The World Health Organization (WHO) has declared the outbreak of respiratory disease caused by a novel coronavirus a pandemic. Many podiatrists are searching for answers about how to address COVID-19 in their practices and personal lives. APMA is here to help with the most authoritative and timely news and tools.
APMA partnered with Marcum LLP to offer its members a one-hour webinar about recent COVID-19 legislation and resources for you and your practice.
APMA has compiled answers to members' frequently asked questions.
The following are articles that have appeared in recent issues of News Brief that may provide additional information or insight for physicians as they help manage the outbreak.
January 12 Update—The SBA and Treasury released interim final rules, an updated form for First Draw PPP loans and a new form for Second Draw PPP loans, and new summaries, and will re-open the PPP loans for application, starting on January 11, through March 31, 2021.
December 22, 2020 Update—Congress passes a $900 billion COVID relief bill, which includes updates and clarifications to the PPP program, among other provisions. Read the full summary here, and go to the PPP section below for PPP-specific updates.
October 16, 2020 Update—The SBA and Treasury have issued new guidance regarding PPP loan holders' changes in ownership status and eased full forgiveness requirements for smaller loans
August 24, 2020 Update—The SBA has opened the lender portal for loan PPP loan forgiveness applications. Check if your bank is accepting your application today. Additionally, the IRS has released a new tax guidance update stating that if a recipient of PPP uses those PPP funds towards expenses that would be otherwise deductible, those expenses will no longer be deductible. Talk to your accountant to make sure that you are in compliance.
July 2, 2020 Update—Congress Extends PPP Application Loan Deadline to August 8, 2020.
June 4, 2020 Update—Congress Passes PPP Flexibility Act.
May 18, 2020 Update—SBA Releases Loan Forgiveness Application for the Paycheck Protection Program.
APMA is providing small business resources that may be available to eligible podiatric offices, and we encourage you to check back often as we continue to update this page as new information becomes available in the coming days and weeks.
In response to the COVID-19 pandemic, the CARES ACT expanded loan options for small businesses, and we expect podiatric offices to take advantage of one or both loan options. Detailed information about both options is available on this page.
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Paycheck Protection Program
Economic Injury Disasters Loan and Loan Advance
Marcum, LLP Articles for Podiatric Practices
Additional Assistance and Resources
Webinar: How Your Practice Can Survive COVID-19
Podcast: Applying for SBA Loans
As a part of the December 2020 $900 billion COVID relief package, Congress provided updates and clarifications to the PPP loans that were previously awarded as well as announced a second round of loans that would be made available to smaller, harder-hit businesses. With regard to all PPP loans, Congress did the following:
FDL and SDL PPP borrowers may receive a loan amount of up to 2.5 times their average monthly payroll costs (capped at $100,000 per employee annualized), in 2019, 2020, or the year prior to the loan. The maximum loan amount is $10 million for first-time borrowers and $2 million for second-time PPP borrowers. Both first and second draw loans are forgivable if the funds are used on the following eligible costs:
To be eligible for full loan forgiveness, PPP borrowers must spend no less than 60 percent of the funds on payroll over a covered period of their choice between eight and 24 weeks.
First Draw Loans (FDLs) - Up to $10 Million
Application: Form 2483—Paycheck Protection Program Borrower Application Form (first draw borrowers)
Eligible entities of 500 employees or fewer include among others:
Reapplying and Loan Increases: Existing PPP borrowers that did not receive loan forgiveness by December 27, 2020 may: (1) reapply for a First Draw PPP Loan if they previously returned some or all of their First Draw PPP Loan funds, or (2) under certain circumstances, request to modify their First Draw PPP Loan amount if they previously did not accept the full amount for which they are eligible.
Second Draw Loans (SDLs) - Up to $2 Million
Application: Form 2483-SD—PPP Second Draw Borrower Application Form (second draw borrowers)
This loan of up to $2 million is available to smaller (300 employees or less) that can demonstrate at least a 25 percent reduction in the first, second, or third quarter relative to the same 2019 quarter. If a business was not in operation in 2019, the Act provides applicable timelines for demonstrating a loss.
