HHS extends deadline for acceptance of terms and conditions for Provider Relief Fund payments

HHS announced another extension to the deadline to accept the Terms and Conditions for Provider Relief Fund payments from the $50 billion general distribution. Providers now have 90 days from the date they received a Provider Relief Fund payment to accept the Terms and Conditions or return the funds. For example, providers that received funds on April 10 will have a new deadline for attestation of July 9. Furthermore, providers that do not accept the Terms and Conditions after 90 days of receipt will be deemed to have accepted the funds and associated Terms and Conditions.

MGMA will continue to track and report developments pertaining to the HHS Provider Relief Funds, including the nearly $100 billion in appropriated funding that has yet to be allocated. 

Newly updated MGMA resource: Commercial health plan COVID-19 policies

MGMA developed and recently updated the Commercial Health Plan COVID-19 Policies resource to help groups better understand key COVID-19 related health plan policies that impact medical practices. The resource incorporates information from large commercial plans such as Aetna, Cigna, Humana, UnitedHealthcare, and others. The resource outlines each plan’s policies on advanced payments, telehealth, prior authorization, billing/coding, and other relevant COVID-19 changes.

SBA releases long-awaited PPP loan forgiveness guidance

The Small Business Administration (SBA) released new interim final rules on Paycheck Protection Program (PPP) loan forgiveness and loan review process. The loan forgiveness guidance mostly clarifies information already published in the PPP loan forgiveness application, such as FTE reduction exceptions, how to calculate employee salary/wage reductions, and when payroll/nonpayroll costs must be incurred and/or paid to be eligible for forgiveness. The SBA loan review procedure guidance describes the process by which SBA plans to undertake PPP loan reviews, and reiterates that a lender must issue a decision to SBA on loan forgiveness within 60 days. That decision can take the form of an approval (in whole or in part), a denial, or a denial without prejudice due to a pending SBA review of the loan.

New draft legislation to amend PPP loans

After hearing from constituents, Congress identified several issues with the PPP as currently implemented. As a result, a number of bills were introduced to amend the PPP to provide borrowers with more flexibility. One of these bills, the Paycheck Protection Flexibility Act, is scheduled for a vote in the House of Representatives today. MGMA supports this legislation, which would allow loan forgiveness for expenses beyond the eight-week covered period, eliminate the restriction that limits nonpayroll expenses to 25% of the loan amount, extend the two-year maximum loan term requirement, and allow PPP borrowers to utilize the payroll tax deferment incentive established in the Coronavirus Aid, Relief, and Economic Security Act.

Provider Relief Fund attestation deadline approaching

Group practices who received a payment from the Department of Health and Human Services (HHS) under the Provider Relief Fund must sign an attestation confirming receipt of funds and agreeing to conditions of payment within 45 days of payment. That means groups who received funding from the initial distribution on April 10 have until May 24 to attest. Notably, not returning the payment within 45 days of receipt will be viewed as acceptance of the funds and associated terms and conditions.

HHS also announced this week that providers have until June 3 to submit revenue information to be considered for an additional payment from the $50 billion general distribution. While HHS automatically disbursed payments from the first tranche ($30 billion) starting on April 10, most group practices must submit a request to receive additional funds from the second tranche ($20 billion).

Finally, HHS updated and clarified FAQs on the Provider Relief Fund general distribution. With the Department updating their FAQs and website periodically without any formal announcement or notification, MGMA recommends that group practices review this new guidance. See MGMA’s resource on financial relief programs for more information.

SBA releases PPP loan forgiveness application

The Small Business Administration (SBA) released an application for Paycheck Protection Program (PPP) borrowers to submit to their lenders when seeking loan forgiveness. The application includes:

• Instructions on how to perform calculations for loan forgiveness;
• A list of documents borrowers must submit with the PPP loan forgiveness application;
• Confirmation that eligible nonpayroll costs still cannot exceed 25% of the total forgiveness amount;
• A newly created “Alternative Payroll Covered Period” for borrowers with biweekly (or more frequent) pay periods, which would allow the eight-week Covered Period to begin on the first day of the first pay period following PPP loan disbursement;
• Clarification that borrowers are generally eligible for forgiveness for payroll/nonpayroll costs paid and payroll costs incurred during the eight-week Covered Period (or Alternative Payroll Covered Period); and
• Additional FTE reduction exceptions.

