This newsletter outlines key federal regulatory developments and highlights PAI’s advocacy on matters that impact physicians and patients, including updates on the Provider Relief Fund, telehealth services, recent presidential executive orders, and more. During the COVID-19 pandemic, these efforts have focused on securing adequate financial supports and regulatory flexibilities to allow physicians to continue to safely care for their patients and remain financially viable. As the COVID-19 Public Health Emergency (PHE) continues to evolve, PAI is working to share feedback to members of Congress and federal regulators on issues that physicians and patients face. Please visit PAI’s COVID-19 Resources page and the Healthsperien COVID-19 Resource Updates page for up-to-date information. 

Provider Relief Fund Updates

On September 19, the U.S. Department of Health and Human Services (HHS) released guidance for Post-Payment Reporting Requirements for the Provider Relief Fund (PRF). These reporting requirements will be applicable to PRF recipients who have received at least $10,000 in the aggregate from the relief fund. Notably, this guidance revises what expenses PRF dollars can be attributed to, and how such expenses are defined and calculated.
Per the guidance, recipients of $10,000 or more from the PRF will need to report how PRF allotments were used to cover: (1) “health care related expenses” related to coronavirus; and/or (2) “lost revenue” attributable to coronavirus (in that succession). If it is determined that a proportion of funds were not used to cover such expenses, they may be subject to recoupment. Importantly, HHS has effectively changed the definition of “lost revenue” in a way that puts practices at risk of recoupment. The definitions of both allowable expense types (i.e., “health care related expenses” and “lost revenues” attributable to coronavirus) are summarized below.

For more information on what payer mix is included in “revenue,” as well as other data elements required in PRF reporting, please view HHS guidance here.
Additionally, applications for the Phase 3 General Distribution are now being accepted through November 6, 2020 by 11:59 p.m. ET. Phase 3 takes into account documentation of the financial impact of COVID-19 as reported by applicants. Payment is based on assessed revenue losses and expenses attributable to COVID-19, 2% of annual patient care revenue, and prior PRF distributions. Providers will be paid a percentage of their change in operating revenues from patient care minus their operating expenses from patient care. Providers must submit both their Taxpayer Identification Number (TIN) and all financial information to the Provider Relief Fund Application and Attestation Portal. Once funds are awarded, recipients must attest to the terms and conditions within 90 days of payment. HHS will require recipients of >$10,000 to submit reports relating to the use of their PRF distribution. For more information on Phase 3 General Distribution, please click the following link.

CMS Announces New Repayment Terms for Accelerated and Advance Payment (AAP) Loans

On October 8, CMS announced new repayment terms for Accelerated and Advance Payment (AAP) loans made to providers during COVID-19. Signed by President Trump on October 1, the Continuing Appropriations Act, 2021 and Other Extensions Act amended the repayment terms for all providers and suppliers who requested and received AAP loans during the COVID-19 PHE. Repayment for such loans will now begin one year from the issuance date of the payment. Originally, providers were required to make payments starting in August of this year.
Beginning one year after the loan issuance date, Medicare will automatically begin to recoup 25% of Medicare payments otherwise owed to the provider or supplier for 11 months. After the 11-month period, recoupment will increase to 50% for another six months. If a provider is unable to repay their total amount borrowed by the end of this time period (a total of 29 months), CMS will issue letters requiring payment of any outstanding balance, subject to an interest rate of 4%. These letters will contain guidance on how to request a debt installment payment plan, also known as an Extended Repayment Schedule, that allows a provider or supplier to pay debts over the course of three years or up to five years in the case of extreme hardship. Notably, to allow for more flexibility, provider relief funds can be used towards the repayment of these Medicare loans. 

