Client Alerts, News Articles & Blog Posts

Everything you need to know about BMD and the industry.

Pondering Over Patient Billing: CARES Act and Provider Relief Fund Lead to More Questions

The Department of Health and Human Services (HHS) released its first round of $30 billion payments to healthcare providers in furtherance of the CARES Act Provider Relief Fund on April 9, 2020. Providers that received Medicare fee-for-service payments in 2019 received an electronic or paper check stimulus payment. Providers have 30 days from the date of payment receipt to log onto the HHS portal and attest to the Terms and Conditions. HHS issued slight clarifications to the Terms and Conditions on April 16, 2020, which makes it easier for providers to attest to the Terms and Conditions. See our alert regarding updates to the new guidance on T&Cs. However, it also raises some additional questions related to patient balance billing and provider record-keeping requirements. 

On April 11, 2020, HHS, along with the Department of Labor and Department of the Treasury, issued jointly prepared FAQs regarding the FFCRA, the CARES Act, and other health coverage issues. The FFCRA was enacted on March 18, 2020 and requires group health plans and health insurance issuers to provide benefits for certain items and services related to diagnostic testing for COVID-19. Additionally, plans and issuers must provide coverage without imposing any cost-sharing requirements (deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements.  

The CARES Act was enacted on March 27, 2020. The CARES Act expanded the range of COVID-related items and services that must be covered by plans and issuers. Again, this coverage cannot impose cost-sharing requirements, prior authorizations, or other medical management requirements. The CARES Act also requires plans and issuers to reimburse a provider of COVID-19 diagnostic testing either (1) the negotiated rate, or (2) the cash price for the service that is published on the provider’s public website. It is important for providers to have fee schedules for COVID-19 diagnostic tests and publish the fee schedule on the provider’s website.   

Here are some important clarifications from the joint FAQs

  • All types of plans are subject to the FFCRA and CARES Act requirements, including fully insured and self-funded plans, private employment-based group health plans, non-federal governmental, and church plans. 
  • Plans and issuers must provide coverage for items or services with dates of service as of March 18, 2020 and continuing throughout the duration of the public health emergency (as determined by the Secretary of HHS). 
  • Plans and issuers must cover approved COVID-19 diagnostic tests (including in vitro diagnostic tests) as well as healthcare provider office visits (both in-person and telehealth visits), urgent care center visits, and emergency room visits that are COVID-related. 
  • Plans and issuers must cover additional items and services that are related to the determination of whether an individual needs a COVID-19 diagnostic test (e.g. influenza test, blood test, etc.) where the result of such additional items or services is that the individual does, in fact, need a COVID-19 diagnostic test. Again, the plan or issuer must provide coverage without imposing cost-sharing obligations, prior authorization or other medical management requirements. 

The FFCRA and the CARES Act largely dealt with group health plans and health insurance issuers. Industry commentary questioned the provider’s responsibility in patient billing to avoid billing surprises. The CARES Act established the Provider Relief Fund, which is a $100 billion fund designed to reimburse eligible health care providers for healthcare related expenses associated with COVID-related items and services provided to uninsured patients. Providers must agree to certain Terms and Conditions in order to accept these funds. The Terms and Conditions state that providers cannot “balance bill” patients “for all care for a possible or actual case of COVID-19.” Additionally, providers must agree to refrain from billing uninsured patients for items and services related to COVID-19 diagnosis. 

On April 16, 2020, HHS clarified that care does not have to be specific to treating COVID-19 as, “HHS broadly views every patient as a possible case of COVID-19.”  While this clarification certainly makes it easier for providers to attest to certain of the Terms and Conditions, it causes uncertainty with respect to balance billing patients and waiving of patient cost-sharing amounts applicable to out-of-network patients. Using HHS’s broad view that every patient is viewed as a possible case of COVID-19, it appears that the Terms and Conditions would require providers to treat and bill each patient as in-network. Further, providers must ensure that payors are properly paying all patient cost-sharing obligations as required by the FFCRA and the CARES Act.  

Providers must ensure proper record keeping related to the Provider Relief Fund payments as well as compliant billing policies and procedures. Providers may schedule a consultation session with Attorney Amanda Waesch at a discounted rate of $250. For more information, please contact Amanda Waesch at alwaesch@bmdllc.com or 330-253-9185. 

Update: President Trump Signs Paycheck Protection Program Flexibility Act of 2020

On June 3, 2020, Congress updated the CARES Act by passing the Paycheck Protection Program Flexibility Act of 2020 (“FA”). The legislation, which has not yet been signed into law by President Trump, would provide more flexibility to small businesses who received loans under the Paycheck Protection Program (“PPP”).

Workers’ Compensation Claims and COVID-19

Can one of my employees file a workers’ compensation claim if they claim that they contracted coronavirus at work? We get that question a lot. Yes, they can, but you should oppose any application for coverage if you receive one. Generally, the claim will not be granted unless the employee has a job that poses a special hazard or risk of exposure to the virus and the employee can prove that he or she contracted the virus at work.

Ohio State Dental Board Implements Teledentistry Rules

Ohio law defines “teledentistry” as the delivery of dental services through the use of synchronous, real-time communication and the delivery of services of a dental hygienist or expanded function dental auxiliary pursuant to a dentist’s authorization.[1] The law requires a dentist who desires to provide dental services through teledentistry to apply for a teledentistry permit from the Ohio State Dental Board (“OSDB”).[2] Pursuant to the mandate under Ohio Revised Code 4715.436, the OSDB is implementing the following teledentistry permit rules and requirements (to be set forth under Ohio Administrative Code Chapter 4715-23). These regulations, which were subject of a public hearing on February 19, 2020, are effective on May 30, 2020.

HHS Addresses Drug Manufacturer Coupons on Out-of-Pocket Limits

On May 7, 2020, the US Department of Health and Human Services (“HHS”) announced their Notice of Benefit Parameters for 2021 in which HHS addressed the application of prescription drug manufacturer copay coupons towards a patient’s out-of-pocket limit. Under this guidance, HHS will permit, but not require, plans and insurers to count direct support offered to enrollees by drug manufacturers (i.e., coupons) for specific prescription drugs toward the annual limits on cost-sharing, regardless of whether a generic equivalent is available.

Important Updates, Deadlines, and Clarifications for the HHS Provider Relief Funds

On May 20, 2020, HHS made important updates and clarifications regarding the General Distribution payments to providers. Between April 10, 2020 and April 24, 2020, HHS distributed an initial $30 billion to providers based on the provider’s 2019 Medicare fee-for-service receipts. These funds were distributed automatically and providers did not need to submit an application in order to receive these funds. The funds were originally touted as a “no strings attached” stimulus payment reserved for healthcare providers. But HHS issued a 10-page Terms and Conditions and required that providers sign an attestation confirming receipt of the funds and agreeing to the Terms and Conditions.