Articles Posted in COVID-19

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In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) created separate payments for audio-only telephone evaluation and management (E/M) services. E/M billing codes apply to medical services related to evaluating and managing a patient, such as, hospital visits, preventive services, and office visits. Coding for E/M services can be complicated because many variables are involved in selecting the proper code. For example, the type and complexity of history, examination, and decision making, as well as time spent with the patient are often factors to be considered. Audio-only telephone E/M services were not previously covered by Medicare under the physician fee schedule (PFS). However, beginning with the March 2020 Interim Final Rule with Comment (IFC), CMS found these types of visits to be clinically appropriate and began to cover certain audio-only codes. CMS further expanded the list of covered audio-only codes in the April 2020 IFC.

CMS soon found that audio-only health services became far more popular than CMS expected, and many beneficiaries were not using video technology to communicate from their homes. Since the new E/M codes were established, providers were seeing beneficiaries for more complex evaluation and management services using audio-only technology, when they would normally utilize telehealth video or in-person visits to evaluate the patient. According to CMS, the intensity and complexity of providing an audio-only visit to a beneficiary during the unique circumstances of the COVID-19 PHE was not properly valued as established in the March 2020 IFC. This was especially true when considering these audio-only services were often being used as a complete substitute for office/outpatient Medicare video telehealth visits. Therefore, CMS established new RVUs based on E/M codes in existence prior to the PHE and the time requirements necessary for telephone service-related codes. Because these audio-only visits were being used in replacement of office/outpatient E/M visits, they should be considered telehealth services and added to the Medicare telehealth service list while the PHE is ongoing.

In the CY 2021 PFS proposed rule, CMS elected not to continue covering the audio-only codes when the PHE ends. This is because, outside the circumstances of the COVID-19 PHE, telehealth services generally must be provided using interactive, two-way audio and video technology. Commenters on the proposed rule broadly supported maintaining payment for audio-only provided services. Commenters stated that many beneficiaries may not have access to two-way audio and video technology and that continuing to pay for these E/M services will help vulnerable populations and those with less access to quality healthcare. However, CMS declined to finalize payment of these E/M codes beyond the PHE. The Social Security Act requires telehealth services to be furnished using a telecommunications system. CMS maintains that there is a longstanding policy of interpreting “telecommunications system” to include technology that allows the telehealth visit to be analogous to an in-person visit. Outside the COVID-19 PHE, CMS continues to believe that the longstanding interpretation of telecommunications system excludes the use of audio-only technology for Medicare telehealth services. The PHE declaration must be renewed in 90-day increments and is currently slated to end April 20, 2021. However, HHS and the Biden administration have signaled that they are likely to repeatedly renew the PHE through at least the end of 2021, thereby allowing Medicare telehealth waivers to continue until the end of the year.

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On February 10, 2021, the United States Department of Justice filed the first criminal charges relating to a alleged violation of the terms the Provider Relief Fund (PRF). The allegations contained in the indictment illustrate some of the pitfalls of the PRF and the importance of compliance with its terms. It may also provide insight into coming enforcement actions.

The alleged defendant was a resident of southeastern Michigan who owned and operated a home health agency in Indiana. The home health agency closed in January 2020 and filed a notice of voluntary termination with Medicare in March 2020. However, despite the filing of this notice, when the first wave of payments under the PRF were automatically deposited into providers’ accounts in April, the defendant’s home health agency received approximately $38,000. The defendant then allegedly submitted an attestation to the terms and conditions of the PRF payment and allegedly distributed the funds to family members in a series of checks, all just under $10,000. The indictment charged the defendant with one count of Theft of Public Money, Property, or Records.

This indictment touches several possible areas of enforcement or audits of PRF payments, including eligibility criteria, attestations, and use of the funds. The first wave of payments under the PRF consisted of $30 billion that was automatically deposited in providers’ accounts in amounts based on a provider’s 2019 Medicare billing. Providers did not make requests or applications for this funding. However, simply because a provider received money did not mean they were entitled to keep it, a provider also had to meet the eligibility criteria, such as the requirement that it provided services after January 31, 2020.

