CARES Act Provider Relief for COVID-19 | Practicing DPMs | APMA
CARES Act Provider Relief for COVID-19

Page last updated on May 21, 2020.

May 20 Update - HHS has announced that the deadline to apply for the second allocation for the Medicare Provider Relief Fund is June 3, 2020.

May 7 Update - HHS has announced that it extended the deadline for health-care providers to attest to receipt of payments from the Provider Relief Fund and accept the Terms and Conditions. Providers will now have 45 days, increased from 30 days, from the date they receive a payment to attest and accept the Terms and Conditions or return the funds. 

On April 10, the US Department of Health and Human Services (HHS) began implementing the Provider Relief fund established by Congress, a $175 billion relief fund to assist health-care providers during the pandemic. For more information, visit the HHS Provider Relief Site at www.hhs.gov/providerrelief and for questions, contact the provider relief hotline at 866-569-3522.

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$30 Billion General Distribution to Health-Care Providers
$20 Billion General Distribution to Health-Care Providers
Terms and Conditions
Targeted Distribution
Provider Relief Webinar
FAQs
Additional Resources

$30 Billion General Distribution to Health-Care Providers

On April 10 and 17, HHS began distributing the initial $30 billion in relief funding to Medicare fee-for-service (FFS) facilities and providers in support of the national response to COVID-19, and part of the $100 billion provider relief fund provided for in the Coronavirus Aid, Relief, and Economic Security (CARES) Act recently passed by Congress and signed by President Trump. Some providers have already received payments from this initial distribution. These funds are grants, not loans, and do not have to be repaid.

This initial $30 billion is being directed to hospitals and physician practices in direct proportion to their share of Medicare FFS spending. The total amount of Medicare FFS spending in 2019 was $484 billion. Hypothetically, if a Medicare provider with a Taxpayer ID Number (TIN) accounted for 1 percent of total Medicare FFS spending in 2019, the TIN would receive 1 percent of the $30 billion. All facilities and health professionals that billed Medicare FFS in 2019 are eligible for the funds.

Note that the funds will go to each organization’s TIN which normally receives Medicare payments, not to each individual physician. The automatic payments will come to the organizations via Optum Bank with “HHSPAYMENT” as the payment description. Within 45 days of receiving the payment, providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment.

HHS has clarified that the total distribution for a provider should be approximately 2 percent of 2018 gross revenue. Additionally, HHS has stated that “names of payment recipients and the amounts received” will be publicly available for “all providers who attest to receipt of a payment and acceptance of the Terms and Conditions.” HHS further notes that a provider should not attest unless the payment is consistent with the estimated allocation.

$20 Billion General Distribution to Health-Care Providers

HHS announced additional plans for distributing funds from the CARES Act Provider Relief Fund, stating that $50 billion would be a “General Distribution” based proportionately on the provider’s 2018 net patient revenue. Providers have already received $30 billion via this fund. Of the remaining $20 billion, approximately $10 billion was scheduled to be released on April 24 to hospitals and other facilities that have already shared cost reports with HHS. The deadline to apply for funds from this second allocation is June 3, 2020.

Providers, including podiatrists, who already have received funds from the initial $30 billion must sign into the general distribution portal to provide revenue data if they would like to receive additional funds. Providers must attest to each payment associated with their billing TIN(s), if they have not already done so. Per the newly released FAQ, providers will also need to attest to the terms and conditions for the first $30 billion, within 45 days of receiving the fund, if they have not already done so.

HHS has released a user guide to assist with this data submission process. One key element of the cost reporting is information from the provider’s tax returns. Additionally, providers will need their W-9 and Medicare or Medicaid ID number.

The total funds being provided in this round will take into account any funds the provider previously received as part of the $30 billion distribution. Subsequent to the funds being deposited, within 45 days of receipt of the funds, the provider is requested to log onto the CARES Act Provider Relief Fund attestation portal to confirm receipt and agree to the terms and conditions. Please note that these terms and conditions are not identical to those for the $30 billion distribution. Additionally, according to HHS, if providers receive a payment from funds appropriated in the Public Health and Social Services Emergency Fund for provider relief (“Relief Fund”) and retain that payment for at least 45 days without contacting HHS regarding remittance of those funds, they are deemed to have accepted the terms and conditions.

