Health Care Providers on High Alert: COVID-19 Billing & Reimbursement Issues

1. An increasing number of patients will be losing their health insurance coverage.

One of the most unfortunate and disruptive aspects of the current crisis is widespread unemployment. Preliminary figures from the US Department of Labor indicate that approximately 30 million people filed for unemployment since mid-March and some experts are predicting that unemployment could be within 25% by mid-summer. Because so many people receive their health insurance coverage through their employer, job loss (as well as reductions in hours) can inevitably lead to loss of health benefits. Patients may be entitled to continue their coverage with their former employer through COBRA, but may find it difficult to afford the unsubsidized premiums themselves. Some patients may qualify to enroll in a federal marketplace qualified health plan during a “special enrollment period” and receive federal subsidies to help pay for the coverage. Others may be best served by enrolling in their state Medicaid program. One thing is certain: it is essential for individuals who require medical services to obtain health insurance to pay for those services.

• Provider Action Item: Consider adopting a protocol to educate patients as to their health insurance options and how to fill gaps in coverage, especially if they require expensive medical treatments.

2. Who will be paying for patient copayments, coinsurance, and deductibles for COVID-related medical services?

Typically, a patient is responsible for paying his or her plan copayments, coinsurance, and deductibles (patient cost-share) to a medical provider. That is not necessarily true now due to COVID-19. Under the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES Act), Congress required group health plans and health insurance issuers to cover without patient cost-sharing (a) diagnostic testing for COVID-19 and (b) items and services furnished to an individual during healthcare provider office visits, urgent care center visits, and emergency room visits that result in the administration of a COVID-19 diagnostic test (but only to the extent the items and services are related to the evaluation of the patient for COVID-19). Consequently, benefit plans and insurers should be paying the full allowable amount for those tests and services, regardless of the normal deductible, coinsurance, or copayment requirements. This means that even if the patient has a high-deductible plan, the plan should be paying for qualifying tests and services – not the patient.

Additionally, several major insurers, including Aetna, UnitedHealthcare, Anthem, and Cigna, have voluntarily agreed to waive patient cost-sharing for all COVID-19 patient treatment, including inpatient admissions, through at least the month of May, for many of their members.

• Provider Action Item: Make sure your clinical records and medical coding clearly indicate COVID-19 testing and related medical services were rendered. Also, closely monitor your accounts receivable to make sure you are receiving the full required payment from the benefit plan or insurer and that the patient is not being required to pay cost-sharing amounts.

3. Keep a close eye on your COVID-19 lab testing activity.

The good news is that, as mentioned above, plans are now required by law to cover diagnostic testing for COVID-19. Moreover, Section 3202 the CARES Act requires benefit plans and insurers to pay either (a) the negotiated rate for the testing in effect before the COVID-19 public health emergency was declared or (b) the “cash price” for the test, if there is no negotiated rate with the provider. Given the enormous existing need for COVID-19 testing and the likelihood that COVID-19 testing needs will increase as state and local stay-at-home restrictions are slowly lifted, health care providers may find their COVID-19 testing services in demand for the foreseeable future. However, providers could wind up in trouble if they submit claims for laboratory testing that do not meet payer requirements or if they enter into improper relationships to generate testing referrals.

• Provider Action Item: Adopt a compliance plan to ensure COVID-19 laboratory testing and billing protocols are appropriate and above-board and meet payer requirements. Vet testing arrangements to make sure they pass muster with state and federal law.

4. Telemedicine is here to stay, but make sure you know plan coverage and payment requirements.

COVID-19 has caused the widespread adoption of telemedicine. Even the Centers for Medicare and Medicaid Services (CMS), which traditionally strictly limited the availability of telemedicine for Medicare program beneficiaries, has embraced telemedicine with the understanding that currently it is the primary way patients can receive medical treatment without exposing patients to undue risk of exposure to COVID-19. Private insurers have also expanded telemedicine coverage and reimbursement, as well. While this transformation has been rapid, one concern is that governmental and private payers have adopted different payment guidelines, criteria, and policies for covering telemedicine visits over a very short time. Moreover, this is the first time many providers are offering telemedicine extensively.

• Provider Action Item: Designate someone in your organization to keep a close eye on payer coverage and billing requirements for telemedicine. Payers are modifying and expanding coverage of telemedicine services regularly, and not entirely consistently, to respond to COVID-19.

5. If you wind up testing and treating a COVID-19 patient who is uninsured, you could still get paid.

As part of FFCRA and the CARES Act, Congress is funding health care providers who render COVID-19 related services to the uninsured. The program is run by the Health Resources & Services Administration (HRSA) and allows providers to receive Medicare rates for their COVID-19 medical services, subject to available funding. Information about participation in the program can be found here.

• Provider Action Item: Track COVID-19 related medical services provided to the uninsured closely and submit claims to HRSA as quickly as possible, since funding for the program is limited and could be quickly exhausted by providers who have seen a surge in COVID-19 uninsured patients.

6. The Medicare sequestration suspension and increased Medicare DRG payments could impact your managed care arrangements.

Section 3709 of the CARES Act temporarily suspended the 2% Medicare sequestration reduction from May 1, 2020, and December 31, 2020. This means Medicare providers should expect to see a 2% increase in Part A and Part B Medicare payments for eight months. Contracted providers may also be entitled to a 2% increase in payments from Medicare Advantage plans, depending on their particular contractual arrangement. Out-of-network providers should also expect a 2% increase in payments from Medicare Advantage plans.

Likewise, Section 3710 increases the weighing factor of the assigned Diagnosis-Related Group (DRG) by 20% for an individual diagnosed with COVID-19 discharged during the public health emergency. Consequently, Medicare Inpatient Prospective Payment Systems (IPPS) hospitals should expect additional reimbursement for inpatient stays for COVID-19. Moreover, as with the sequestration suspension, it is possible that a hospital’s Medicare Advantage contracts will require those plans to pay additional reimbursement as well for inpatient COVID-19 medical care.

• Provider Action Item: Review your managed care contracts to see if the federal legislation requires your contracted Medicare Advantage plans to increase their payments. Track your out-of-network Medicare Advantage patient accounts to make sure you are receiving the sequestration payment.

Arent Fox’s Health Care Payer Disputes & Reimbursement team knows the ins-and-outs of the issues to come, and we are here to help. Our group is composed of lawyers in Arent Fox's Complex Litigation and Health Care practice groups. We have substantive experience in ERISA, COBRA, FEHB, HIPAA, the ACA, the Medicare Secondary Payer Act, Medicare Advantage, Medicaid Managed Care, TRICARE, state insurance laws, and federal and state health care regulatory law. We know health care reimbursement.