Eligible entities of 300 or fewer employees include among others:
An eligible entity may only receive one PPP second draw loan. For loans of $150,000 or less, the entity may submit a certification attesting that the entity meets the revenue loss requirements on or before the date the entity submits its loan forgiveness application.
FDL and SDL forgiveness:
Recipients of both first draw and second draw loans would be eligible for forgiveness equal to the sum of their payroll costs, as well as covered mortgage, rent, and utility payments, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures incurred during the covered period. The 60/40 cost allocation between payroll and non-payroll costs in order to receive full forgiveness will continue to apply.
Borrowers should contact their lenders for additional information on the loan forgiveness process.
There are two loan forgiveness applications, dependent on how much money your practice received:
APMA encourages borrowers to contact their accountants to assist with preparing the appropriate documentation. There is no explicit deadline for submission, PPP loan recipients should contact their lender directly for information on submitting the loan forgiveness application.
NOTE: You have until December 31, 2020, to restore your full-time employment and salary levels for any changes made between February 15 and April 26, 2020.
The PPP Flexibility Act added additional exemptions to the reduction in the amount of loan forgiveness. Under the new law, the amount of loan forgiveness will not be reduced based on a reduction in the number of full-time equivalent employees if the borrower, in good faith:
Currently only community financial institutions (CFIs) are able to process a PPP loan application. CFIs include:
The SBA and Treasury have indicated that this will open more widely to other banking entities, but hasn't given a specific date.
You may owe money when your loan is due if you use the loan amount for anything other than payroll costs, mortgage interest, rent, and utilities payments over the eight weeks after getting the loan. You will also owe money if you do not maintain your staff and payroll. If any or portion of the loan is not forgiven, these loan terms apply for all borrowers.
Changes in Ownership if Owner has received a PPP Loan
On October 2, the SBA also released additional guidance on whether or not the SBA needs to approve any change in ownership. The SBA clarified that for 7(a) loans made under the PPP, no approval is required if the borrower has repaid its PPP loan in full or if it has applied for forgiveness with a final determination on forgiveness having been made (as evidenced by the SBA's payment to the lender) with either the full amount of the loan forgiven or the borrower having repaid any unforgiven amount.
If you have PPP amounts outstanding, it depends on several factors.
The borrower must seek approval of the SBA before effectuating any other ownership change, regardless of whether it is an equity or asset sale. As part of the approval process, the borrower must submit certain information to the SBA (through its lender), including the following:
The SBA will issue a determination within 60 days of the receipt of a complete request.
Additional Resources from APMA Partners
EIDLs are available to small businesses, independent contractors, and sole proprietors in declared disaster areas, which now includes all 50 states and territories. To qualify for an EIDL, the applicant must have suffered “substantial economic injury” from COVID-19. Substantial economic injury generally means a decrease in income from operations or working capital with the result that the business is unable to meet its obligations and pay ordinary and necessary operating expenses in the normal course of business.
Eligible recipients can receive up to $2 million in assistance, which can include a $10,000 Emergency EIDL (cash advance grant). EIDL loans under the CARES Act are based on a company’s actual economic injury determined by the SBA (less any recoveries such as insurance proceeds)
Unlike PPP, EIDLs generally do not have any loan forgiveness provisions. However, applicants that already applied for an EIDL loan can refinance their EIDL under the PPP. Additionally, the Emergency EIDL loan (next section) of up to $10,000 is not expected to be repaid, even if you are subsequently rejected for an EIDL.
$10,000 Emergency EIDL (Cash Advance Grant)
Proceeds of the overall EIDL may be used for:
Applications for an EIDL and Emergency EIDL can be submitted from January 31–December 31, 2020.
Eligible small businesses can apply for a loan at https://disasterloan.sba.gov/ela. For questions, please contact the SBA disaster assistance customer service center at 1-800-659-2955 (TTY: 1-800-877-8339) or email firstname.lastname@example.org. Eligible businesses should expect a disbursement of monies within five business days of a successful application.
