Administration proposes $400 billion increase in funding for home and community-based care: Your COVID-19 Briefing
In this edition
Use the links listed below to jump between sections.
NEWS
Vaccine passports
Are Americans starting to reemerge from COVID hibernation?
Medicaid coverage expansion may be in the works
OIG reports how hospitals have fared during the pandemic
COMPLIANCE
CLINICAL
ADMINISTRATIVE
Good news and bad news on Medicare sequestration
Accelerated Payments: time to repay the piper
CMS revises home health billing instructions
Extension of Review Choice Demonstration phase-in
Please note
The views, information, and guidance in this resource are provided by the author and do not necessarily reflect those of WellSky. The content provided herein is intended for informational purposes only. The information may be incomplete, and WellSky undertakes no duty to update the information. It is shared with the understanding that WellSky is not rendering medical, legal, financial, accounting, or other professional advice. WellSky disclaims any and all liability to all third parties arising out of or related to this content. WellSky does not make any guarantees or warranties concerning the information contained in this resource. If expert assistance is required, please seek the services of an experienced, competent practitioner in the relevant field. WellSky resources are not substitutes for the official information sources on COVID-19. Providers should continue to track developments on official CMS and CDC pages, including:
CMS response to Coronavirus and latest program guidance
CDC interim infection prevention and control recommendations
Current cases & maps
At this time last year, many states across the country were in various phases of a lockdown that closed schools and businesses, brought an abrupt halt to travel, and left most of us with an impending feeling of doom that was not dispelled by news reports of what we could expect. In the April 6, 2020 edition of the COVID-19 Briefing, we reported that there were, at that time, 337,000 diagnosed COVID-19 cases that had resulted in the deaths of 9,600 people. Here we are a year later with the total number of COVID-19 cases in the United States well on the way to 31 million and mortalities attributable to the virus at nearly 554,600. We are adding 64,000 cases of COVID-19 a day, representing an increase of 18% over the last two weeks with the areas of concern being the Northeast and upper Midwest, especially Michigan. In spite of the concerns in those two areas, the overall map from the New York Times shows that, following the spike in cases during January, new case counts have dropped significantly. This is a welcome trend after the spike in cases at the beginning of the year.
Hospitalization rates, which were also a significant concern earlier in the year, have stabilized and show no meaningful rate of change over the last two weeks. However, we are beginning to hear more about the long–term effects of the virus, especially from those who were hospitalized with severe illness. I can’t help but wonder about the long–term effects of COVID-19 on care at home in the future.
The mortality rate has been dropping by 23% over the last two weeks, which is the best news of all.
The New York Times heat map, which in recent iterations of this report has been painted bright red, is also showing signs of abatement due largely to continued social distancing, moderation of group activity, and vaccination efforts, which are proving to be successful.
The New York Times also publishes a graphic of county risk for the virus, with the greatest risk shown as purple followed by red, orange, yellow, and green indicating the most to least concentrated areas of risk. While there is precious little green on the map as of April 4, there is some, and the purple hues of the holidays are fading away. We need to keep it that way, and I hope it will show us much more green next month.
On March 19, President Biden announced that the Administration’s goal of vaccinating at least 100 million people by his hundredth day in office would clearly be met. Then he upped the goal to 200 million. The nation appears to be on track to meet that goal, too.
As of April 5, a total of 207.9 million doses of vaccine had been distributed across the country and over 167 million doses had been administered. That amounts to about 80% of the doses that have been sent out. Over 106 million people have received at least one dose and about 32% of the population – more than 61 million people – are now fully vaccinated. The map below from the New York Times shows the percentage of all residents, by state, who have now been fully immunized against COVID-19. States in the upper Midwest and New England are generally leading the pack.
Many experts have indicated that between 70% and 90% of the population will need to be vaccinated to reach the point of herd immunity such that the transmission of the virus will substantially slow. However, the threat of variants on the virus may complicate progress toward acceptable levels of nationwide immunity.
Over the last month, many states have also relaxed eligibility rules for vaccination with most states now allowing vaccination of young adults as well as the elderly and individuals at high risk or who work in critical infrastructure. There are a handful of states that still limit vaccines to those aged 60 or older – Hawaii, Washington, Oregon, Missouri, Pennsylvania, Virginia, New Jersey, Rhode Island, and Massachusetts; however, the Administration has indicated its intention to move up the deadline for making all adults eligible for vaccination from May 1 to April 19.