While the application is helpful, it does not resolve all outstanding questions. MGMA hopes to see additional loan forgiveness guidance from SBA and will update membership on future developments. working from home, and other recommendations. In addition, the toolkit outlines the recently-released guidance from the Office for Civil Rights on HIPAA enforcement discretion for telehealth.

MGMA advocates for additional relief for physician practices, ACOs

Last week, Democratic leadership in the U.S. House of Representatives introduced the ‘‘Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act,” which includes several provisions that directly pertain to medical practices. The legislation would make further amendments to the PPP, Medicare’s Advance Payment Program, and the Provider Relief Fund. While this bill is not expected to pass due to lack of bipartisan support, MGMA offered several key recommendations for consideration as Congress works to come to a bipartisan agreement.

Additionally, MGMA and other industry-leading associations have urged the Centers for Medicare & Medicaid Services (CMS) to provide flexibility for practices participating in a Medicare accountable care organization (ACO) and to protect them from potentially harmful losses created by the COVID-19 pandemic. Specifically, MGMA called on CMS to:

New COVID-19 resource: Maintaining cyber security while working remotely To assist members in ensuring the security of their patient’s information when working outside their medical practice, MGMA has developed the new Maintaining Cyber Security while Working Remotely Toolkit. Home offices are increasingly being used during the COVID-19 pandemic, and they are generally more vulnerable to cyber attacks than systems located in medical offices. The resource offers action steps to ensure the physical security of devices, improve the security of your network, practical tips when

• Adopt a policy to give ACOs an option to be protected from losses in exchange for a reduced shared savings rate, no less than 40%;
• Extend the current June 1 Medicare Shared Savings Program (MSSP) deadline to voluntarily terminate to avoid financial losses to no earlier than Oct. 31;
• Reverse its decision to cancel the 2021 MSSP application cycle; and
• Pay ACO shared savings payments and advanced alternative payment model bonuses as soon as possible.

Regulatory alert: CMS increases telehealth payments and makes ACO changes

Today, the Centers for Medicare & Medicaid Services (CMS) issued another round of regulatory waivers through an interim final rule intended to expand care to Medicare beneficiaries and provide more flexibilities to the providers that treat them. The changes outlined below will be effective for the duration of the COVID-19 public health emergency (PHE).

Changes to telehealth policy:

• Following MGMA advocacy, CMS is increasing payment for audio-only telephone E/M services (CPT codes 99441-99443) such that they are paid at the same rate as similar office and outpatient E/M visits, resulting in increased payments from $14-$41 to $46-$110. CMS believes that the resources required to furnish these services during the PHE are better captured by RVUs associated with level 2-4 established office/outpatient E/M visits. CMS is not increasing payment for CPT codes 98966-98968, which are intended for practitioners that cannot separately bill for E/M. This policy is retroactive to March 1, 2020.
• For telehealth services other than CPT codes 99441-99443 and 98966-98968 (now added to the list of covered telehealth services), Medicare continues to require modalities that have both audio and video capabilities.
• CMS is forgoing its typical rulemaking process to add new services to the list of Medicare services that may be furnished via telehealth. Instead, CMS will add new telehealth services on a sub-regulatory basis to speed up the process of adding codes to the list.

Changes to Medicare Shared Savings Program (MSSP):

• There will be no application cycle for a Jan. 1, 2021 start date, and ACOs in the last performance year of their current agreement period (mainly Track 1 ACOs and Track 1+ Model ACOs) will be allowed to voluntarily extend their agreement period by an additional performance year in 2021.
• ACOs participating in the BASIC track glide path will be permitted to maintain their current risk level under the BASIC track for PY 2021 and freeze progression to higher risk.
• CMS is removing all Part A and B payment amounts for episodes of care involving the treatment of COVID-19 for the purposes of determining benchmark year and performance year expenditures.
• The list of primary care services used for beneficiary attribution will be expanded to include additional telemedicine services.

MGMA Government Affairs will continue to inform medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. CMS’ press release on the changes can be found here and a fact sheet on MSSP changes can be found here.

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments.

CMS had expanded these temporary loan programs to ensure providers and suppliers had the resources needed to combat the beginning stages of the 2019 Novel Coronavirus (COVID-19). Funding will continue to be available to hospitals and other health care providers on the front lines of the coronavirus response primarily from the Provider Relief Fund. The Accelerated and Advance Payment (AAP) Programs are typically used to give providers emergency funding and address cash flow issues for providers and suppliers when there is disruption in claims submission or claims processing, including during a public health emergency or Presidentially-declared disaster.

