Medical Review Audits Suspended

Reliant has worked closely with the National Association for the Support of Long Term Care (NASL) to raise awareness of the activity associated with Medicare’s medical review process during this pandemic, including pre-pay targeted probe and educate (TPE) activity and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas, First Coast and CGS have suspended TPE activity until further notice. Our contacts indicate current pre-pay TPEs will be released and paid in the coming weeks.

According to an FAQ released on 3/30/2020, CMS indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the reviews for TPE and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are suspended for the duration of the Public Health Emergency (PHE).

The FAQ also notes that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” Current post-payment review by the MACs, SMRCs, and RACs will be suspended and released from review as well. CMS is suspending these medical review activities for the duration of the PHE, but could conduct medical reviews “during or after the PHE if there is an indication of potential fraud.”

Medicare Advantage Plans Prior Authorization Suspended

In response to the COVID-19 pandemic, Medicare Advantage plans are issuing temporary suspensions in prior authorization requirements for post-acute settings and revising policies to improve patient access to care.

UnitedHealthcare (UHC) is suspending prior authorization requirements for post-acute settings through May 31, 2020, with the waiver applying to skilled nursing facilities (SNFs), long-term care facilities (LTCFs), and acute inpatient rehabilitation (AIR).  In addition, UHC will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology, emphasizing state laws and regulations apply.

Cigna has indicated a similar suspension for commercial and Medicare Advantage plans, noting it will make it easier for hospitals to transfer patients to long-term acute-care hospitals (LTACHs) and other sub-acute facilities to help manage the demands of increasingly high volumes of COVID-19 patients

Medicare Accelerated and Advanced Payments Now Available

On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded the current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief and the Economic Security (CARES) Act, is one way CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic and ensures the nation’s providers can focus on patient care.

Eligibility qualifications state the provider/supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form
  • Not be in bankruptcy
  • Not be under active medical review or program integrity investigation
  • Not have any outstanding delinquent Medicare overpayments

Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.   

Access CMS’ step by step guide for eligibility and processes here.

COVID-19 Medicare Waivers

CMS is empowered to take proactive steps through 1135 waivers and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are available: 

  • Three-Day Stay Waiver: CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay, providing temporary emergency coverage of SNF services without a qualifying hospital stay for those who need to be transferred as a result of the effect of a disaster or emergency.
  • SNF Part A 100-Day Benefit Waiver: For certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.
  • MDS Completion and Submission Waiver: CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.

Read the Coronavirus 1812(f) waiver.

New Targeted Plan for Healthcare Facility Inspections

On March 23, 2020 CMS released guidance to state survey agencies further prioritizing and suspending most federal and state surveys and delaying revisit surveys for the next three weeks beginning March 20.

CMS has released this survey tool to review infection prevention and control practices. Providers are encouraged to perform a self-assessment utilizing this same tool. Surveyors will review for:

  • Overall effectiveness of the Infection Prevention and Control Program (IPCP) including policies and procedures
  • Standard and transmission-based precautions (with the understanding that certain essential supplies are scarce, and facilities should not be penalized for not having certain supplies if they are unable to obtain them)
  • Quality of resident care practices, including those with COVID-19 (laboratory-positive cases), if applicable
  • Surveillance plan
  • Visitor entry and facility screening practices
  • Education, monitoring and screening practices of staff
  • Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19

Click here for the Survey Prioritization Fact Sheet.

PPE Guidance from CDC and CMS

The CDC issued guidance for optimizing the PPE supply, specifically facemasks, gowns and eye protection, including suggestions on what to do in case of shortages.

CMS recommends reaching out to a health care coalition (HCC) in your area for emergency response assistance. Click here for an interactive map with contact information.

Additionally, AHCA has warned providers to beware of COVID-19 scams selling PPE or other supplies. To aid in differentiation between legitimate businesses and scams, the Federal Trade Commission (FTC) has provided general guidance on COVID-19-related scams.

CDC and CMS COVID-19 Resources

As the COVID-19 pandemic continues to evolve, the guidance from the CDC and CMS is updated regularly. Reliant is monitoring the below sites and encourages our care partners to do the same.

March Clinical Appeals

Denial Reason Code W7020- NCCI Edit Update

In February, CMS rescinded the National Correct Coding Initiative (NCCI) Edits which restricted the billing of CPT codes 97530 and 97150 on the same day as billing of PT/OT evaluation codes (97161, 97162, 97163, 97164, 97165, 97166) retroactively to January 1, 2020. Nonetheless, many providers have experienced line item denials due to the edit enacted for the short duration. These line item denials are reflected by reason code W7020. To resolve, CMS will be correcting the NCCI edit, beginning April 6, 2020. Medicare Administrative Contractors (MACs) will automatically reprocess claims, without provider action.  When reconciling payments,

  • Review Part B line items for denial of HCPCs 97530 and 97150, in the presence of evaluation codes 97161, 97162, 97163, 97164, 97165, 97166.
  • If line item denials are identified, determine if reason code W7070 is appended.
  • If confirmed, flag impacted claims for review for automatic reprocessing following CMS correction of the edit, beginning April 6, 2020.
  • CMS has indicated provider action is not required.
  • Follow up with your MAC should reprocessing not occur or occur with errors.

SNF Claims Incorrectly Cancelled

From January 26 through February 16, 2020, a software issue caused SNF claims to be incorrectly cancelled with a message that there was no three-day qualifying hospital stay. This issue has been corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.

  • Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly.
  • Submit claims in sequence and wait at least 2 weeks before billing subsequent claims.
  • Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field.

Click here for more information.

HIPAA Privacy & COVID-19

In this unprecedented time with worldwide infection of COVID-19, there are provisions within the HIPAA Privacy Rule to address use and disclosure of patient information in a public health emergency to aid in prevention and control of the spread of disease. While this provision addresses use and disclosure to authorized public health authorities, Covered Entities and Business Associates must continue to safeguard patient information from impermissible uses and disclosures.

Refer to the bulletin released by the Office of Civil Rights (OCR) in February 2020 at this link OCR HIPAA Privacy and COVID-19 for more information regarding HIPAA Privacy Rule relating to infectious disease control.

Enhancing the Quality of Life of Individuals with Lung Disease

Individuals with respiratory illnesses often take shallow breaths causing chest muscle weakness, reduced oxygen circulation, shortness of breath and fatigue. Effective pulmonary programs can increase quality of life and reduce unnecessary hospitalizations.

Three types of breathing exercises

  1. Pursed Lip Breathing: Helps to increase the length of expiration

a.         Relax neck and shoulders

b.         Breathe in for two counts through nose

c.         Breathe out for three to four counts through pursed lips.

d.         “Smell the roses, blow out the candles!

2. Deep Breathing: Helps to calm nerves and exercise the diaphragm

a.         Inhale for 4 seconds

b.         Hold for 4 seconds

c.         Exhale for 4 seconds

d.         Hold for 4 seconds

3. Diaphragmatic Breathing: Helps train the abdominal muscles to aid during exhalation to fully empty the lungs

a.         Place one hand on your upper chest and the other just below the ribcage.

b.         Breathe in slowly through your nose, so your stomach moves out against your hand. The hand on your chest should remain as still as possible.

c.         Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips.

Key Benefits of Breathing Properly: 

•          Endorphins, the body’s natural painkiller, are released

•          Improved blood flow

•          Improves posture

•          Reduces inflammation

•          Detoxifies the body by releasing toxic carbon dioxide

•          Stimulates lymphatic system

•          Improves digestion

•          Relaxes the mind and body