As cases of COVID-19 continue to increase throughout the U.S., the Centers for Medicare and Medicaid Services (CMS) announced an unprecedented array of temporary regulatory changes to equip heath care providers with maximum flexibilities during the pandemic.

The latest announcement, made on March 30th, builds on a number of actions CMS has taken in recent weeks to provide short-term adjustments to Medicare, Medicaid, CHIP, and other healthcare regulations.  Combined with the passage of three coronavirus related bills, government entities have acted quickly to provide relief to the disruptions caused by COVID-19.

The goals of the newest actions are to ensure health systems can increase capacity by allowing for temporary expansion sites, remove barriers to healthcare workers entering the workforce, increase access to telehealth services covered by Medicare, expand in-place testing, and provide temporary relief from certain paperwork, reporting, and auditing requirements so clinicians can focus on providing patient care.

The interim ruling from CMS covers a variety of topics, some of which have already been adjusted during the health emergency. In an effort to help keep track of the rapidly moving changes to the healthcare landscape, we’ve put together short summaries and resources for the most relevant updates:

Financial Relief

The passage of the CAREs act expanded economic relief available to individuals and small businesses impacted by COVID-19.   It is important to note that many of these options cannot be used concurrently.  Therefore, it is essential to discuss all options with your financial and legal advisors before implementation.

SBA Disaster Loans – Available in states that have been declared ‘disaster areas, borrowers can apply for up to $2 million dollars in loan assistance at an interest rate of 3.75% (2.75% for non-profits) with a term of up to 30 years for repayment. Loan proceeds can be used for working capital, payroll and other expenses that the applicant could have paid had the disaster not occurred. Loan proceeds are not intended to be used to replace lost profits or to finance business expansion.

Paycheck Protection Program – The Paycheck Protection Program is a loan designed to provide a direct incentive for small businesses to keep their workers on the payroll. SBA will forgive loans if all employees are kept on the payroll for eight weeks and the money is used for payroll, rent, mortgage interest, or utilities. The Paycheck Protection Program will be available through June 30, 2020.

Small Business Debt Relief – This program will provide immediate relief to small businesses with non-disaster SBA loans, in particular 7(a), 504, and microloans. Under it, SBA will cover all loan payments on these SBA loans, including principal, interest, and fees, for six months. This relief will also be available to new borrowers who take out loans within six months of the signing of the CAREs act.

For FAQs on each of the above from US Senate Committee on Small Businesses – CLICK HERE

For additional specifics and information on how to apply from our legal counsel, IceMiller – CLICK HERE

Employee Retention Credit – This program allows eligible employers to take a tax credit of 50% of wages paid to employees from March 12, 2020 to January 1, 2021.  The maximum amount of the credit is $5,000.  Eligible employers are those employers who see a significant decline in collections or are required to fully or partial suspend their operations.  For more information on this program – CLICK HERE

Provider Lost Payment Program – While details are still to come, the CAREs act set aside $100 billion in funds to reimburse providers for expenses incurred to prevent, prepare, and respond to coronavirus. Recipients must maintain documentation and submit reports to the Secretary of Health and Human Services (HHS) on an as-requested basis to ensure compliance with the required conditions.  Again, specifics should be available in the upcoming weeks.

For our earlier article on the CAREs act – CLICK HERE

Medicare Advanced/Accelerated Payment Program – CMS has expanded the Advanced/Accelerated Payment Program which allows Medicare Administrative Contractors (MACs) to distribute advanced payments to Medicare providers.  With the update, most providers and suppliers enrolled in any Medicare program are now eligible to request up to 100% (or more for Critical Access Hospitals) advancement for 3 months of payments. Medicare would recoup this advance by offsetting future payments.   For more details – CLICK HERE

Other Medicare Reliefs – Under the Budget Control Act of 2011, Medicare providers and plan payments are subject to a -2% percent “sequestration” reduction through FY 2029. The CAREs act pauses the sequestration requirement starting May 1, 2020 through December 31, 2020, which will provide an immediate boost to all providers and plans.  Additionally, CMS is temporarily extending the GPCI (geographic practice cost index) floor of 1.0 and increasing payments related to COVID-19 treatment by 20%.

For additional analysis from ReedSmith on all the above – CLICK HERE  

Enrollment Flexibilities

Provider Enrollment – CMS is expediting the enrollment process and permitting providers to obtain temporary Medicare billing privileges.  Certain requirements, such as application fees and finger-print based background checks are being waived during the health emergency.  Additionally, CMS has temporarily waived requirements that out-of-state provers be licensed in the state where they are providing services under certain conditions. For further details– CLICK HERE

CMS Fact Sheet on Provider Enrollment – CLICK HERE

Hospitals Without Walls – Hospitals may now render and be reimbursed for services in alternative locations such as ambulatory surgery centers or non-hospital buildings.  Surgery centers can either contract with local healthcare system or enroll and bill as a hospital during the emergency.  Non-hospital buildings may be used for patient care or quarantine sites, provided that State approval is obtained. Physician-owned hospitals may temporarily increase the number of their licensed beds, operating rooms, and procedure rooms.

