May 22, 2020: National Advocacy Update

The AMA has received many questions from physicians and medical societies related to the Coronavirus Aid, Relief and Economic Security (CARES) Act Provider Relief Fund and has been in touch with senior U.S. Department of Health and Human Services (HHS) officials about them.

Certain formulas that were previously on the HHS website led some physicians to believe they may have received more money from this fund than they were supposed to and they were worried that it will be recouped by HHS. Because the AMA informed the administration of the concerns and alarm the previous formulas and language about overpayments were causing many physicians, HHS removed it from the website.

There have been several other updates to the website. Most recently, HHS announced that providers need to take action by June 3, 2020. Providers must accept the HHS terms and conditions and submit revenue information to be considered for an additional general allocation payment.

HHS has asked for people to provide documentation of certain revenue information so that it can make the calculations specific to each TIN (Taxpayer Identification Number). HHS removed the formula and overpayments language from the portal last week to allay concerns from physicians who had done their own estimates and reached conclusions about potential overpayments instead of relying on HHS to do the calculations. On May 15, seeking to clarify some of the recent confusion, HHS posted another website update with revised FAQs on the Provider Relief Fund General Distribution Portal (PDF):

How did HHS determine the additional payments under the General Distribution? (Added 5/14/2020)

HHS is distributing an additional $20 billion of the General Distribution to providers to augment their initial allocation so that $50 billion is allocated proportional to providers' share of 2018 net patient revenue. The allocation methodology is designed to provide relief to providers, who bill Medicare fee-for-service, with at least 2% of that provider's net patient revenue regardless of the provider's payer mix. Payments are determined based on the lesser of 2% of a provider's 2018 (or most recent complete tax year) net patient revenue or the sum of incurred losses for March and April. If the initial General Distribution payment received between April 10 and April 17 was determined to be at least 2% of annual patient revenue, you will not receive additional General Distribution payments.

How can I estimate 2% of patient revenue to determine my approximate General Distribution payment? (Added 5/14/2020)

In general, providers can estimate payments from the General Distribution of approximately 2% of 2018 (or most recent complete tax year) patient revenue. To estimate your payment, use this equation:

(Individual provider revenues/$2.5 trillion) x $50 billion = Expected combined general distribution.

To estimate your payment, you may need to use "Gross Receipts or Sales" or "Program Service Revenue." Providers should work with a tax professional for accurate submission.

This includes any payments under the first $30 billion general distribution as well as under the $20 billion general distribution allocations. Providers may not receive a second distribution payment if the provider received a first distribution payment of equal to or more than 2% of patient revenue. Also, HHS has made publicly available a list of the providers who have received and accepted money from the Provider Relief Fund. In addition, HHS added several more updates to its FAQs this week.

CMS has confirmed that the contractors will reprocess audio-only claims at the new rates, which AMA had been urging them to do. The March 30 Interim Final Rule with Comment Period added coverage during the Public Health Emergency for audio-only telephone evaluation and management visits (CPT codes 99441, 99442 and 99443) retroactive to March 1. On April 30, a new Physician Fee Schedule was implemented increasing the payment rate for these codes. Medicare Administrative Contractors (MAC) will reprocess claims for those services that they previously denied and/or paid at the lower rate.

There are also a number of add-on services (CPT codes 90785, 90833, 90836, 90838, 96160, 96161, 99354, 99355 and G0506) which Medicare may have denied during this Public Health Emergency. MACs will reprocess those claims for dates of service on or after March 1.

The AMA is encouraging CMS to accept information that physicians may gather about their patients' diagnoses through audio-only visits for use in their Medicare Advantage network's risk scores. In part as a response to AMA advocacy, CMS recently made a policy change to accept data gathered through audio-video telehealth visits in Medicare Advantage plan risk scores, so this recommendation would extend that change to audio-only visits.

On May 15, the Small Business Administration (SBA) and Department of Treasury released the Payroll Protection Program (PPP) loan forgiveness application, along with instructions and worksheets, to guide borrowers. The application and instructions are the first details released by the SBA and Treasury regarding computing PPP loan debt forgiveness and clarify several issues, including the expenses that count for forgiveness, guidance on calculating the full-time equivalent and wage/salary reduction provisions, and aligning the 56-day period with borrower's own payroll period.

Last week, the AMA issued new guidelines on how physicians and the general public should consider the use of serological tests for antibodies to SARS-CoV-2. The guidelines follow an explosive growth in the number of antibody tests on the market, with varying degrees of performance and limited regulatory oversight. The AMA guidelines highlight the inherent limitation of serology tests, as well as the potential risks of relying on serology test results during the current public health crisis. The guidelines recommend use of serology tests only in limited situations, and do not recommend use by physicians or the general public to determine an individual's immunity to COVID-19. 

Immune response after COVID-19 infection is currently unknown. While it is likely individuals develop some level of immune response post-infection, the timing, strength and duration of immunity is currently unknown. Further, serology tests run the risk of returning a number of false positive results. The risk for false positives increases when disease prevalence is low, which is currently true for COVID-19 in the U.S. 

(Note: A story on these guidelines was also published in last week's edition of Advocacy Update.)

The AMA sent a letter urging Congress to pass the Medicare Accelerated and Advance Payments Improvement Act of 2020 expeditiously. Contained within the legislation are several policy changes that will ensure that once the current public health emergency has passed there is a stable, accessible and physician practice-based health system for all to receive quality care.

These provisions include:

• Resumption of the program for Part B entities
• Postponement of the recoupment of disbursed funds until 365 days after the advance payment has been issued to a physician practice
• Reduction of the per claim recoupment amount from 100% to 25%
• Extension of the repayment period for physicians to two years
• Reduction of the existing 10.25% interest rate accruing during the extended payment period to 1%
• Treatment of the payments through this program as if they were made from the General Fund of the U.S. Treasury

These policy changes will support the efforts of practices to stay open throughout the COVID-19 public health emergency and strengthen their ability to deliver services under a significantly altered environment. The reduction of the interest rate for the Accelerated and Advance Payment Program will also afford physician practices additional relief. 

Physician practices will undoubtedly have to invest in additional telehealth and practice operation measures stemming from COVID-19 and the current 10.25% interest rate on funds would be just another impediment to implementing these much-needed adaptations. The AMA is encouraged that the current interest rates are deemed by many as excessive under these circumstances and believe the lower rate is much more workable.  

• May 22, 2020: State Advocacy Update 
• May 22, 2020: Judicial Advocacy Update