The state of Texas made the news recently for abandoning its mask mandate, but it is not the only state to do so. A total of 18 states now have no mask mandate, with two — Kansas and South Carolina — requiring masks only in certain situations. All other states have continuing mask orders in place.
News
Vaccine passports
We have heard rumblings about the creation of vaccine passports that are already being used in Israel and actively contemplated in parts of Europe. Designed primarily to help the travel industry, the concept has been met with only tepid support here in the U.S. And, as one might expect, the general conversation has run along political party lines even though the Administration has indicated that it does not intend to overtly pursue the idea at the federal level. That said, the Department of Health and Human Services (HHS) may offer development guidelines to steer private sector initiatives in the right direction with respect to patient privacy.
The so-called passports are essentially apps that operate on a smartphone stating that the bearer has been vaccinated against COVID-19. Among the concerns are protection of personal health information and access to the technology for everyone who might need it if the passports become widely required. While there is a limited government partnership between the State of New York and a private company offering Excelsior Pass, a “free, fast and secure way to present proof of COVID-19 vaccination or negative test results,” a number of state legislatures are actively pondering the idea of banning such apps in their states for a variety of reasons ranging from too much government oversight to privacy and data integrity issues.
In a recent article from the Associated Press, Dr. Brian Anderson of Mitre, a company that operates federally funded research centers and a participant in a collation working to develop a vaccination credential, notes, “There will be organizations that want to use these. There will be organizations that don’t want to use them.” According to the article, Albert Fox Cahn, founder and executive director of the Surveillance Technology Oversight Project at the Urban Justice Center, a New York–based civil rights and privacy group, has said that the version of the pass in use in New York “creates a new layer of surveillance without sufficient details about how it collects data or protects privacy.” Cahn explained, “We basically only have screenshots of the user interface and not much more.” I suspect this is a conversation that will be around for a while.
Are Americans starting to reemerge from COVID hibernation?
A recent Wall Street Journal article compared activities during the period from January to early March of this year to the same period in 2020 to gauge the change in mobility illustrated by trips away from home for a duration of at least 10 minutes. The results are interesting with the clear takeaway that life – as we used to know it – has not yet returned to normal in most parts of the country.
People in North Dakota, South Dakota, and Wyoming are showing the greatest increase in activities outside their homes, and the data shows that retail establishments, gyms, churches, and restaurants are essentially open in those states. The exception is movie theaters which have not returned to normal operations. At the other end of the scale are California, the District of Columbia, Hawaii, Massachusetts, and New York which show varying degrees of resurgence based on the type of activity.
Long story short – we have a way to go yet, and it will probably be later in the summer when a greater percentage of the population has been vaccinated before things really start getting back to normal.
Medicaid coverage expansion may be in the works
A significant outcome of the public health emergency — and its latent effect on state treasuries — is the dent that that was made in Medicaid funding following the loss of tax revenues in many states. Last week, the Administration unveiled a two trillion-dollar infrastructure initiative that would, among other things, result in an increase of $400 billion in funding for home and community-based care. If Congress approves the funding, it would be one of the largest financial investments in home and community-based services in more than a decade and would affect more than five million people who receive Medicaid services. The initiative has been called a “gamechanger” by many industry organizations and watchers.
The Kaiser Family Foundation has estimated that as many as 800,000 people have been waitlisted for services since 2018, many of whom have developmental or intellectual disabilities. It can sometimes take years for those who are eligible to actually receive needed services. Thus, providing a financial safety net would mean that states would be able to move people from the waitlist to receiving assistance at home much more quickly than they can now — especially with looming Medicaid cutbacks. The National Association for Home Care and Hospice (NAHC) called the move “a monumental advance in the decades long effort to provide full access to healthcare outside of an institution.” NAHC is urging Congress to take action to approve the funding. It is hoped that eventually, Congress will also establish a baseline of required Medicaid home care benefits that will eliminate caps on the number of people who can be served (a program constraint in some states) and their often years–long wait for help.
The plan also calls for the preservation of the federal Medicaid program known as Money Follows the Person (MFP), which provides short–term funding that allows nursing home residents to move out of facilities and into their own homes.
