On April 9, ACO experts from Caravan Health and CPAs and Business Advisors from Eide Bailly came together to discuss the recent CMS changes and how the new rules will likely affect rural health systems across the nation. CMS recognized the pandemic as an extreme circumstance and released a new set of rules and waivers that includes quality reporting and performance loss relief for MSSP ACOs.

The webinar, part of the ongoing COVID-19 educational series, began with Greg Paris, VP of Customer Success at Caravan Health, discussing the COVID-19 public health emergency and its effects on rural providers. Presenters with Eide Bailly included Senior Manager’s Joy Krush and Deyon Suchla, Brian Bertsch, Principal, and Ralph Llewellyn, PIC of Critical Access Hospitals. The presenters exchanged positions at the helm to lead the discussion on the implications of the emergency funding considerations.

Key discussion points included:

  • Revenue Cycle & Telehealth
  • Cost Reporting & Reimbursement Concerns
  • Operations & Funding
More than 350 participants attended and were welcome to ask questions and a synopsis of the questions and responses follows.

The discussion concluded with a reiteration to pursue funding opportunities and preserve cash flows. It will be important to make wise long-term decisions and to not cut things in the short-term that could harm your facility in the future. Telehealth is likely here to stay and considering how you plan to utilize the service, with a large portion of staff doing telehealth, will be helpful. The ‘new normal’ will likely involve seeing a surge in non-essential and non-critical services and preparing for the surge will be essential.
 
Q&A
On the accelerated payments, the calculation states a time period of 7/1/19 to 12/31/19 x 125%...is this based on service date or claim paid date?
We aren’t sure what CMS released about this, but we are guessing it was probably from the dates of service that were paid during that timeframe between 7/1 and 12/31. This is typically how CMS has handled this although we’ve not seen anything specifically clear on that one item.
 
Can we revisit the pt, OT and speech pathology telemedicine codes and whether these can or cannot be utilized/billed?
For therapy services, some health plans are moving toward using facility based/institutional therapists since they are allowed to bill on the UB-04 using the expanded codes - as long as they provide it as a "telehealth" (audio /visual live) and follow their billing requirements as outlined in their policy. 
The following information provided is for Medicare only. We recommend continuing to monitor for changes.

In the interim final rule and in a document published by CMS following the signing of the CARES act, therapy codes (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507) were added as codes which can be provided via telehealth.  What was not added, was additional providers to the list of qualified providers which can perform and bill for telehealth.  Therapists are not currently on the list of qualified providers who can bill for telehealth services to Medicare. Whether a hospital therapist or an independent therapist, neither group can bill telehealth using the codes listed above to Medicare. 

There have been other codes discussed for therapists.  This set of codes are:
  • G2061 – G2063 - Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes / 11-20 minutes / 21 or more minutes.
  • Therapists can report these; however, it appears that only therapists who are independent and bill under their own NPI on a 1500 could report this to Medicare.  The codes are a status indicator M (service not billable to MAC).  Based on the status indicator, it does not appear the codes would go through on a hospital claim with revenue code 420/430.  The codes are a professional service and we do not believe they would pass through as a “hospital service”.   During this public health emergency, codes G2010 and G2012 were added as codes which can be reported for professionals that can report G2061- G2063. However, note in the information posted below, in the final rule they use the terminology “private practice”.  This is another indication that the codes are only to be used by therapists who bill on the 1500. 
    • In the interim final rule published by CMS, additional G codes were added during this emergency period. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits. (HCPCS codes G2061-G2063). 
    • On an interim basis, during the PHE for the COVID-19 pandemic, we are also broadening the availability of HCPCS codes G2010 and G2012 that describe remote evaluation of patient images/video and virtual check-ins. We recognize that in the context of the PHE for the COVID-19 pandemic, practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists might also utilize virtual check-ins and remote evaluations instead of other, in-person services within the relevant Medicare benefit to facilitate the best available appropriate care while mitigating exposure risks. We note that this is not an exhaustive list and we are seeking input on other kinds of practitioners who might be furnishing these kinds of services as part of the Medicare services they furnish in the context of the PHE for the COVID-19 pandemic  Further, to facilitate billing of the CTBS (communication technology based service) services by therapists for the reasons described above, we are designating HCPCS codes G2010, G2012, G2061, G2062, or G2063 as CTBS  “sometimes therapy” services that would require the private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. CTBS therapy services include those furnished to a new or established patient that the occupational therapist, physical therapist, and speech language pathologist practitioner is currently treating under a plan of care.

 
When you stated, ‘interim final rule’, does this mean they are able to be used now, or do we have to wait for actual ‘final rule’? If so, when should we expect this?
Typical rule making by CMS is a proposed rule, followed by a comment period and the publication of a final rule. All official CMS rules are published in the Federal Register. As this rule was for the public health emergency, it was published as an interim final rule.  The publication in the Federal Register has already occurred. The document published in the Federal Register is the official HHS-approved document. CMS has published many guidance documents from this rule.
 
Are these only for rural health and CAHs or do these rules apply to all providers regardless of setting?
The rules are not specific to RHC or CAH only.  Free standing clinics, provider-based clinics, and PPS facilities are also included. It is important to understand how the rule applies in each setting.
 
Can you clarify that an RHC can bill a 99201-99215 with a 95 modifier for an audio and video visit?  Or can we only bill G0071?
As of the date of this webinar, guidance has not been received from CMS how to bill an audio/visual (telehealth) E/M visit to Medicare performed in an RHC. 
 
Guidance for RHC that has been published to date: CMS has removed some regulatory requirements and added additional flexibilities to assist RHCs and FQHCs in furnishing services during the COVID-19 Public Health Emergency (PHE). These include a) Expansion of Virtual Communication Services for RHCs and b) FQHCs to include online digital evaluation and management services.
 
