues attributable to COVID-19? (Modified 3/31/2021)
Yes. As explained in the notice of reporting requirements on the Provider Relief Fund website, funds must be expended no later than June 30, 2021. HHS will provide directions in the future about how to return unused funds. HHS reserves the right to audit Provider Relief Fund recipients now or in the future, and is authorized to collect any Provider Relief Fund amounts that were overpaid or not used in a manner consistent with program requirements or applicable law. All payment recipients must attest to the Terms and Conditions, which require the submission of documentation to substantiate that these funds were used for health care-related expenses or lost revenue attributable to coronavirus.
What oversight and enforcement mechanisms will HHS use to ensure providers meet the Terms and Conditions of the Provider Relief Fund? (Modified 3/31/2021)
Providers receiving payments from the Provider Relief Fund must comply with the Terms and Conditions and applicable legal requirements. Failure by a provider that received a payment to comply with any term or condition can result in action by HHS to recoup some or all of the payment. Per the Terms and Conditions, all recipients will be required to submit documents to substantiate that these funds were used for health care-related expenses or lost revenue attributable to coronavirus, and that those expenses or losses were not reimbursed from other sources and other sources were not obligated to reimburse them. HHS monitors the funds distributed, and oversees payments to ensure that Federal dollars are used in accordance with applicable legal and program requirements. In addition, the HHS Office of the Inspector General fights fraud, waste and abuse in HHS programs, and may review these payments.
In order to accept a payment, must the provider have already incurred eligible expenses and losses higher than the Provider Relief Fund payment received? (Modified 3/31/2021)
No. Providers do not need to be able to prove, at the time they accept a Provider Relief Fund payment that prior and/or future lost revenues and expenses attributable to COVID-19 (excluding those covered by other sources of reimbursement) meet or exceed their Provider Relief Fund payment. HHS expects that providers will only use Provider Relief Fund payments in accordance with legal and program requirements. These requirements specify that if, on June 30, 2021, providers have remaining Provider Relief Fund money that they cannot expend on permissible expenses or losses, then providers will return this money to HHS. HHS will provide directions in the future about how to return unused funds. The Provider Relief Fund Terms and Conditions and legal requirements authorize HHS to audit Provider Relief Fund recipients now or in the future to ensure that program requirements are met. HHS is authorized to recoup any Provider Relief Fund amounts that were made in error or exceed lost revenue or expenses due to COVID-19, or in cases of noncompliance with the Terms and Conditions.
How does cost-based reimbursement relate to my Provider Relief Fund payment? (Modified 3/31/2021)
Recipient must follow CMS instructions for completion of cost reports available here.
Under cost-based reimbursement, the payer agrees to reimburse the provider for the costs incurred in providing services to the insured population. In these instances, if the full cost was reimbursed based upon this method, there is nothing eligible to report as an expense attributable to coronavirus because the expense was fully reimbursed by another source. Provider Relief Fund payments cannot be used to cover costs that are reimbursed from other sources or that other sources are obligated to reimburse. Therefore, if Medicare or Medicaid makes a payment to a provider based on the provider's Medicare or Medicaid cost, such payment generally is considered to fully reimburse the provider for the costs associated with providing care to Medicare or Medicaid patients and no money from the PRF would be available for those identified Medicare and Medicaid costs. However, in cases where a ceiling is applied to the cost reimbursement or the costs are not reimbursed under cost-based reimbursement (such as costs for care to commercial payer patients) since the reimbursed amount by Medicare or Medicaid does not fully cover the actual cost, those non-reimbursed costs are eligible for reimbursement under the Provider Relief Fund.