In the larger scheme of things, the spending associated with the plan is spread over ten years and paid for by corporate tax increases. In the short-term, the plan would have a multiplier effect of 1.5 which means that for every dollar of investment there would be a $1.50 increase in the gross domestic product.
Congress will need to support and pass the measure to make it into law. No word yet on how or when that might happen.
OIG reports how hospitals have fared during the pandemic
There is a new report from the HHS Office of the Inspector General (OIG) entitled “Hospitals Reported that the COVID-19 Pandemic Has Significantly Strained Health Care Delivery.” Taken from a survey in February, the report includes information from 320 hospitals and concludes that hospitals are operating in “survival mode.” According to one administrator, “We have patients in the acute care setting that really do not belong here in terms of what they need clinically but can’t move on because there is not an available option.” The report notes that discharge delays affected available capacity that adversely impacted the range of available patient services.
The following findings in the report may be of interest to post-acute providers:
- The survey emphasized the significant clinical challenges in treating COVID-19 patients, some of whom were very ill with long-term effects lingering after their recovery from acute stages of the illness. There were also reports of difficulty in creating a balance between the needs of COVID-19 patients and others due to challenges in discharging patients to post-acute settings during their recovery. This is something we need to pay attention to.
- Hospitals reported that patients have often delayed or forgone routine healthcare as a result of the pandemic which, in turn, has resulted in worsening patient conditions. Administrators predicted that these delays in care will ultimately result in higher hospitalization rates and the need for more complex hospital care (and presumably, post-discharge care) in the future.
- Hospitals reported that telehealth has become an important care delivery tool, but there are challenges with its use, as telehealth cannot cover all aspects of care delivery. There were also reports that some patients, especially those in underserved communities, do not have devices or internet access that enable them to participate in video calls, creating disparity with respect to available care.
- Many hospitals reported concerns with staffing shortages, particularly among nurses, which raises concern about patient safety and quality of care. There were concerns about the future of the healthcare workforce as the recruitment pool for nurses and other healthcare workers continues to shrink.
- Although hospitals view their vaccination efforts as a positive step, several noted that the effort comes at a cost, further stretching limited clinical staff and straining hospital finances. Differences in government guidance as to eligibility also created challenges. They reported that some staff members were distrustful of the rapid development of the vaccines and the approval process and had concerns that the vaccines may not be effective or may pose unknown health risks.
The report is interesting and worth the read. As we think about hospitals in our communities, one thing comes to mind. Home health, especially, as a downstream destination for hospitalized patients, can and should provide an outlet for hospitals and their discharge efforts. For a long time, many in our industry have complained about the inefficiency of the discharge process. Now may be a good time to step up and work with inpatient institutions in the community to see what can be collectively done to smooth out the process for the benefit of all.
Compliance
Updates to Provider Relief Fund FAQs
Last week, HHS released new modifications to the Provider Relief Fund FAQs with additional information directed at the terms and conditions of the program, ownership structures, and use of funding. Here, we paraphrase the questions and modified answers from March 31:
- 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? Recipients must demonstrate that lost revenues and COVID-19–related expenses meet or exceed total Provider Relief Fund payments. Monies that have not been appropriately expended by the end of the final reporting period must be returned to HHS. Moreover, HHS has the right to audit Provider Relief Fund recipients now or in the future to ensure that program requirements are met. Payments that were made in error or that exceed lost revenue or COVID-19–related expenses and do not otherwise meet program requirements must be returned, and HHS is authorized to recoup those funds.
- Is there a set period of time in which providers must use the funds to cover allowable expenses or lost revenues attributable to COVID-19? Yes. Provider Relief Funds must be expended no later than June 30, 2021. HHS will provide direction in the future about the process for returning unused funds. All payment recipients must attest to the Terms and Conditions, which require the submission of documentation to substantiate that these funds were used for healthcare–related expenses or to cover lost revenues attributable to COVID-19.
- What oversight and enforcement mechanisms will HHS use to ensure providers meet the Terms and Conditions of the Provider Relief Fund? Providers must comply with the Terms and Conditions related to Provider Relief Funds. Failure to comply can result in action to recoup some or all funds that were advanced. All recipients will be required to submit documents to substantiate that funds were used for healthcare–related expenses or lost revenue and that those expenses were not reimbursed from other sources, including that other sources were not obligated to provide reimbursement, even if they did not.