Since expanding the AAP programs on March 28, 2020, CMS approved over 21,000 applications totaling $59.6 billion in payments to Part A providers, which includes hospitals. For Part B suppliers, including doctors, non-physician practitioners and durable medical equipment suppliers, CMS approved almost 24,000 applications advancing $40.4 billion in payments. The AAP programs are not a grant, and providers and suppliers are typically required to pay back the funding within one year, or less, depending on provider or supplier type. Beginning today, CMS will not be accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.

Significant additional funding will continue to be available to hospitals and other health care providers through other programs. Congress appropriated $100 billion in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (PL 116-136) and $75 billion through the Paycheck Protection Program and Health Care Enhancement Act (PL 116-139) for health care providers. HHS is distributing this money through the Provider Relief Fund, and these payments do not need to be repaid.

The CARES Act Provider Relief Fund is being administered through HHS and has already released $30 billion to providers and is in the process of releasing an additional $20 billion, with more funding anticipated to be released soon. This funding will be used to support health care-related expenses or lost revenue attributable to the COVID-19 pandemic and to ensure uninsured Americans can get treatment for COVID-19.

For more information on the CARES Act Provider Relief Fund and how to apply, visit: hhs.gov/providerrelief.

For an updated fact sheet on the Accelerated and Advance Payment Programs, visit: https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf.

Congress passes aid package to assist healthcare providers and small businesses

Today, Congress passed an economic aid package to assist healthcare providers and small businesses. The Paycheck Protection Program and Health Care Enhancement Act (H.R. 266) includes $321 billion for the recently depleted Paycheck Protection Program (PPP), $60 billion for Economic Injury Disaster Loans (EIDL) loans and grants, $75 billion for hospitals and healthcare providers, and $25 billion for COVID-19 testing. If signed into law, the Small Business Administration can once again begin accepting PPP applications. The $75 billion for healthcare providers would be in addition to the original $100 billion in relief funds allocated under the CARES Act and distributed in the future by the Department of Health and Human Services (HHS). President Trump has signaled support and is expected to sign the bill into law.

MGMA advocates for CARES Act Provider Relief fund distribution and clarifications MGMA urged HHS to clarify certain terms and conditions associated with accepting Provider Relief grant funds under the CARES Act. HHS distributed $30 billion in funds to Medicare providers starting April 10 and requires all recipients to sign an agreement form and attestation confirming receipt of the funds within 30 days. Medical group practices that do not wish to agree to the terms and conditions may return the payment, but any practice that does not return the funds or attest within 30 days will be deemed to have accepted the funds and associated conditions. Following numerous member questions and concerns about ambiguous or unclear attestation conditions, MGMA recommended HHS expeditiously release additional guidance so that group practices can make informed decisions before submitting attestations. On April 22, HHS announced it is distributing another $20 billion which, together with the initial $30 billion, is described as a $50 billion “general allocation.” The $20 billion will be disbursed based on 2018 net patient revenue, not just Medicare fee-for-service. MGMA is seeking clarification on this announcement. Visit the Provider Relief landing page for more information.

CMS releases guidelines for reopening facilities to provide non-emergent, non-COVID care This week, CMS announced phase 1 criteria to guide health systems and facilities as they consider resuming in-person care of non-COVID-19 patients in regions with low incidence of COVID-19 disease. The agency explains that careful planning is required to resume in-person care of patients requiring non-COVID-19 care, and all aspects of care must be considered, including: Adequate facilities, workforce, testing, and supplies; and Adequate workforce across phases of care (such as availability of clinicians, nurses, anesthesia, pharmacy, imaging, pathology support, and post-acute care). MGMA will update members as CMS releases additional recommendations.

HHS announces delay of major parts of its interoperability rules Due to the impact of the COVID-19 pandemic, HHS announced a delay in its implementation and enforcement of a number of important provisions of recently-released interoperability regulations. For example, the requirement that hospitals provide practices patient data on admissions, discharge and transfer is delayed six additional months, going into effect one year after implementation of the final rule. In addition, the EHR vendors have an additional three months to comply with the requirement to support patient access to their data via third-party apps. The clock for implementation of the final rules does not start until they are published in the Federal Register, expected to occur early next month. HHS' Office of Inspector General also unveiled its proposed rule to impose financial penalties on certain entities that violate the information-blocking rules.

