Medical Billing Services

CMS waivers during COVID-19

COVID-19 massively affected US health care. The American Hospital Association estimates that American hospitals incurred more than $202 billion in losses between March 1st and June 30th. Medical billing also affected due to COVID-19.

According to healthcare lawyer Delphine O’Rourke, clinical documentation is critical to serving patients with COVID-19 but also avoiding medical billing and payment issues in the months and years following the pandemic. This is advice to all providers to thoroughly document care delivery to avoid medical billing issues due to arise from the COVID-19 pandemic.

“There’s a lot of confusion over what the blanket waivers cover versus what happens under specific waivers versus what governors are stating. We find in emergencies, that for months and years afterward, you are dealing with payment and insurance issues”, said Delphine O’Rourke, partner at Duane Morris and former associate general counsel for Ascension.

The Trump administration declared a national emergency. Trump administration granted HHS the authority to waive some Medicare, Medicaid, and CHIP policies and allow states to provide flexibility for providers. Providers managed to attempt this pandemic situation with these flexibilities with a finite amount of resources.

1135 Waivers

As the President declared a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act, the Secretary is authorized to take certain actions in addition to her regular authorities.

1135 waivers or modifications include:

  • Conditions of participation or other certification requirements
  • Program participation and similar requirements
  • Preapproval requirements
  • Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State
  • Emergency Medical Treatment and Labor Act (EMTALA)
  • Stark self-referral sanctions
  • Performance deadlines and timetables may be adjusted (but not waived)
  • Limitations on payment for health care items and services furnished to Medicare Advantage enrollees by non-network providers

According to CMS, the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers regulation applicable to all 17 provider types, also requires inpatient providers to have policies and procedures that address the facility’s role under an ‘‘1135 waiver’’. See the final rule for more information or contact your Regional Offices.

With the surge of COVID-19 patients, providers are trying to prepare and figure out how they’re going to care for these patients within existing regulations. Limitation on hospitals is a major challenge for critical access hospitals trying to fight with the pandemic. HHS relaxes that rule with a blanket waiver. This rule allowed critical access hospitals to increase capacity and get paid for it.

There are different kinds of 1135 waivers, including Medicare blanket waivers. When there’s an emergency, sections 1135 or 1812(f) of the SSA allow us to issue blanket waivers to help beneficiaries access care.  When a blanket waiver is issued, providers don’t have to apply for an individual 1135 waiver.

1135 blanket waivers

According to CMS 1135 blanket waivers, if you’re an entity in the declared emergency area, you can apply for an 1135 waiver. You’ll usually hear back from us within 2-3 days, but if your request is more complicated, it may take up to a week. If your waiver request has 1 or 2 items, we may get back to you within 24 hours.

Once approved, waivers have a retroactive effective date of March 1, 2020, and will end no later than when the emergency declaration’s ended.

Waivers don’t offer grants or financial assistance. They also don’t allow you to be paid for services that aren’t usually covered or for people to be eligible for Medicare who aren’t otherwise eligible. You also shouldn’t base your response decisions, like evacuations, on waivers. Once your waiver’s approved, as always to be reimbursed accurately, be sure to keep careful records about the services you provide and the beneficiaries you provide them to.

These blanket waivers will apply to all providers automatically. These waivers will help providers to provide effective and quick treatment of patients with COVID-19.


Medical Billers and Coders

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