- In order to accept a payment, must the provider have already incurred eligible expenses and losses higher than the Provider Relief Fund payment received? No. Providers do not need to be able to prove revenue losses or expenses at the time that funds are accepted. The requirements specify that, if on June 30, 2021, providers have remaining funds that they cannot expend on permissible expenses or losses, then providers must return the money to HHS.
- When reporting my organization’s healthcare expenses attributable to coronavirus, how do I calculate the “expenses attributable to the coronavirus not reimbursed by other sources?” Expenses related to coronavirus may include items such as supplies, equipment, information technology, facilities, employees, and other healthcare–related costs for the calendar year. The classification of items into categories should align with how the organization already maintains its records. Providers can identify their expenses and then apply any amounts received through other sources that include direct patient billing, commercial insurance, Medicare/Medicaid/Children’s Health Insurance program or other funds received from the Federal Emergency Management Agency (FEMA), the Provider Relief Fund, and other sources such as Paycheck Protection Program funding 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.
- 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 healthcare 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? Yes. If the healthcare 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 healthcare provider from being eligible for Phase 3 – General Distribution; however, the healthcare provider must substantiate that the Provider Relief Fund payments were used for healthcare–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.
New Administration and new shifts at the DOL
As Marty Walsh, former Mayor of Boston and a labor proponent, was confirmed as the Biden Administration’s Secretary of Labor, all employers should expect a slight shift in the Department of Labor’s (DOL) priorities. COVID-19 workplace safety, worker classification, and minimum wage issues will all be front and center – and each will likely be important to post-acute providers.
In mid-March, the Occupational Safety and Health Administration (OSHA) issued new guidance on employees returning to work and the safety measures that employers should adopt. A new National Emphasis Program (NEP) has been established with more agency resources dedicated to COVID-19–related inspections. Inspections were scheduled to begin in late March, and by May, states will need to inform OSHA of their own programs and intent. This will certainly be a priority for Secretary Walsh.
The program is designed to “ensure that employees in high-hazard industries are protected from the hazard” of contracting COVID-19. The NEP is intended to augment OSHA’s ongoing efforts to ensure workplace safety by targeting specific high-hazard industries where there is increased potential exposure to COVID-19. The NEP will also address protection from workplace retaliation and will be tasked with, among other things, referring allegations of retaliation to the whistleblower protection program.
In the meantime, many also expect the DOL to increase scrutiny of employer classification issues related to treatment of workers as independent contractors. This has been an issue in past years for some post-acute providers, so a watchful eye will be worthwhile as it will likely be more difficult for borderline independent contractor classifications to hold up under added scrutiny. If your agency has independent contractors, now would be a very good time to revisit the rules.
Finally, there are expectations that the DOL will actively support the Administration’s goal of moving the federal minimum wage to $15, which will be especially significant for home care providers.
Clinical
Expanded access to antibody treatments
The Food and Drug Administration (FDA) has recently issued an emergency use authorization (EUA) for monoclonal antibody therapies, bamlanivimab and etesevimab, administered together, for treatment of mild to moderate COVID-19 in adults and children (12 years of age or older weighing at least 40 kilograms [about 88 pounds]) with positive test results who are at high risk for severe disease. Bamlanivimab and etesevimab can only be administered together in settings capable of responding to severe reactions such as anaphylaxis. High–risk patients are those:
- With a body mass index (BMI) ≥35,
- With chronic kidney disease,
- With diabetes,
- With an immunosuppressive disease,
- Who are currently receiving immunosuppressive treatment,
- 65 or older,
- 55 or older with cardiovascular disease, hypertension or COPD, or other chronic respiratory disease, or
- Who are between 12 and 17 and have:
- BMI in the 85th percentile or higher for their age,
- Sickle cell disease,
- Congenital or acquired heart disease,
- A neurodevelopmental disorder such as cerebral palsy,
- A medical-related technological dependence such as a tracheostomy, gastrostomy, or positive pressure ventilation, or
- Asthma, reactive airway, or other chronic respiratory disease that requires daily medication for control.