RHCs and FQHCs can bill for online digital evaluation and management services using the RHC/FQHC HCPCS code G0071. The payment for G0071 will be the PFS national non-facility payment rate for HCPCS code G2012 (communication technology-based services), HCPCS code G2010 (remote evaluation services), CPT 99421, CPT 99422, and CPT 99423. The new payment rate is $24.76.
 
 
Can you talk about the Medicare RHC Telehealth visits, and how they affect the Encounter Visit numbers (Total visits and Medicare visits), and how the costs involved in providing the visits should be handled for Cost Report purposes?
Per the Cares Act legislation, it indicated that telehealth service costs should not be used in establishing the RHC all-inclusive rates, as these services would be paid similarly to the national average payment rates for comparable telehealth services under the Medicare physician fee schedule. Since telehealth services performed by RHCs would be paid under fee schedule rates and not the all-inclusive rate, the costs of practitioners performing telehealth services should be carved out of the RHC cost report. In addition, both the total and Medicare telehealth visits should not be included in the face-to-face visits included on the cost report.
 
What do you do if the Medicare Advanced Payment was incorrect i.e., as a CAH we should have received 125% of 6 months, but only received 3 months at 100%?
Per the CMS fact sheet, IPPS, and Children’s & Cancer Hospitals will receive 100% of Medicare payments up to a 6-month period. Critical Access Hospitals will receive up to 125% of Medicare payments up to a 6-month period. All other Part A providers and Part B suppliers will receive 100% of Medicare payments up to a 3-month period. Based upon our communications with the Medicare Administrative Contractors (MACs), there have been multiple interpretations in determining how much should be paid out under the Medicare Advanced/Accelerated Payments. It is our understanding that some MACs have determined to pay up to the six months for all PTANs associated with either an IPPS or CAH facility, while others have determined to pay only the three months for non-hospital PTANs. It is our understanding that there aren’t any appeal rights regarding the advance/accelerated payments, but you may reach out to your MAC to clarify the calculation.
 
To clarify, the PTAN for our skilled and RHCs will get paid 125% of Medicare payments up to 6-month period if we choose the advance payment since we are associated with a CAH AND get a year to pay that back?  What about Part B (pro fees)?
Per the CMS fact sheet, IPPS, and Children’s & Cancer Hospitals will receive 100% of Medicare payments up to a 6-month period. Critical Access Hospitals will receive up to 125% of Medicare payments up to a 6-month period. All other Part A providers and Part B suppliers will receive 100% of Medicare payments up to a 3-month period. Based upon our communications with the Medicare Administrative Contractors (MACs), there have been multiple interpretations in determining how much should be paid out under the Medicare Advanced/Accelerated Payments. It is our understanding that some MACs have determined to pay up to the six months for all PTANs associated with either an IPPS or CAH facility, while others have determined to pay only the three months for non-hospital PTANs. We recommend reviewing the payment you receive for each of your PTANs and for the Part B professional fees. If your MAC only paid the three-month amount at 100%, you will be subject to the repayment terms of up to 210 days from the date of the advance payment.
 
How are costs (CCM and telehealth) that are not in the cost report reflected in cost accounting for the MSSP? Also, should we assume that AIR will likely increase to max given reduced volume?
CCM and telehealth services for RHCs are not paid within the all-in rate for RHCs, these are paid under the Medicare physician fee schedule. CMS considers these payments when setting future rates for CCM and telehealth as part of the Medicare physician fee schedule.
 
Assuming medically necessary face-to-face visits are declining in the RHC and costs are staying relatively the same, it would be likely that the all-inclusive rate that Medicare pays would increase. However, if you have also reduced costs in your RHC due to lower volume, the all-inclusive rate could stay the same or perhaps decrease. We recommend occasionally completing an interim cost report to determine your interim rates.
 
Are you aware if CMS is waiving patients having to sign Important Message from Medicare Forms if they are an inpatient and a Medicare Outpatient Observation Notice Form if a patient is in observation during this time period?
We are not aware that the requirements for IMM or MOON have been waived during this time period. The requirement for the updated forms (April 1) has been relaxed:

April 6, 2020: Hospitals are strongly encouraged to begin using the new Medicare Outpatient Observation Notice (MOON) as soon as possible and no later than May 1, 2020.

April 6, 2020: Hospitals are strongly encouraged to begin using the new Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) as soon as possible and no later than May 1, 2020.

How will hospitals facing 90% reduction in inpatient revenues remain viable through this? This is multiple millions/month reductions in revenue for many.
This is a very valid question. Based on the fragile financial situation for many of our healthcare providers, we can only anticipate that this may be the straw that breaks the camel’s back. At the same time, we believe this emergency has refocused attention on how important access and diversification of service locations is for the long-term health of our country.
 
In the short term, providers are probably going to have to focus on a couple of areas. The first is the immediate infusion of cash. This will include loans and grants. Not all funding will be free without strings attached. We understand the concern with loans and repayment in the future. However, the reality is that not all funding is going to be forgivable. Obviously, great effort should be expended to ensure all grants, forgivable loans, etc., are accessed, but this may not be enough. Providers will need to continue to monitor to make sure they are receiving what they are entitled to.
 
Expense management/reductions are also going to have to be part of the solution. This may involve staff reductions, changes in how we do business, tough choices on programing with marginal benefit, etc. None of this will be popular or easy. In some situations, it may mean more of a delay in expenditures with postponement of capital outlays, education requiring travel, etc.
 
Finally, organizations are going to have to create a vision of what health care will look like after this emergency. Will we see a return to in-office visits to historical levels or will our patients change their behaviors and more readily accept and/or demand telehealth, virtual and e-visits? If so, consideration will be needed regarding change of processes, staffing, and revenue stream generation.

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