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On March 15, 2021, the Centers for Medicare & Medicaid Services (CMS) announced it will increase the amount Medicare pays providers for administering the COVID-19 vaccine. For vaccines administered on or after March 15, 2021, the new national average payment rate for physicians, pharmacies, hospitals, and other providers who administer the vaccine of $40 per single-dose vaccine and $80 per two-dose vaccine. The exact payment rates will be based on the type of provider offering the vaccine and will be adjusted based on the location of the provider. For vaccines administered prior to March 15, 2021, Medicare rates will remain $28.39 per single-dose vaccine and $45.33 for both doses of a two-dose vaccine.

These changes in Medicare payment rates are based on new information regarding the costs of vaccine administration for different types of providers and more resources needed to safely administer the vaccine. The goal of CMS is to increase the number of providers offering the vaccine and further emphasize that no beneficiary, whether a beneficiary with private insurance, Medicare, or Medicaid, should pay cost-sharing to receive the COVID-19 vaccine. The new payment rate is effective for COVID-19 vaccines given on or after March 15, 2021.

In order to receive COVID-19 vaccines at no cost from the federal government, providers cannot charge patients for administration of the vaccine. Providers that receive federally purchased vaccines during the public health emergency must contractually agree to administer COVID-19 vaccines to patients regardless of their ability to pay; Providers are therefore prohibited from charging a patient any amount for administration of the vaccine, including a copay, coinsurance, or deductible, including seeking reimbursement from patients, such as balance billing. CMS provides payment information for various programs, to ensure consistent coverage across payers, such as:

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On March 11, 2021, President Biden signed  the $1.9 trillion American Rescue Plan, a legislative package to help fund vaccinations, provide immediate relief to families during the COVID-19 pandemic, increase COVID-19 testing and identify new and emerging strains of COVID-19.  The final bill includes several sources of funding for COVID-19 response and other healthcare programs:

Development of a national vaccination program

  • The bill includes $20 billion for a nationwide vaccination program, in partnership with state and local authorities. The vaccination program will include the creation of community vaccination centers as well as mobile vaccination units. Under the plan, the Biden Administration will work with Congress to expand the Federal Medicaid Assistance Percentage (FMAP) to 100%, to ensure all Medicaid enrollees will be vaccinated.
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As part of the response to the COVID-19 pandemic, Congress provided funding for testing of patients without health insurance. To receive this reimbursement for testing, providers must attest that the patient is uninsured. However, it is not clear how providers must gather this information, exposing providers to risk of enforcement actions.

For claims for COVID-19 testing and testing-related items and services, a patient is considered uninsured if the patient does not have coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time the services were rendered. For claims for treatment for positive cases of COVID-19, a patient is considered uninsured if the patient did not have any health care coverage at the time the services were rendered. For claims for vaccine administration, this means that the patient did not have any health care coverage at the time the service was rendered.

The funding of testing for the uninsured is administered by the Health Resources & Services Administration (HRSA) under the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program. Congress has allocated $2 billion to this program through The Families First Coronavirus Response Act (FFCRA) and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA), as well as a portion of the Provider Relief Fund.

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On February 12, 2021, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced the details of its previously-announced discretion in the enforcement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act related to privacy, security, and date breaches. OCR will not penalize covered health care providers or their business associates for non-compliance under HIPAA for the good faith use of online or web-based scheduling applications (WBSAs) for scheduling COVID-19 vaccination appointments during the COVID-19 pandemic.

During the COVID-19 public health emergency, HIPAA covered providers, such as large pharmacy chains, or business associates acting on behalf of the covered providers, may utilize WBSAs to schedule individual appointments for COVID-19 vaccinations. For the purposes of this exercise of discretion, a WBSA is an online or web-based application that only allows the intended parties to access the data and that provides individual appointment scheduling related to largescale COVID-19 vaccination. Technology that directly connects to electronic health records (EHR) systems used by covered providers is not included in this discretionary measure and does not constitute a WBSA. The HIPAA privacy rules allow business associates of a covered entity to use and disclose protected health information (PHI) for certain functions, only as dictated by a business associate contract or other agreement. However, during the COVID-19 pandemic, health care providers need to quickly schedule many appointments for COVID-19 vaccinations and often do this through WBSAs. Some of these online scheduling applications, and the way in which healthcare providers use them, may not comply with the HIPAA privacy rules.  Furthermore, vendors of the WBSAs may not know providers are using these applications to create and send PHI, potentially making the WBSA vendors business associates under HIPAA.

