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May 22, 2020

National Update

CMS addresses physician concerns on CARES Act fund distribution

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:

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 adjusts rates for audio-only E/M visits retroactive to March 1

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.

Small Business Administration Payroll Protection Program update

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.

AMA issues guidelines on use of antibody tests for SARS-CoV-2

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.)

AMA urges passage of the Medicare Accelerated and Advance Payments Improvement Act

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.  

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State Update

State reports of increased opioid-related mortality continue to increase

News accounts of increases in opioid-related mortality continue to increase during the COVID-19 global pandemic, according to an updated AMA issue brief. Reports from more than 25 states raise ongoing concerns for those with a mental illness or substance use disorder about the need for access to evidence-based treatment. This includes access to harm reduction services, including naloxone to help save lives from opioid-related overdose, as well as access to syringe services programs.

In light of these reports, the AMA has updated its state-focused recommendations to help patients with opioid use disorder, pain and for harm reduction efforts. This includes a reminder for states and medical societies to emphasize the importance of co-prescribing naloxone to patients at risk of opioid-related overdose.

The AMA also recommends that states include in future grant requests an emphasis on sterile needle and syringe services programs. As the U.S. Substance Abuse and Mental Health Services Administration—and other federal agencies—are provided new funding for emergency grants, grant funding to support sterile needle and syringe exchange can help protect public health, reduce the spread of blood-borne infectious disease and encourage those with an opioid use disorder to enter treatment

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Judicial Update

Doctors to high court: Now is worst time to undo ACA coverage gains

Striking down the Affordable Care Act (ACA) and its provisions that extend health coverage to millions would be a self-inflicted wound that could take decades to heal.

The AMA and 20 leading physician organizations tell the U.S. Supreme Court that Congress never intended to invalidate the entire Affordable Care Act (ACA) when it cut the tax penalty to $0 for failure to comply with the law's individual mandate to purchase health insurance.

That argument is stated in an amicus brief filed in the case California v. Texas. The plaintiffs in the case claim that congressional action, in the 2017 Tax Cuts and Jobs Act, to get rid of the ACA's individual tax means the entire ACA should be eliminated also.

The AMA and the other physician organizations call on the court to declare the individual mandate constitutional, "as a tax or otherwise." But, even if it doesn't, they are urging the court "to give proper weight" to the fact that Congress chose to leave the rest of the ACA intact when it passed the 2017 legislation. They also warn against taking people's health insurance away during the COVID-19 crisis.

"Plaintiffs have attempted to reduce this law, which touches every corner of the health care delivery system, to one issue," the brief states. "They purport to tie the fate of the entire ACA to the so-called 'individual mandate.'"

In so doing, the physicians argue that Texas, the Trump Administration and other plaintiff states are asking the court to do what Congress has chosen not to: "invalidate the entire ACA." Multiple precedents are cited noting that the individual mandate can indeed be severed from the rest of the ACA, allowing the law to be remain in effect if the one provision is eliminated.

Along with the legal arguments, the brief also explains why it would be unwise to strike down a law currently "serving as the backbone of the safety net for the millions of Americans facing sudden unemployment" due to the global COVID-19 pandemic. The Kaiser Family Foundation has estimated that job losses following COVID-19 will leave nearly 27 million people without employer-sponsored health insurance.

"Invalidating provisions that have expanded access to health insurance coverage such as the guaranteed-issue and community rating provisions—or the entire ACA—would have a devastating impact on doctors, patients, and the American health care system in normal times," the amicus brief says. "However, striking down the ACA at a time when the system is struggling to respond to a pandemic ... would be a self-inflicted wound that could take decades to heal."

If the Supreme Court allows the current 5th U.S. Circuit Court of Appeals decision to stand, the ACA's fate will remain uncertain while a district court determines which provisions may remain and which get eliminated. These patient protections hang in the balance:

  • Patients would no longer have guaranteed coverage for pre-existing conditions, including COVID-19.
  • Young adults would no longer have coverage under their parents' health insurance plan until age 26 
  • Insurers would be allowed to generate higher profits and provide even less coverage for patient care.
  • 100% coverage for certain preventive services would cease.
  • Individual marketplace and premium subsidies based on income would be eliminated.
  • Medicaid eligibility expansion would end, as would federal funding for Medicaid expansion.
  • Annual and lifetime caps on coverage could be reinstated, leading to more bankruptcies due to health care costs.

Because numerous studies have found that uninsured patients live shorter and sicker lives, the AMA advocates expanded coverage and key health insurance reforms to help patients. The AMA's highest priority is to ensure that the millions of Americans who have gained health care insurance because of the ACA maintain their coverage and patient protections.

The Supreme Court announced March 2 that it would hear California v. Texas, formerly Texas v. United States. But the date to hear oral arguments has not been set and will most likely be in the fall after the start of the court's next term in October. That term expires in late June next year and the decision must be delivered before then.

Other News

AMA advocates for prior authorization reform before ONC Task Force

The AMA recently presented to the Office of the National Coordinator for Health Information Technology (ONC) Intersection of Clinical and Administrative Data (ICAD) Task Force, which is charged with making recommendations to improve the electronic exchange of information to support health plans' prior authorization (PA) programs. The AMA urged the Task Force to make concrete, immediately actionable suggestions that will address the significant burdens that PA poses for both patients and physician practices.

The AMA stressed the importance of establishing payer-agnostic electronic transaction standards that integrate with physicians' electronic health record (EHR) workflows for both determining PA requirements for drugs and medical services at the point of care and automating the exchange of data needed to support PA requests. The ICAD Task Force was also encouraged to recommend further research and pilots to evaluate the viability of newer technologies and the feasibility of implementation across practices of all sizes—particularly smaller physician groups that lack the financial resources to make significant investments in health information technology.

Finally, the AMA highlighted the critical need to address the high volume of drugs and services subject to PA, as this will directly impact the scalability of any PA electronic standard solutions. To learn more about the AMA's PA advocacy efforts, visit FixPriorAuth.org.

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