CMS Announces Expanded Telehealth Flexibilities to Combat the Ongoing COVID-19 PHE 

On October 14, CMS announced an expanded list of telehealth services that Medicare Fee-For-Service (FFS) will cover during the ongoing COVID-19 PHE. CMS has decided that an additional 11 services will be added to the Medicare telehealth services list, including certain neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. Since the beginning of the COVID-19 PHE and including this month’s additions, there are now 144 services performed via telehealth that Medicare will pay for, a full list of which can be found here.
Furthermore, CMS released preliminary state Medicaid and Children’s Health Insurance Program (CHIP) data detailing the scope of telehealth utilization during the COVID-19 PHE. These data show that there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and June of this year. This represents an increase of more than 2,600% when compared to the same period during the previous year.

PAI Submits Comments for CY 2021 Proposed Rules for the Medicare Physician Fee Schedule and Quality Payment Program

On October 5, PAI submitted a comment letter in response to the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Proposed Rule published by CMS in August of this year. PAI provided extensive feedback on several changes and flexibilities proposed by the Agency, concerning both COVID-19 and non-COVID-19-related issues.

In summary, PAI provided recommendations that CMS should:

  • Finalize expanded telehealth, remote physiologic monitoring (RPM), and communication technology-based services’ (CTBS) flexibilities and reimbursement rates, as well as flexibilities for supervision requirements, in a responsible manner that improves patient access to quality services provided by physicians and their respective care teams, while refraining from expanding the scope of practice of non-physician practitioners (NPPs) beyond that supported by their licensure, education, and training prior to the PHE.
  • Avoid finalizing drastic changes to Merit-Based Incentive Payment System (MIPS) participation, submission mechanisms and its categories (including scoring and reporting requirements/options) that would require substantial retraining for physicians and other eligible clinicians during the ongoing COVID-19 PHE.
  • Maintain the weight of the QPP Cost category at 15% and refrain from raising the MIPS performance threshold in the 2021 performance year.
  • Continue to offer Extreme and Uncontrollable Circumstance (E&UC) reporting/scoring exemptions and options for practices that continue to be impacted by the pandemic, and refrain from using CY 2021 data for Quality benchmark purposes.
  • Finalize proposed flexibilities for Advanced APM and QP determinations in performance year 2021 that reduce administrative burden and complexity during the COVID-19 PHE.
  • Continue to solicit substantial stakeholder feedback regarding MIPS Value Pathway (MVP) development, as well as implementation of the APM Performance Pathway (APP) framework and the associated Quality measures set involved.

PAI also commented on several other technical proposals for the MPFS and QPP (specifically MIPS performance categories). To view the letter in full, please click the following link.

Summary of Recent Presidential Executive Orders

Since August, President Trump has issued three executive orders (EOs) addressing various health care policies that include prescription drug prices, surprise billing, and mental/behavioral health needs. Key provisions of the EO on surprise billing, titled “An America-First Healthcare Plan," are summarized below. The EO:

  • States that if Congress does not reach a legislative solution for surprise medical billing by the end of the year, the HHS Secretary will take administrative action to end surprise medical billing.
  • Directs HHS to expand access to affordable medicines by accelerating the approval of generic and biosimilar drugs, facilitating the importation of prescription drugs from other countries, and improving transparency on drug price and quality.
    • Specifically, the EO directs HHS to update the Hospital Compare website to inform beneficiaries of hospital billing quality by March 23, 2021.
  • Calls upon HHS to improve care delivery quality for veterans, and to build upon existing actions to expand access to affordable health care.

Kelly Kenney, CEO of PAI, issued a statement expressing that, “Congress should support a fair, easy-to-access, independent dispute resolution process that considers several factors, including the comparable rates in the same geographic area, as established by an independent data collection entity, and the complexity of the specific case. Legislation must also address the root cause of surprise medical bills: the skimpy networks of doctors built by insurers that do not assure in-network access for all of patients’ healthcare needs. These so-called narrow networks encourage patients to see physicians outside of their insurer’s network, generating surprise bills that could have been prevented.”

To read the full statement, please click the following link.

California Medical Association - Connecticut State Medical Society - Medical Association of Georgia - Medical Society of the State of New York - Nebraska Medical Association - North Carolina Medical Society - South Carolina Medical Association - Tennessee Medical Association - Texas Medical Association
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