To determine whether you will likely receive additional funding from this second allocation of $20 billion, you should examine your 2018 gross patient revenue, as detailed below. 

  • If the provider received less than 2 percent of 2018 gross revenue from the initial $30 billion distribution, then the provider may be eligible to receive additional funding up to the 2 percent calculation.
  • If the distribution from the initial $30 billion is more than 2 percent of 2018 gross revenue, HHS has stated in its FAQs that you will likely not receive additional General Distribution payments. There may be additional distributions in the future for which providers are eligible.
  • Note that this calculation should be done for all TINs tied to 2018 net patient revenue amount.

Please note that if you did not receive any funds from the initial $30 billion general distribution, you are currently not eligible to receive funding through this second $20 billion general distribution. However, HHS notes that such providers may still be eligible for payments from the Provider Relief Fund through other mechanisms, including the Targeted Distributions being made from the Fund.

Terms and Conditions

Terms and Conditions for the General Allocation

For the $30 billion allocation, the initial terms and conditions were provided on April 10 and updated on April 13, April 20, and April 24. In comparing the latest version of the $30 billion terms and conditions to the initial terms and conditions for the $20 billion, the language is identical, except that the $20 billion terms and conditions includes additional language specific to the allocation.

In reviewing the terms and conditions, there are a few key items for providers to consider, as detailed below.

Possible or actual cases. Providers must attest that they “[provide] or provided after January 31, 2020, diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.” The initial terms and conditions did not include the specific date. While this information is not included in the terms and conditions, HHS on its website further noted that “HHS broadly views every patient as a possible case of COVID-19.” With the addition of the date and the HHS clarification, providers may be able to attest to this requirement if they treated any patient after January 31, whether via telehealth or in person.

Reallocating funds. At this time, there is a not a process to allow an entity to reallocate the funds to different a TIN in light of changes in ownership or new providers. This situation is a particular issue given that the legacy TINs may not be able to attest to the ability to treat patients and, as such, may have difficulty in attesting to retain the funds.

Bans balanced billing. In essence, to retain the funds, a provider must not balance bill for “all care for a presumptive or actual case of COVID-19.” For those patients, the provider must not seek from the patient more than the patient would have been obligated to pay if the provider was an in-network provider. While it is still unclear which cases would be “presumptive or actual” cases, one could attest that this subset of patients is different from “possible or actual” (which is essentially all patients) but would still apply to all patients in that subset, regardless of payer. And, given that this language does not have a similar date qualifier (i.e., the January 31 date), it is unclear when HHS expects the balance billing requirement to be in effect. This situation is particularly troubling, given that, so far, there has been no discussion regarding the amount of payment required.

Note that the secretary has concluded that the COVID-19 public health emergency has caused many health-care providers to have capacity constraints. As a result, patients who would ordinarily be able to choose to receive all care from in-network health-care providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, the recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network recipient.

No other reimbursement. One additional requirement is that the “recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.” Unfortunately, HHS did not provide enough information for providers to easily untangle how to provide appropriate accounting for these items, especially given that many health-care services may be under additional obligations (e.g., Medicare payment for certain telehealth services), interactions with other government programs (e.g., the Paycheck Protection Program), etc.

Salary cap. The funds provided cannot be used to “pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II.” According to OPM, Executive Level II is $197,300 for 2020. On its website, HHS has stated that “these are payments, not loans” but has not clarified whether this is an “extramural mechanism” subject to this restriction.

Use of funds. Another key requirement is that the “recipient certifies that the payment will only be used to prevent, prepare for, and respond to coronavirus, and shall reimburse the recipient only for health-care related expenses or lost revenues that are attributable to coronavirus.” This requirement is confusing at best, and it seems virtually impossible to use the fund at the same time for both care and lost revenue. Therefore, additional clarity is needed, especially in light of the extensive reporting requirements for the program.

Not an exhaustive list. The terms and conditions include a statement that “[t]his is not an exhaustive list and you must comply with any other relevant statutes and regulations, as applicable.” Further, the notice states that “[n]on-compliance with any term or condition is grounds for the secretary to recoup some or all of the payment made from the Relief Fund.”

Subcontractors. Another key statement is that “[t]hese terms and conditions apply directly to the recipient of payment from the Relief Fund. In general, the requirements that apply to the recipient, also apply to subrecipients and contractors, unless an exception is specified.”