The interest rate on EIDL loans is 3.75 percent fixed for small businesses and 2.75 percent for nonprofits. The EIDL loans have up to a 30-year term and amortization (determined on a case-by-case basis).
The accounting and business advisory firm of Marcum, LLP is providing information to help podiatric practices survive during the pandemic and economic downturn and to start planning for the recovery.
Article 1: Guide to COVID-19 Small Business Loans
APMA has compiled resources on other SBA loans, state loans for small businesses, private resources and consumer assistance available to podiatric practices.
APMA partnered with Marcum LLP to offer its members a one-hour webinar about recent COVID-19 legislation and resources for you and your practice. Download a copy of the presentation and a copy of the Q&A from the presentation. Marcum LLP provides a detailed guide to small business loans as an update to its How Your Practice Can Survive COVID-19 webinar.
Disclaimer: This resource is for information purposes only. APMA advises doctors of podiatric medicine to speak with an attorney or financial advisor duly licensed in their jurisdiction.
During the COVID-19 Public Health Emergency, there are four non-face-to-face service types podiatrists can provide to most patients. A provider’s ability to employ these services may differ based on the patient’s insurance and state licensure. Some private insurers have issued guidelines that vary from what is listed below. Always check with payer and state licensure guidelines before providing any service.
For all of the services described below, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health-care providers who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 emergency.
The four service options include:
As of March 30, 2020, CMS is allowing all four of these services to be provided for both new and established patients.
1. Telehealth for Medicare Part B and Medicare Advantage Patients—Services that are normally furnished in person which are instead furnished remotely using interactive, real-time telecommunication technology
On March 17, CMS announced that providers can perform certain E/M services when performed remotely. The provider can be in any location and the patient can be in any location. More services were added to that list and further clarification was provided on March 30, 2020.
Some private payers have followed suit, also allowing certain E/M services to be provided remotely. Check private payer policies for details.
2. Use G2012 when a virtual check-in is provided to a Medicare Part B or Medicare Advantage patient using telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission
APMA suggests obtaining informed consent for these services. APMA further suggests that members advise patients that there will be a charge for these services, that copays and deductibles may apply, and referrals may be necessary if required by the insurance plan.
We have recorded a special episode of The APMA Podcast about providing telemedicine services. Listen below.
Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency http://hhs.com/assets/docs/covid-final-ifc.pdf
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983–2019 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Reference: 2020 CPT Professional
CPT codes and their descriptions do not reflect or guarantee coverage or payment. Just because a CPT code exists, payment for the service it describes is not guaranteed. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APMA and its employees, consultants, and officers do not claim responsibility for any consequences or liability attributable to the use of any information, guidance, or advice contained in this communication or liability attributable to the use of any information, guidance, or advice contained in this communication.
The Consolidated Appropriations Act of 2021 includes COVID relief legislation. Read a high-level summary of provisions that may be of interest to APMA members. APMA will continue to review the legislation and provide more information to members as it becomes available.
Congress and the administration have heard from medical practices nationwide about the substantial impact of COVID-19 on their businesses. APMA’s partner, Capitol Hill Consulting Group, has created the following summary of provisions in the Coronavirus Aid, Relief, and Economic Security (CARES) Act that may have an impact for our member physicians. For more information, email email@example.com.
APMA has been working to protect you and your practice since the COVID-19 public health practice began.
Members can find all COVID-19 CMS-related news on this page. For relevant COVID-19 related APMA resources, including APMA recommendations and access to financial resources during this public health emergency, visit www.apma.org/COVID19.
|Physicians and Non-Physician Practitioners||
|All Other Providers and Suppliers (including DMEPOS)||
Additionally, the FAQ addresses the process for physician and non-physician practitioners to initiate temporary Medicare billing privileges, including through an enrollment hotline, licensure, revalidation, and more.
|Colorado||Louisiana||New Mexico||Utah (no COVID-19 waiver to date)|
|District of Columbia||Massachusetts||North Dakota||Washington|
|Georgia||Minnesota||Ohio (no COVID-19 waiver to date)||Wisconsin (no COVID-19 waiver to date)|
Some states have not yet applied for or received their 1135 Medicaid waivers. CMS has issued an FAQ to address this situation.