CMS Fact Sheet on Hospital FlexibilitiesCLICK HERE

Regulatory Updates

Blanket Waivers – CMS added numerous blanket waivers available to states and healthcare providers, building on the list announced immediately following the declaration of a national emergency earlier this month. Now, these waivers do not require a request to be made or a notification to be sent to CMS.

Expanded Medicare TeleHealth Services – 80 additional CPT codes have been temporarily added to CMS’s list of telehealth services reimbursable under Medicare.  Practitioners are now allowed to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from your currently enrolled location.  The frequency limit for telehealth services, typically every three days, has been temporarily removed.  Under regular circumstances, telehealth services generally required that patients be established and give consent to have a service performed via teleconferencing.

The Department of Health and Human Services (HSS) had originally announced that they would not enforce the established patient requirement during the health emergency, CMS has now officially waived the requirement and added ‘new patient’ related CPT codes to the list of telehealth services.

During the public health emergency, providers choosing to render telehealth services can utilize platforms such as Skype or Facetime without HIPAA law being enforced for those acting in good faith.  CMS further clarified that providers may evaluate beneficiaries who have audio only phones

Providers can bill for telehealth visits at the same rate as in-person visits. Reversing their original recommendations for telehealth billing during the public health emergency, CMS is now directing providers to use modifier 95 instead of POS code 02 to indicate a service was rendered via telehealth. For more details on the new telehealth guidance:  CLICK HERE

As a reminder, these telehealth related updates pertain to Medicare beneficiaries.  While other private payers have generally been following CMS in terms of expanding access to telehealth during the pandemic, policies will vary from payer to payer.

Supervision Requirements – Supervision, for services requiring direct supervision by a physician or other practitioner, can now be provided virtually using real-time audio/video technology. CMS is waiving the requirement that Medicare patients in the hospital be under the care of a physician. This allows hospitals to use other practitioners, such as physician’s assistant and nurse practitioners, to the fullest extent possible in accordance with a state’s emergency preparedness or pandemic plan.

Additional “Stark Law” Concessions – CMS will permit certain referrals and the submission of related claims that would otherwise violate the Stark Law. Stark Law prohibits a physician from making referrals for certain healthcare services payable by Medicare if the physician (or an immediate family member) has a financial relationship with the entity performing the service.  CLICK HERE

Medicare Appeals Extended – Medicare Administrative Contractors (MACs) are now allowed to make adjustments to the claim’s appeals process.  MACs may waive requirements for timeliness for requests for additional information to adjudicate appeals for all Medicare plans except for Medicare Advantage.  Medicare Advantage plans may extend the timeframe by 14 calendar days. Additionally, CMS will now allow for MACs to process appeals that may be missing information as long as good cause requirements are satisfied. Check your individual MAC website for further details on MAC specific guidance on COVID-19 updates.  A list of MACs is available here.

Verbal Orders and Medical Records – CMS is relaxing requirements pertaining to verbal orders, waiving several requirements such as requiring orders to be dated/signed and authenticated promptly and requiring medication administration to be based on a written and signed order.  Standards for medical record documentation are temporarily waived including requirements for organization, form, retention, content, and the completion of medical records within 30 days of patient discharge. CLICK HERE

Quality Payment Program Updates – In an effort to relieve administrative burden to clinicians, CMS announced adjustments made to the 2019 performance year for the Quality Payment Program.  On the MIPs side, CMS has extended the submission deadline to April 30th and will automatically apply ‘hardship circumstances’ reweighting to MIPs eligible clinicians who fail to submit data by the new deadline.  These individual clinicians, who otherwise would have been required to submit data and receive the maximum penalty for failing to do so, will receive a neutral payment adjustment in the 2021 payout year.  In the most recent update from March 30th, CMS is adding a new improvement activity for 2020 relating to COVID-19 testing and extending the ‘hardship circumstances’ application deadline for the 2020 performance year to April 30th.  Per the QPP service center, further details on the application process will be released.  For more details on the updates to the QPP program due to COVID-19, CLICK HERE

As the COVID-19 situation continues to develop, additional guidance from the administration is likely to come in the upcoming weeks. Our legal counsel, Ice Miller has excellent business resources on COVID-19 available on their website HERE.  As always, ADVOCATE will continue to keep you informed on the issues impacting medical groups as they develop.


Kayley Jaquet

Manager of Regulatory Affairs