Extended 2019 MIPS data submission ends April 30, plus new 2020 COVID-19 improvement activity

The 2019 Merit-based Incentive Payment System (MIPS) data submission extension will end on April 30, 2020, at 8 pm. Individual MIPS eligible clinicians (ECs) who have not submitted any data, and who do not submit their MIPS data by the submission deadline will qualify for the 2019 automatic extreme and uncontrollable circumstances policy. MIPS ECs, groups, and virtual groups that submitted some data, but not able to complete their 2019 MIPS submission can now apply for a 2019 extreme and uncontrollable circumstances exception due to the COVID-19 pandemic. 

The Centers for Medicare & Medicaid Services (CMS) also announced that ECs may now earn 2020 MIPS credit for participation in a clinical trial and reporting clinical information by attesting to the new COVID-19 Clinical Trials improvement activity. In order to receive credit for the new improvement activity, ECs must attest that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study. Click here for additional information on 2019 MIPS data submission and this new improvement activity.

The Department of Health & Human Services (HHS) announced today it is beginning distribution of $30 billion in grants to hospitals and providers as part of the $100 billion fund authorized by the CARES Act; more information on the initial disbursement can be found here. These are payments, not loans, that have no repayment obligations and could be delivered via direct deposit as early as today. 

This announcement follows MGMA advocacy urging HHS to provide immediate financial support to group practices in order for them to sustain operations and continue treating patients. We will continue to press HHS to disburse remaining funds directly to medical group practices in an expeditious, efficient manner.

Healthcare entities eligible for the initial $30 billion include all facilities and providers that received Medicare fee-for-service (FFS) payments in CY 2019. Importantly, this is only the first wave of funds under the $100 billion, and MGMA expects forthcoming distributions will focus on providers with lower shares of Medicare FFS reimbursement or who predominantly serve the Medicaid population.

Payment distribution amounts are determined by the eligible provider’s share of 2019 Medicare FFS reimbursements. HHS is partnering with UnitedHealth Group and Optum Bank to assist in the delivery of the initial $30 billion; funds will be distributed to the eligible provider’s billing tax identification number (TIN) using direct deposit information on file with United, Optum, or Medicare (with “HHSPAYMENT” or “HHS Stimulus” as the payment descriptor), or via paper check for those that normally receive reimbursement this way. Within 30 days of payment, HHS requires providers to attest to receipt of the funds and agree to certain terms via a portal opening on April 13. 

The $30 billion being distributed was authorized under the CARES Act, which was the third COVID-19 economic stimulus bill passed by Congress. The CARES Act designates $100 billion in funding through the Public Health and Social Services Emergency Fund and requires HHS to distribute capital through grants or “other mechanisms” to eligible healthcare entities, which include hospitals and group practices that are experiencing financial losses due to COVID19. Unlike the small business loans authorized under CARES, there are no employer size limitations.

MGMA Government Affairs developed two new resources to inform medical groups of available financial assistance opportunities set forth in the CARES Act, which was signed into law on March 27, 2020. The resources are organized by medical group size because the U.S. Small Business Administration (SBA)’s Paycheck Protection Program (PPP) and Economic Injury Disaster Loans (EIDL) are only available to businesses with 500 employees or less. Please note that financial lenders should start accepting applications for PPP loans today, although it has been reported that not all lenders are prepared. In the meantime, SBA has supplied a sample application form for applicants to understand what will be requested of them.

Resource for medical groups with less than 500 employees: The CARES Act allocated money to fund the PPP loans and EIDLs. Loans under the PPP can be forgiven if the employer keeps their employees on the payroll for eight weeks after the loan origination date. EIDL loans are available to businesses who have suffered substantial economic injury. Small businesses who have applied for EIDL loans can receive an advance of $10,000 ("emergency EIDL grants") within three days after the SBA receives their application. Please review MGMA’s resource for more details on both programs.

Resource for medical groups of all sizes: CMS’s Accelerated and Advance Payment Program (APP) and funds distributed from the “Public Health and Social Services Emergency Fund” are two available financial assistance options. The APP provides a quick mechanism for healthcare entities to obtain an accelerated cash flow, which is subject to repayment – funding through this mechanism can be accessed now. Little is known yet on how the $100 billion from the emergency fund will be distributed, but these funds are intended to reimburse eligible healthcare entities for healthcare related expenses and lost revenue stemming from COVID-19.

