While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following
“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.
Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.
Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”
Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.
CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.
The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.
The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.
View the full press release from CMShere. The toolkit can be accessed here.
After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country. State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.
CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:
Case status in community
Case status in the nursing home(s)
Access to adequate testing
Universal source control
Access to adequate personal protective equipment (PPE) for staff
Local hospital capacity
Reliant’s Real Time Memo on this topic can be accessed here.
“In lieu of visits, facilities should consider offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)”1
When choosing to use video communication, the US Department of Health and Human Services provides guidance regarding which video communication platforms are safe to use and which are not. For example, FaceTime and Skype* are classified as non-public facing remote communication products while TikTok, Facebook Live, and Twitch are public-facing products. Public-facing products are not acceptable to use.
When video chatting, be mindful of the following:
Obtain proper authorization for use or disclosure from the resident/patient/responsible party.
Make reasonable efforts to ensure others, not authorized to participate in the video chat, cannot hear the discussions.
Ensure other patients are not in the background of the video chat to prevent unauthorized use or disclosure of that individual.
Confirm the party answering the video chat is the appropriate party before proceeding with discussions.
Be sure when ending video chat that it successfully ends so that other conversations or videos are not accidentally seen or overheard.
*FaceTime and Skype means of communication are not supported by HIPAA regulations outside of the current healthcare emergency. The Office of Civil Rights states:
“Health care providers may use popular applications that allow for video chats, such as FaceTime and Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”2
The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care. In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning.
Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control. Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully.
Consider the following strategies:
Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
Provide patients reassurance as often as necessary that protocols in place are in their best interest.
Address needs for a sense of normalcy by developing new routines, roles, and habits.
Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
Utilize technology to facilitate connections with family and friends, when possible.
There are no shortages of avenues for success with TIC, but communication is critical for them all. At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization. Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes.
The current SNF coverage decisions, under the COVID-19 Section 1135 Waivers, allow providers to render skilled services to LTC residents, considered “skilling in place.” It is important to note that the previous requirements for skilled care need as defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual remain unchanged.
of our documentation should not change regardless of payer; however, when an
1135 waiver is evoked, extensive care should be taken to document the reasoning
for the initiation of the Part A benefit (e.g., change in condition) and why
the qualifying event (e.g., 3 day hospital stay or wellness period) was waived.
According to CMS FAQs regarding the waivers, if “continued skilled care need…is
unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her
the emergency may include:
early hospital discharge due to resource need or
avoiding hospital transfer due to exposure risk.
is our defense when under review—as we continue to provide care to our
residents, educate nursing and therapy to demonstrate the complexity,
sophistication, and medical necessity of the services provided throughout the
episode of care. Our services have a positive impact on many areas of the
patient’s life. It’s important that the work we do with each of them carries
over onto paper to fortify defensibility following this pandemic and to ensure our
patients continue to have access to quality care.
are increasing reports of scams and phishing attempts referencing COVID-19.
These attacks many times appear as innocent emails looking for assistance or
providing information regarding the COVID-19 crisis. Bad Actors are taking
advantage of this crisis to prosper or do damage. Their criminal
actions are becoming more and more sophisticated and look very official as
though coming from government agencies and health organizations.
It is critical to remain vigilant with all email correspondence
and websites, but particularly those referencing COVID-19 updates, maps,
donations, notifications etc.
avoid becoming a victim, follow the guidelines below:
Never click on links or open attachments
within unexpected emails.
If you receive a suspicious
email appearing to come from a legitimate organization such as CDC, WHO, FEMA
etc., confirm its legitimacy. Make sure
links direct you to the official site by hovering over the link. Report suspicious email to your company’s
Information Security Department.
If you visit a website
or receive a pop-up window directing you to a phone number for support desk
assistance, DO NOT call the number, instead contact your company’s Information
Never share your
password with anyone.
noted to date include:
Malicious Websites – sites
referencing coronavirus or COVID-19 in the URL. Thousands of new websites
have recently been registered to distribute malware when the user accesses the
Spam – emails trying
to grab your attention to sell information or goods now in high demand such as
masks, hand sanitizers, COVID-19 drugs, etc.
Phishing – emails
posing to be from legitimate organizations such as Center for Disease Control
(CDC), the World Health Organization (WHO), Federal Emergency Management Agency
(FEMA), etc. These emails contain malicious links, and some are collecting
Fake Charities –
emails and websites asking for donations for studies, healthcare professionals,
victims, or other activities related to COVID-19
Fake internal HR or IT
communications such as coronavirus surveys pretending to be from your company’s
HR or IT department – these sites are attempting to obtain your User ID
and password or other personal information.
Fake notification of
infection – beware of emails reporting you have been exposed to an
infected individual, particularly ones asking for personal information to
Because our patients and residents typically are older,
often have underlying chronic medical conditions and live in a community
together, they are at the highest risk of being affected by COVID-19. During
this unprecedented time, our residents rely on the members of their
interdisciplinary team to ensure that their health and safety needs are met.
With a team approach of collaboration, communication and demonstration of the value and essence of our skilled professions, we will answer the call to protect this vulnerable population in the pursuit of No Patient Left Behind. Whether it’s clinical considerations in the recovery wake of a COVID-19 diagnosis or ensuring they are supported to continue to attain and maintain the highest level of practicable function within this modified environment, nursing facilities are equipped to meet the needs of the residents who call our facilities home.
Each member of the interdisciplinary team – including therapy, nursing and administrative team members – has specific skills that can help meet the residents’ needs. Collaborative efforts to integrate each team member’s contributions allow for greater positive impact on the care provided. Timely and effective communication of changes in function should be ongoing between nursing and therapy to identify emerging conditions and potential symptoms of COVID-19. Each patient is unique and requires screenings relative to their specific diagnoses, history and risks. It is our imperative to ensure dignity, quality of life and the highest level of independence possible. Members of the care team have been empowered to own their distinct role in resident-centered advocacy, which ultimately leads to successful outcomes.
of the interdisciplinary team can lead the advocacy efforts for each resident
by observing changes in the resident’s ability, ensuring timely notification,
developing a resident-specific plan of care and thoroughly planning for the
next level of care. Care delivery must be adapted by team members to occur in
bundled sessions with enhanced in-room treatment techniques. By working
together, we can help curb the potential anxiety and psychosocial effects
perpetuated by a world in pandemic and affirm that no patient is left behind.
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
According to an FAQreleased 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.”
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.
(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
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.
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
step by step guide for eligibility and processes here.
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:
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
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.
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.
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:
effectiveness of the Infection Prevention and Control Program (IPCP) including
policies and procedures
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)
of resident care practices, including those with COVID-19 (laboratory-positive
cases), if applicable
entry and facility screening practices
monitoring and screening practices of staff
policies and procedures to address staffing issues during emergencies, such as
transmission of COVID-19
CDC issued guidance for
optimizing the PPE supply, specifically facemasks, gowns and eye protection, including suggestions on what to do
in case of shortages.
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.
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
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
Part B line items for denial of HCPCs 97530 and 97150, in the presence of evaluation
codes 97161, 97162, 97163, 97164, 97165, 97166.
line item denials are identified, determine if reason code W7070 is appended.
confirmed, flag impacted claims for review for automatic reprocessing following
CMS correction of the edit, beginning April 6, 2020.
has indicated provider action is not required.
up with your MAC should reprocessing not occur or occur with errors.
SNF Claims Incorrectly Cancelled
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
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.
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.