Additional language from $20 billion allocation. The additional language in the terms and conditions for the second tranche (e.g., $20 billion allocation) is as follows: “The recipient shall also submit general revenue data for calendar year 2018 to the secretary when applying to receive a payment, or within 30 days of having received a payment. The recipient consents to the Department of Health and Human Services publicly disclosing the payment that recipient may receive from the Relief Fund. The recipient acknowledges that such disclosure may allow some third parties to estimate the recipient’s gross receipts or sales, program service revenue, or other equivalent information.”

Targeted Distribution

In addition to the general distribution, HHS will make the following targeted allocations:

  • Allocation for treatment of the uninsured
  • Allocation for COVID-19 high impact areas ($10 billion)
  • Allocation for rural providers ($10 billion)
  • Allocation for Indian Health Services ($400 million)
  • Additional allocations to SNFs, dentists, and providers who solely take Medicaid

View the allocation chart for more information.

Provider Relief Webinar

In the recorded webinar below, Shana Christrup, VP for Health Policy with Hart Health Strategies, gives an overview of the Provider Relief Fund, including common questions about the terms and conditions, and explains how podiatrists can apply to receive additional distributions.

FAQs

Which portal should I use?
Given the number of portals included within the CARES Act Provider Relief Fund, see below for all of the relevant links and some general information.

  • General Distribution: If a provider received funds from the initial $30 billion distribution and would like to be eligible to receive additional funds from the $20 billion distribution, visit the General Distribution Portal, which was launched on April 24.
  • Attestation Portal: To attest to the terms and conditions for the initial $30 billion of the general distribution and to confirm receipt of these funds, visit the attestation Attestation Portal, which was launched April 16.
  • Uninsured Claims Reimbursement Portal: To register and submit claims related to the uninsured, visit the uninsured claims reimbursement Uninsured Claims Reimbursement Portal, which was launched on April 27.

How does changing calculations for distribution effect my allocation?
HHS initially distributed the funds proportionally based on 2019 Medicare FFS but then later opted to use 2018 net patient revenue. At this time, it is unclear if HHS is going to request that providers return some funds from the initial $30 billion if the new formula would result in a lower payment amount.

How can I estimate the total payment amount I can anticipate through the General Distribution?
In general, providers can estimate payments from the General Distribution of approximately 2 percent of 2018 (or most recent complete tax year) patient revenue. To estimate your payment, use this equation:

(Individual Provider Revenues/$2.5 Trillion) x $50 Billion = Expected Combined General Distribution.

To estimate your payment, you may need to use “Gross Receipts or Sales” or “Program Service Revenue.” Providers should work with a tax professional for accurate submission. This includes any payments under the first $30 billion general distribution as well as under the $20 billion general distribution allocations. Providers may not receive a second distribution payment if the provider received a first distribution payment of equal to or more than 2 percent of patient revenue.

Are the funds taxable?
The information provided does not make the tax status clear, although one may assume that is it likely taxable income. We have requested that HHS provide clarification regarding what taxes, if any, should apply to the funds.

What if I haven’t received any provider relief funds from the initial $30 billion distribution?

  1. The first step is to confirm you are eligible for funds:
    • Did you bill Medicare in 2019?
    • Are you an employed physician? If you are an employed physician, then we suggest checking with your employer as it may have received funds. Employers have discretion as to how they want to use and/or distribute the funds.
    • Did you change jobs or billing TIN in 2019? Funds were distributed to the TIN associated with your 2019 Medicare Part B billing. Unfortunately, HHS did not provide guidance or a mechanism for transferring funds over to a different TIN as the TIN that received the funds has to attest to the terms and conditions.
  2. The second step is checking the appropriate account. Funds were distributed at the TIN level, so we recommend checking the account associated with the billing TIN to confirm funds were not received there.
  3. If you are eligible and funds were not received, contact the Provider Relief Hotline: 866-569-3522. Ask that they investigate why you did not receive the funds and ask that someone follow up with you.
  4. If you still do not receive any funds, contact APMA at healthpolicy.hpp@apma.org.

I bill Medicare through the Medicare Advantage program. I did not receive funding in the general distribution. When can I expect to receive funding?
Providers who did not receive funding under the General Distribution may be included in future allocations under the Provider Relief Fund. Additional information will be posted as available at https://www.hhs.gov/provider-relief/index.html.