Page last updated on October 5, 2020.
October 5 Update - The portal to apply for Phase 3 General Distribution funds is now open.
October 2 Update - HHS announced a new $20 billion allocation for the Phase 3 General Distribution.
September 22 Update - CMS updated its Post-Payment Notice of Reporting Requirements.
August 3 Update - HHS announced the deadline to apply for the Medicaid/CHIP provider relief fund tranche is now August 28, 2020. HHS also announced that starting the week of August 10, HHS will allow Medicare providers who missed the opportunity to apply for additional funding from the $20 billion portion of the $50 billion Phase 1 Medicare General Distribution.
July 20 Update - HHS announced the timeline for reporting requirements, applicable to providers who received one or more payments exceeding $10,000 in the aggregate from the general or targeted distributions.
June 9 Update – HHS announced distribution of provider relief funding for Medicaid providers.
May 20 Update - HHS announced that the deadline to apply for the second allocation for the Medicare Provider Relief Fund is June 3, 2020.
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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Post-Payment Reporting Requirements
$30 Billion General Distribution to Health-Care Providers
$20 Billion Phase 2 General Distribution to Health-Care Providers
$20 Billion Phase 3 General Distribution to Health-Care Providers
$15 Billion Distribution to Medicaid/CHIP Providers
Terms and Conditions
Provider Relief Webinar
CMS updated its Post-Payment Notice of Reporting Requirements. These revised requirements still have lowered the threshold from the August 14 Notice – from $150,000 in the Terms and Conditions to $10,000. These forms provide complete, detailed information on provider reporting guidelines, including intent, use of funds, and data elements requested. The reporting system will now be available in early 2021.
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 90 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.
UPDATE: HHS announced that starting the week of August 10, HHS will allow Medicare providers who missed the opportunity to apply for additional funding from the $20 billion portion of the $50 billion Phase 1 Medicare General Distribution. These providers will have until August 28th to apply.
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 90 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 90 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 90 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.
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.
On October 1, HHS announced an additional $20 billion allocation for Phase 3 General Distribution. Under this allocation, providers who have already received Provider Relief Fund payments will be invited to apply for additional funding that considers financial losses and changes in operating expenses caused by the coronavirus. Previously ineligible providers, such as those who began practicing in 2020, will also be invited to apply. Providers can begin applying for funds on Monday, October 5, 2020, with applications due no later than November 6, 2020. HHS strongly recommends submitting your application as soon as possible, to expedite the review process. Attestation, terms, and eligibiltiy can be found at https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/for-providers/index.html.
HHS is making a large number of providers eligible for Phase 3 General Distribution funding, including:
Payment Methodology – Apply Early
All eligible providers will be considered for payment against the following criteria:
All payment recipients will be required to attest to receiving the Phase 3 General Distribution payment and accept the associated Terms and Conditions.
Providers will have from October 5, 2020 through November 6, 2020 to apply for Phase 3 General Distribution funding.
On June 9, 2020, HHS announced the distribution of approximately $15 billion from the Provider Relief Fund to eligible providers that participate in state Medicaid and Children’s Health Insurance Program (CHIP) and have not received a payment from the Provider Relief Fund General Distribution. The payment to each provider will be approximately 2 percent of reported gross revenue from patient care; the final amount each provider receives will be determined after the data is submitted. HHS has released a fact sheet on this third round. Providers who receive funds from this distribution have 90 days to attest to the terms and conditions, via the Enhanced Provider Relief Fund Payment Portal. Instructions on how to apply can be found on the main HHS Provider Relief Fund Provider page. Providers have until August 28, 2020 to apply.