When reporting my organization's healthcare expenses attributable to coronavirus, how do I calculate the "expenses attributable to coronavirus not reimbursed by other sources?" (Modified 3/31/2021)
Healthcare related expenses attributable to coronavirus may include items such as supplies, equipment, information technology, facilities, employees, and other healthcare related costs/expenses for the calendar year. The classification of items into categories should align with how Provider Relief Fund recipients maintain their records. Providers can identify their healthcare related expenses, and then apply any amounts received through other sources, such as 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) that offset the healthcare related expenses. Provider Relief Fund payments may be applied to the remaining expenses or costs, after netting the other funds received or obligated to be received which offset those expenses. The Provider Relief Fund permits reimbursement of marginal increased expenses related to coronavirus provided those expenses have not been reimbursed from other sources or that other sources are not obligated to reimburse. For example, assume the following:
A $5 increase in expense or cost to provide an office visit is calculated by pre-pandemic cost vs. post-pandemic cost, regardless of reimbursement source:
- Pre-pandemic average expense or cost to provide an office visit = $80
- Post-pandemic average expense or cost to provide an office visit = $85 Examples of reimbursed amounts may include, but not be limited to:
- Example 1 - Medicaid reimbursement: $70 (Report $85-$80 = $5 as expense attributable to coronavirus but unreimbursed by other sources)
- Example 2 - Medicare reimbursement: $80 (Report $85-$80 = $5 as expense attributable to coronavirus but unreimbursed by other sources)
- Example 3 - Commercial Insurance reimbursement: $85 (Report $5, commercial insurer did not reimburse for $5 increased cost of post-pandemic office visit)
- Example 4 - Commercial Insurance reimbursement: $85 + $5 insurer supplemental coronavirus- related reimbursement (Report zero since insurer reimbursed for $5 increased cost of post-pandemic office visit)
- Example 5 - COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured: $80 (Report $5 as expense attributable to coronavirus but unreimbursed by other sources)
Is a health care provider eligible to receive a payment from the Phase 3 – General Distribution even if the provider received funding from the Small Business Administration's (SBA) Payroll Protection Program or the Federal Emergency Management Agency (FEMA) or has received Medicaid HCBS retainer payments? (Modified 3/31/2021)
Yes. If the health care provider otherwise meets the criteria for eligibility, receipt of funds from SBA and FEMA for coronavirus recovery or of Medicaid Home-and Community-Based Services (HCBS) retainer payments, does not preclude a health care provider from being eligible for Phase 3 – General Distribution; however, the health care provider must substantiate that the Provider Relief Fund payments were used for health care related expenses or lost revenue attributable to COVID-19, and those expenses or lost revenue were not reimbursed from other sources or other sources were not obligated to reimburse.
Information Blocking Regulations Will Take Effect April 5, 2021
Beginning April 5, 2021, physicians, health IT developers of certified health IT (e.g., EHR vendors), Health information exchanges (HIEs), and Health information networks (HINs) will be subject to information blocking requirements related to the sharing of electronic health information (EHI) data.
The AMA has created a two-part educational resource to help physicians and their medical practices understand the requirements and develop an information blocking compliance program. Part 1 outlines what information blocking is; key terms to know, examples of information blocking practices and a summary of exceptions for when physicians may restrict access; exchange and use of EHI. Part 2 helps physicians start down the path of compliance, including questions to consider; considerations for maintaining a compliance program, and next steps.
As a reminder, the 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule implements provisions from the 21st Century Cures Act passed by Congress that promotes patient access to their electronic health information and addresses industry-wide information blocking practices. For more information, please access the Information Blocking Frequently Asked Questions (FAQs).
Open Payments Pre-publication Review and Dispute Now Available
On April 1, CMS announced that the pre-publication review and dispute for the Program Year 2020 Open Payments data is now open through May 15, 2021. CMS will publish the Open Payments Program Year 2020 data and updates to the previous program years' data in June 2021.
Physician and teaching hospital review of the data is voluntary, but strongly encouraged. Please keep in mind the following reminders:
- Disputes must be initiated by May 15, 2021, in order to be reflected in the June 2021 data publication. For more information on review and dispute timing and publication, refer to the Review and Dispute Timing and Data Publication Quick Reference Guide.
- CMS does not meditate or facilitate disputes. Physicians and teaching hospitals should work directly with reporting entities to resolve disputes.
- Registration in the Open Payments system is required in order to participate in review and dispute activities.
If you have never registered with Open Payments before, make sure you have your National Provider Identifier (NPI) number and State License Number (SLN). Initial registration is a two-step process:
- Register in the CMS Identity Management System (IDM);
- Register in the Open Payments system
Users that have registered during previous program years do not need to re-register.
Please note: If the account has not been accessed for within the last 60 days the account will have been locked due to inactivity. To unlock an account go to the CMS Enterprise Portal, enter your user ID and correctly answer all challenge questions to gain access to your account. You will be prompted to create a new password.
If the account has not been accessed for 180 days or more, the account will be deactivated. To reinstate the account, call the Open Payments Help Desk at 1-855-326-8366; (TTY Line:1-844-649-2766)