Last night, the Centers for Medicare & Medicaid Services (CMS) issued a series of temporary regulatory waivers to further support the ability of the nation’s healthcare system to respond to COVID-19. The changes outlined below will take effect immediately across the entire country:

• New telehealth codes. CMS will pay for 80 additional telehealth codes, including home visits, emergency department visits, and therapy services. Providers can waive copayments for all telehealth services for Original Medicare beneficiaries.
• Virtual check-ins. Clinicians can provide virtual check-in services (HCPCS G2012, G2010) to both new and established patients. Previously, these services were limited to established patients only.
• Telephone codes. CMS will reimburse for telephone evaluation and management services provided by a physician (CPT 99441-99443) and telephone assessment and management services provided by a qualified nonphysician healthcare professional (CPT 98966-98968). These codes are only available to established patients but may be furnished using audio-only devices.
• E-visits. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS G2061-G2063). These codes are only available to established patients and must be initiated by the patient.
• Removal of frequency limitations on Medicare telehealth. Subsequent inpatient visits (CPT 99231-99233), subsequent skilled nursing visits (CPT 99307-99310), and critical care consult codes (CPT G0508-G0509) no longer have limitations on the number of times they can be billed.
• Medicare physician supervision requirements. Physician supervision can be provided virtually using real-time audio/visual technology for services requiring direct supervision by a physician or other practitioner.
• “Stark Law” waivers. CMS is implementing waivers that exempt providers from sanctions for noncompliance of certain Stark Law rules, permitting certain referrals and the submission of related claims that would otherwise violate the Stark Law.
• MIPS flexibilities. CMS will allow clinicians adversely affected by COVID-19 to submit an application to request reweighting of the MIPS performance categories for the 2019 performance year.

MGMA Government Affairs will continue to educate medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. For a comprehensive list of Medicare telehealth waivers and regulatory developments, please click here.

On Saturday, the Centers for Medicare & Medicaid Services (CMS) announced nationwide expansion of the existing accelerated Advance Payment Program (APP), making the program available for most Medicare physicians and group practices. The APP provides a quick mechanism for healthcare entities to obtain accelerated, interest-free cash flow. Specifically, the APP fact sheet outlines that:

• Physician practices can request an advanced payment of up to 100% of the Medicare payment amount based on a three-month lookback period. Hospitals can request up to 100% (125% for critical access hospitals) based on a six-month lookback period. The guidance does not specify how the lookback period is determined.
• Healthcare entities must make a request for an accelerated payment under the APP by submitting a form to their Medicare Administrative Contractor (MAC).
• Once requested, CMS anticipates MACs will issue payment within seven calendar days from the request.
• The criteria for applying for the APP are:
• Having billed Medicare for claims within 180 days immediately prior to the date of request;
• Not in bankruptcy;
• Not under active medical review or program integrity investigation; and
• No outstanding delinquent Medicare overpayments.
• APP payments are subject to repayment, which for most healthcare entities begins 120 days after the payment is received.
• During the 120-day period, the healthcare entity will continue to be paid like normal for claims submitted to Medicare.
• After the 120 days, the recoupment process starts and every claim submitted will be offset to repay the advanced payment.

This announcement is a step in the right direction; however, MGMA is advocating that the Administration make available funding that is not subject to repayment or recoupment. Recently passed legislation (the CARES Act) creates several financial assistance programs, including $100 billion in grants for Medicare physicians and hospitals. Although the APP fact sheet states that the APP reflects the passage of the CARES Act, which did expand the APP, this program is not part of the $100 billion in funding authorized under that law.  

In response to MGMA calling on the Centers for Medicare & Medicaid Services (CMS) to ease quality reporting and other regulatory requirements, the deadline to submit 2019 MIPS performance data is extended from March 31 to April 30, 2020. MIPS eligible clinicians who have not submitted any MIPS data by April 30 will qualify for an automatic exemption from reporting responsibilities for “extreme and uncontrollable circumstances” and will receive a neutral payment adjustment for the 2021 MIPS payment year. Various other quality reporting programs, such as those applicable to hospitals and post-acute providers, have new flexibilities as well. CMS is also evaluating options for providing relief around participation and data submission for the 2020 performance year. Read more here.