At Advis, we strive to keep clients informed about the latest regulatory updates. The experts at Advis summarize some of the most important recent updates below.
Rural Emergency Hospitals – Congress established the framework, details remain needed from CMS
Several providers have shown interest in the new Medicare provider type, Rural Emergency Hospital (“REH”). Congress recently established REHs as a Medicare provider type effective January 1, 2023. The new legislation provides a mechanism for critical access hospitals (“CAHs”) and other certain rural hospitals to convert to the REH provider type. REH services specifically identified in the legislation include emergency department services and observation care (no acute care inpatient services may be provided), with payment at the Outpatient Prospective Payment System (“OPPS”) rate plus five percent. There is also an additional facility payment as determined by a statutory formula.
While Congress set out a high-level framework for REHs, several key questions will need to be answered through the federal rulemaking process and at the state level. More specifically, what type of information will need to be maintained by REHs to support receipt of additional facility payments? When will the enrollment process start? How will the state in which the facility is located treat this new provider type from a licensure standpoint?
Over the next few months, CMS will release rulemaking to address at least some of these outstanding questions. States will also need to weigh in on various regulatory matters. When additional information becomes available, providers will need to be well informed and positioned to determine proper strategy.
– Preston Sisler, Vice President and Asst. General Counsel
Expanded Medicare Telehealth Coverage for RHC Mental Health Services
Per traditional CMS criteria, RHCs are permitted to serve as an “originating site” for telehealth services. An originating site is the location where an eligible patient receives telehealth services, meaning a patient must go to the RHC to receive telehealth services. However, during the COVID-19 PHE, due to CMS waivers and other flexibilities, RHCs have not historically been authorized to serve as the “distant site” for telehealth services. The distant site is where a practitioner is located during the telehealth service. Now CY 2022 Medicare program policy updates have expanded coverage for telehealth “Mental Health” services.
CMS has expanded the definition of RHC “Mental Health Visits” to include an encounter where services are furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions for certain cases.
- This regulatory change allows for continuation (post PHE) for RHC patients to receive Mental health services from their homes.
- This regulatory change permits RHCs to receive payment (e.g., AIR reimbursement) for qualified Mental health visits when serving as either the “originating” or “distant” telehealth site.
- For “Medical Health Visits”, RHCs continue to only be allowed to serve as and bill Medicare as the originating site.
The is a welcomed change for healthcare providers across the nation. Greater access is now afforded to a particularly vulnerable population who are in increased need of treatment for a plethora of mental health disorders.
– Ryan Yokley, Vice President
Provider Relief Funding and FEMA and PHE
As of April 2022, the HRSA Provider Relief Fund has run out. There remains approximately $3.5B in Phase 4 dollars to be distributed to 8% of remaining applicants. However, after these slated distributions, no new funding opportunities will be available. This coincides with the closure of the Uninsured and Underinsured coverage funds as well, under which providers were able to submit claims-like data for self-pay and underinsured patients to receive reimbursement for COVID-19 treatment, testing, and vaccinations. Without any signs on the horizon in Congress for additional funding, providers will next turn to their states and the FEMA process for any unfunded COVID-19 impacts.
Many states are rolling out programs to distribute American Rescue Plan Act funding directly to providers, often to cover staffing, construction, or equipment expenses, and in some cases to close any remaining lost revenue gaps. As for FEMA, providers have until July 1, 2022 to file a Request for Public Assistance, if they have not already done so. Thereafter, submissions for eligible expenses (e.g., COVID-19-related PPE, equipment, construction, contract labor, etc.) incurred prior to July 1, 2022, must be filed before the end of this calendar year. These expenses will be funded by FEMA at 100%, so long as they are found to be eligible through the scrutinous review process. Any claims for eligible expenses incurred post-July will be funded at 90%, with an official end date not yet set by FEMA.
As for the overall Public Health Emergency, signs continue to point to its expiration this July. HHS has said it will provide 60-days’ notice prior to the termination of the PHE, with the key date to watch right now being May 16, 2022. If the PHE indeed expires, many regulatory flexibilities will also sunset. Congress has already extended waivers for telehealth for 151 days after the PHE closes, yet it remains to be seen whether any regulatory/legislative action will be taken to extend other popular waivers.
– Ryan Bailey, Vice President
CMS Limits Donor Community Hospital Bills to Organ Procurement Organizations for Organ Acquisition Costs
In a December 27, 2021, Final Rule, CMS revisited organ acquisition payment policies. One regulatory change finalized serves to limit the amount “donor community hospitals” may bill to organ procurement organizations (OPOs). Donor community hospitals are Medicare-certified non-transplant hospitals that procure organs from cadaveric donors for transplantation. CMS noted in the final rule that one donor community hospital billed an OPO $194,000 for acquisition costs while its actual costs were $11,000 according to CMS’s application of the donor community hospital’s cost-to-charge ratio. The Medicare program ultimately assumes much of the donor community hospital charges when it makes organ acquisition reimbursement to transplant hospitals and OPSs according to reasonable cost principles.
CMS finalized a new rule addressing organ acquisition costs and billing that is effective for hospital cost reporting periods beginning on or after February 25, 2022. Donor community hospitals and transplant hospitals incurring costs for services provided to cadaveric donors must bill the OPO the lesser of its customary charges that are reduced to cost or a negotiated rate. Hospitals are to determine costs by applying their most recently available hospital-specific cost-to-charge ratio for the period in which the services were rendered. CMS did not quantify an expected cost savings to the Medicare program but noted that 62 percent of all transplanted organs in 2017 and 2018 originated from donor community hospitals.
– Robert Monroe, Vice President and General Counsel
Physician Assistants Can Be Directly Reimbursed by Medicare
Effective January 1, 2022, Physician Assistants (PA) have the option to be reimbursed through their employer or be directly reimbursed by Medicare. PAs can now be sole proprietors as well as establish PA groups the same as any other mid-level practitioner types. With this said, there is no change to the provider enrollment CMS-855I (Individual Practitioner) Application process as CMS-855R (Reassignment of Benefits) Applications are still not applicable to PAs. A PA group can submit a CMS-855B (Group) Application that should be accompanied by the CMS-855I Application. No actions are necessary for currently enrolled PAs that want payments to continue to their employers.
– Valerie Ford, Vice President, Enrollment
– Andrea Graham, Vice President, Enrollment
In the first update to the IDTF regulations since 2008, finally CMS has acknowledged the at-home IDTF testing model and allows for some relaxations associated with the development of these IDTF models. The have also keyed the phrase “Indirect IDTF” when referring to these IDTFs which are commonly used for heart monitoring or home sleep studies. In short, these entities generally, though not exclusively, have two overriding characteristics. First, the tests they perform do not involve direct patient interaction, meaning that the test is conducted away from the patient’s physical presence and is non-invasive. Second, the test involves off-site computer modeling and analytics.
As a result of these model’s expansive growth in recent years, which CMS admittedly indicated diverge from the original intent of the IDTF model, CMS has issued some exemptions, including:
- Waiver from comprehensive liability insurance
- Exemption from written clinical complaint documentation,
- Exemption from posting the IDTF standards
- If no state licensure requirements exist, the IDTF need not have additional documentation for its technicians.
These exemptions are strictly for IDTFs exclusively performing tests involving no beneficiary interaction, treatment, or testing.
– Jake Beechy, Vice President