The products, offered by Eli Lilly and Company can be coded for payment using:
- Q0245 – For injection of bamlanivimab and etesevimab 2100 mg, or
- M0245 – For IV infusion of bamlanivimab and etesevimab
Administrative
Good news and bad news on Medicare sequestration
The good news is that both the House of Representatives and the Senate have taken separate actions to further suspend Medicare sequestration cuts to reimbursement. The House got there first with HR 1868, followed by the Senate’s version which now must go back to the House before it can be presented to the President for signature. In addition to the suspension of sequestration reductions, the pay–as–you–go requirement is also waived under the House bill which means that any lifting of sequestration reductions does not have to be offset by other spending cuts. The Senate bill lacks that provision; thus, the Senate bill needs to go to the House for approval. The suspension would delay the reimposition of sequestration reductions through the remainder of 2021.
The bad news is that the Centers for Medicare & Medicaid Services (CMS) has told the Medicare Administrative Contractors (MACs) to postpone payment of claims for care provided on or after April 1 ostensibly until the legislative matter is settled. The reasoning is that the continuation of the moratorium was slated to go into effect on April 1. Payments to some providers could be delayed while the issue is pending.
Accelerated Payments: time to repay the piper
MACs are starting to recoup Accelerated Payments that were granted last year based on the one-year anniversary of the payments to providers.
For a period of 11 months, CMS will recover the payments from claim payments due to providers at a rate of 25%. After the 11-month term is up, if full payment has not been made, CMS will continue its recovery of payments at the rate of 50% for six months or until the full amount is repaid. If the accelerated payments are not fully repaid at the end of the 17-month period, CMS will issue a demand letter for the remaining balance, and if payment is not received within 30 days, interest will accrue at the rate of 4% starting with the date of the demand.
Recoupment balances will be shown on remittance advices as an adjustment in the Provider Level Balance or PLB.
CMS revises home health billing instructions
CMS has revised Change Request 11855 through Transmittal 10696, which came out on March 31. The revisions note that the primary diagnosis reported on the Request for Anticipated Payment (RAP) need not be the actual primary diagnosis that will be reported on the final claim for reimbursement. Additionally, confirming what we have already learned due to system issues, the date associated with the 0023 Revenue Code must be the first day of the payment period on both the RAP and Final bill to enable matching of the RAP and Final prior to payment. The exact changes are quoted below:
- For “From” dates on or after January 1, 2021, the RAP may report any valid diagnosis code, in order to facilitate timely submission. Since these RAPs are not paid, the accurate principal diagnosis code that supports payment is needed only on the claim for the period of care.
- For initial episodes/periods of care, the HHA reports on the 0023 revenue code line the date of the first covered visit provided during the episode/period. For subsequent episodes, the HHA reports on the 0023 revenue code line the date of the first visit provided during the episode/period, regardless of whether the visit was covered or non-covered, unless the HHA submitted the corresponding RAP using the first day of the period of care as the service date on the 0023 line. In that case, the HHA reports a service date on the 0023 revenue code line that matches the date submitted on the RAP. This is necessary in order to ensure Medicare systems can correctly match the claim to the RAP during processing.
Extension of Review Choice Demonstration phase-in
The phase-in of the Review Choice Demonstration (RCD) for Florida and North Carolina agencies has been extended for an additional 90 days due to the continuation of the public health emergency.
If a provider is interested in participating in RCD, Cycle 2 choices should be made by April 15. Cycle 2 will begin on May 1, 2021. Depending on the provider’s Cycle 1 results, a different choice can be selected for Cycle 2. Those providers that make no choice selection may continue to submit review requests with the understanding that claims that are processed with an assigned Unique Transaction Number (UTM) will be saved from further medical review. Claims that are submitted without going through the pre-claim review process will not be subjected to the 25% payment reduction but could be subjected to further medical review. If a provider chooses not to participate, no further action is needed.
In closing . . .
COVID-19 is still with us, but it’s slowly and surely becoming less of a force in our lives. It has been a very long year for many, especially those of you taking care of patients who need you more than ever. I am, like many, grateful for all that you do and for the many wonderful ways that providers across the country have risen to the occasion. As warmer weather gives us a glimpse of better things to come, I have hope for the light at the end of the tunnel. I’ll be back next month with more. Until then, be careful, stay safe, and above all, stay positive.