What if I did not receive any payments from the first $30 billion allocation. Can I still receive funding though this second $20 billion distribution?
No, unfortunately only providers who have already received a previous payment under the General Distribution are eligible to receive funding through this distribution.

What should I do if my General Distribution payment is greater or less than expected or received in error?
Providers that have been allocated a payment must sign an attestation confirming receipt of the funds and agree to the Terms and Conditions within 45 days of payment via ACH or within 60 days of check payment issuance. If a provider believes it was overpaid or may have received a payment in error, it should reject the entire General Distribution payment and submit the appropriate revenue documents through the General Distribution portal to facilitate HHS determining their correct payment. If a provider believes they are underpaid, they should accept the payment and submit their revenues in the provider portal to determine their correct payment.

How should I return these funds, if I do not believe I am entitled to them or I do not wish to accept the terms and conditions for monies received under either the first and/or second allocation?
Providers may return a payment by going into the attestation portal within 45 days of receiving payment via ACH or within 60 days of check payment issuance and indicating they are rejecting the funds. The CARES Act Provider Relief Fund Payment Attestation Portal will guide providers through the attestation process to reject the funds.

To return the money, the provider needs to contact their financial institution and ask the institution to refuse the received Automated Clearinghouse (ACH) credit by initiating an ACH return using the ACH return code of “R23 - Credit Entry Refused by Receiver." If a provider received the money via ACH they must return the money via ACH. If a provider was paid via paper check, after rejecting the payment in the attestation portal, the provider should destroy the check if not deposited or mail a paper check to UnitedHealth Group with notification of their request to return the funds.

What should I do if I received funds via an electronic payment return funding and my financial institution will not allow me to return the payment electronically?
Contact UnitedHealth Group’s Provider Support Line at 866-569-3522.

I submitted my financial information on the Provider Relief Fund Payment Portal. Why have I not received funds yet?
HHS is in the process of reviewing providers’ uploaded financial information. Payments will go out weekly, on a rolling basis, as information is validated. HHS may seek additional information from providers as necessary to complete its review.

If I accept these funds, and attest to the terms and conditions, am I banned from balance billing for all patients and/or all care, because “HHS broadly views every patient as a possible case of COVID-19”?
No. As set forth in the terms and conditions, the prohibition on balance billing applies to “all care for a presumptive or actual case of COVID-19.”

How is a presumptive case of COVID-19 defined?
A presumptive case of COVID-19 is a case where a patient’s medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in their medical record. 

If I provide out-of-network care to an insured, presumptive, or actual COVID-19 patient, can I bill the patient’s insurer any amount, as long as I don’t bill the patient directly? 
The terms and conditions do not impose any limitations on the ability of a provider to submit a claim for payment to the patient’s insurance company. However, an out-of-network provider delivering COVID-19-related care to an insured patient may not seek to collect from the patient out-of-pocket expenses, including deductibles, copayments, or balance billing, in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

How will I know the in-network rates to be able to comply with the requirement to bill a presumptive or actual COVID-19 patient for cost-sharing at the in-network rate?
Providers accepting the Provider Relief Fund payment should submit a claim to the patient’s health insurer for their services. Most health insurers have publicly stated their commitment to reimbursing out-of-network providers that treat health plan members for COVID-19-related care at the insurer’s prevailing in-network rate. But if the health insurer is not willing to do so, the out-of-network provider may seek to collect from the patient out-of-pocket expenses, including deductibles, copayments, or balance billing, in an amount that is no greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

Does HHS anticipate recouping the General Distribution payments?
Generally, HHS does not intend to recoup funds as long as a provider’s lost revenue and increased expenses exceed the amount of Provider Relief funding a provider has received. HHS reserves the right to audit Relief Fund recipients in the future to ensure that this requirement is met and collect any Relief Fund amounts that were made in error or exceed lost revenue or increased expenses due to COVID-19. Failure to comply with other terms and conditions may also be grounds for recoupment.

Do you have other guidance?
Especially in light of the application of whistleblower protections, all internal conversations regarding the funds (especially as related to any ambiguities) should be well documented.

Additional Resources

Note: Above resources and information adapted from Hart Health Strategies


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