OCR will exercise discretion in the enforcement of HIPAA privacy rules and will not penalize covered healthcare providers, their business associates, or WBSA vendors who are technically business associates, for noncompliance as it relates to the scheduling of individual COVID-19 vaccination appointments during the COVID-19 pandemic. This enforcement discretion applies to covered healthcare providers and their business associates, which are, in good faith, using WBSAs to schedule COVID-19 vaccination appointments, as well as WBSA vendors whose platform is being used to schedule COVID-19 vaccination appointments. Discretion does not apply to covered providers or business associates for activities unrelated to the scheduling of COVID-19 vaccinations or if the covered providers or business associates fail to act in good faith. Instances where a covered provider or business associate are not acting in good faith include: the use of a WBSA that allows the sale of personal information collected, the use of a WBSA for purposes other than scheduling COVID-19 vaccination appointments, the use of a WBSA without reasonable safeguards to protect the PHI, and the use of a WBSA to screen individuals for COVID-19 before an in-person visit.

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The Michigan Department of Health of Human Services (MDHHS) recently announced various support programs to help Michigan residents sign up for and gain access to the COVID-19 vaccine. Methods to obtain a COVID-19 vaccine in Michigan have been difficult for individuals 65 and older; many county local health departments are not offering the vaccine and will not provide vaccine information over the phone. These resources may be useful to providers when consulting with elderly patients.

Since individual physician providers cannot yet distribute the vaccine, the only other option for older qualifying individuals is to make an appointment with a local hospital system or pharmacy that is currently distributing the vaccine. However, these hospitals require patients to have an active online chart account with the hospital. In addition, hospital vaccine appointments are given to online chart account holders at random, and patients must continue to monitor their emails for appointment notifications. Many pharmacies, such as Right Aid and Meijer, are following a similar format for those 65 and older, and require patients to schedule appointments online or through the pharmacy’s smartphone application. These processes have caused difficulty for elderly individuals seeking the vaccine, who may have more trouble navigating online portals, emails, and smartphone applications.

Due to the varying degrees of technological access and understanding of Michigan residents 65 and older, MDHHS is working with community partners to make the COVID-19 vaccine appointment process smoother. Qualifying residents can visit Michigan.gov/COVIDvaccine for the most current COVID-19 vaccine information or call the COVID-19 Hotline at 888-535-6136 for assistance. MDHHS has also partnered with 2-1-1, a free, confidential website service that helps connect Michigan residents with COVID-19 information and community organizations across Michigan with thousands of different programs. 2-1-1 utilizes a comprehensive database of health and human services in Michigan with more than 7,000 agencies providing over 36,000 services across the state. MDHHS first began its partnership with 2-1-1 in June of 2020 to help individuals in Michigan find and register for COVID-19 testing, over the phone or internet, and expanded its partnership on February 12, 2021 to include directing individuals to local vaccination clinics.

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On February 17, 2021, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) updated its FAQ’s concerning the COVID-19 public health emergency. In the update, OIG gave guidance on its enforcement discretion regarding administrative services provided to COVID-19 vaccination sites on a per-vaccine basis. It should be noted that this guidance is not an advisory opinion, is not binding on OIG, and does not constitute a waiver of any statutory or regulatory requirement, though it may be helpful when structuring these arrangements.

OIG addressed the question of whether a non-provider philanthropic entity could contract to provide administrative services to a healthcare provider relating to the operation of COVID-19 vaccination sites and be compensated on a per-vaccine basis. The entity would provide administrative services including arranging for the physical vaccination sites, data systems, online and web-based scheduling, site development and training, and reporting to state agencies. The healthcare provider would provide clinical staff, oversee administration of the vaccine, and bill third-party payors, including federal healthcare programs.

After billing for the vaccine administration, the healthcare provider would retain a certain amount per hour for compensation and to cover staffing costs. The remainder of the compensation would flow to the entity providing the administrative services. OIG specified that there would be no other arrangements between the entity, the healthcare provider, any beneficiary, or other person capable of arranging for referrals for items or services payable by a federal healthcare program.

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On December 28, 2020, the Michigan Department of Health and Human Services (MDHHS) announced that skilled nursing home residents and staff members would begin to receive the Moderna COVID-19 vaccine immediately. This effort is made possible by the state of Michigan’s participation in the Pharmacy Partnership for Long-term Care (LTC) Program.

As a result of the COVID-19 pandemic, the Pharmacy Partnership for LTC Program is a partnership between the Centers for Disease Control and Prevention (CDC) and CVS, Walgreens, and certain participating Managed Health Care Associates, Inc. (MHA) pharmacies, to offer COVID-19 vaccination for residents and employees of nursing homes and assisted living facilities. Starting in November 2020, long term care facilities (LTCFs) could sign up for the program and choose a federal pharmacy partner. The CDC worked with local jurisdictions to match facilities with their selected pharmacy partner. Pharmacy partners then reached out to their assigned LTCF to coordinate the vaccine process. Through the program, LTCFs will receive the vaccine free of charge, and will be provided with end-to-end management of the vaccine process, including on-site administration of vaccinations, scheduling, and coordination of on-site clinic dates, ordering vaccines and necessary supplies, and the implementation of reporting requirements. The goal of the program is to reduce the burden on LTCFs and local health departments, while increasing vaccination to vulnerable, priority populations.

Skilled nursing home residents and staff are among the highest risk for severe illness and death due to COVID-19. In Michigan, over 5,000 LTC facilities, including 400 skilled nursing facilities, are enrolled in the vaccine program. There are approximately 91,000 skilled nursing residents and employees to be vaccinated, with the process estimated to require three weeks to completely vaccinate this population. Other facilities eligible for the Pharmacy Partnership for LTC Program, such as, assisted living facilities, personal care homes, residential care, adult family homes, adult foster homes, HUD supportive housing for the elderly and veterans’ homes, will soon receive vaccinations as well. Adult day care facilities, independent living facilities, facilities exclusively for children or adolescents, psychiatric rehabilitation or behavioral treatment facilities, and drug or alcohol rehabilitation centers are not eligible for the program.

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The Michigan Department of Health and Human Services (MDHHS) has released two new tools to help reduce COVID-19 infections, deaths, and identify exposure risks, amidst the COVID-19 pandemic. The MI COVID Alert App is a free, anonymous app that alerts users if they have had a recent COVID-19 exposure. In addition to the MI COVID Alert App, the MDHHS launched CV19 CheckUp, a free, anonymous, online service that allows an individual to evaluate his or her personal COVID-19 risks.

In a partnership with MDHHS and the Michigan Department of Technology, Management and Budget (DTMB), the MI COVID Alert App was released statewide on November 9, 2020. The app is free, voluntary to use, and alerts users to recent COVID-19 exposures. Users can anonymously submit a positive COVID-19 test result as well, informing others nearby that they may have been exposed to the virus. When a person tests positive for COVID-19, the individual will receive a randomly generated PIN number from the local health department or State of Michigan, which the user can then enter into the app. If a user receives an exposure notification, this alerts the individual that he or she may have been within 6 feet for a minimum of 15 minutes of another individual with a positive test result. Notably, no information that can be used to personally identify or track a user’s location is required or shared; no names are necessary to use the app, and Bluetooth technology is used instead of GPS, to prevent location tracking. One month since its launch, the app has received 461,192 downloads. MDHHS claims the app has potential to decrease infections and mortality, even with only a 15% population use rate.

In addition to the app, on December 15, 2020, MDHHS launched the CV19 CheckUp tool. This free tool, available to all individuals in Michigan, offers users a personalized risk analysis for COVID-19. After completing an online questionnaire that takes into account an individual’s life situation and personal behavior, users are provided with a COVID-19 risk assessment as well as recommendations and connections to support services, if necessary. Although this tool is available for all Michigan residents, it is specifically created for older individuals, those 60 and over, who represent 24% of confirmed COVID-19 cases and 89% of confirmed COVID-19 deaths in Michigan. Like the MI COVID Alert App, the CV19 CheckUp tool is anonymous, and no name, email address, or other personal identifier is necessary to use and receive a personal risk and recommendation analysis. Rather than placing the burden on the individual to browse various websites and other COVID-19 related resources, the CV19 CheckUp tool uses data from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), as well as artificial intelligence, to analyze each person’s data, providing them with a risk level, an easy-to-understand evaluation of that risk, and steps that can be taken to minimize that risk.

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