HHS announced that it will be releasing detailed reporting instructions by August 17, 2020. These reporting requirements apply to to Provider Relief Fund recipients that received one or more payments exceeding $10,000 in the aggregate from the general or targeted distributions. The reporting system will become available to recipients for reporting on October 1, 2020. All recipients must report within 45 days of the end of calendar year 2020 on their expenditures through the period ending December 31, 2020.
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.”
In addition to the general distribution, HHS will make the following targeted allocations:
View the allocation chart for more information.
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.
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.
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?
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.
Note: Above resources and information adapted from Hart Health Strategies
Many podiatric practices are beginning to reopen and care for patients in their offices as well as resuming elective surgeries. APMA is providing resources to assist members with opening their offices in a safe manner for their patients and staff.
While these resources provide background information and practice solutions for podiatric physicians, APMA is not rendering legal or other professional advice. APMA encourages readers of these resources who need assistance to consult with an attorney duly licensed in your jurisdiction.
The CDC and CMS have information, recommendations, and guidance for nursing homes and long-term care facilities. If you provide care at nursing homes or long-term care facilities, check out these resources.
The CDC provides general information on Nursing Homes and Long-Term Care Facilities as it relates to COVID-19.
CMS has created the Nursing Home Resource Center where you can find nursing home resources including COVID-19 public health emergency response information and a series of short podcasts for front-line nursing home staff.
The CDC provides guidance pertaining to the Response to Newly Identified SARS-CoV-2-infected Healthcare Personnel or Residents.
CMS provides recommendations relating to Nursing Home Visitation – COVID-19, including visiting providers.
With the holidays approaching, CMS has recommendations regarding holiday celebrations that include recommendations for nursing home staff to protect their vulnerable residents. The CDC also has more general information regarding holiday celebrations.
The CDC’s information on Preparing for COVID-10 in Nursing Homes includes information on testing healthcare personnel and evaluating and managing health-care personnel. There are additional Testing Guidelines for Nursing Homes and the Interim Guidance on Testing Health-Care Personnel for SARS-CoV-2 shares appropriate use of testing among healthcare personnel, including:
“Currently, testing asymptomatic health-care personnel without known or suspected exposure to SARS-CoV-2 is recommended for health-care personnel working in nursing homes.”
CMS provides recommendations for state and local officials regarding nursing home reopening including access to adequate testing. CMS also has guidance for facilities to meet requirements related to testing residents and staff, including individuals providing services under arrangement and volunteers.
APMA, the CDC, and CMS provide information, recommendations, and guidance regarding the COVID-19 vaccination.
APMA has advocated that DPMs be included in the first group (health-care workers) prioritized for the COVID-19 vaccine.
To provide even more support for your profession, you can write your governor today regarding COVID-19 vaccine distribution with just a few clicks at APMA’s eAdvocacy site.
APMA has also requested that residency directors advocate for podiatric medical students rotating in clinical experiences to receive the COVID-19 vaccination.
APMA's regulatory consultant, Hart Health Strategies Inc., has prepared a new COVID resource document on the topic of COVID vaccines.
Information on the different COVID-19 vaccines, including information on vaccines in clinical trials, is available from the CDC.
The CDC has information on the phased approach to vaccine distribution.
The New England Journal of Medicine (NEJM) has a Covid-19 Vaccine Resource Center, which features a collection of resources on Covid-19 vaccines, including frequently asked questions, continuing medical education, published research, and commentary. In particular, NEJM has COVID-19 Vaccine Training to ensure that you understand the science and practicalities of the new COVID-19 vaccines.
CMS provides information related to COVID-19 vaccine administration to ensure the vaccine is covered and available free of charge for every American. CMS also has a tool kit regarding vaccine administration specifically for health-care providers.
Clinical resources from the CDC are available for the administration, storage and handling, patient education, and more for COVID-19 vaccine.
The CDC has information for preparing your practice for COVID-19 vaccination.
Q: Can podiatrists prescribe and/or administer vaccines for COVID-19?
Whether or not podiatrists have the authority to prescribe and/or administer COVID-19 vaccines is dependent on state law. While still subject to state law, the US Department of Health and Human Services (HHS) amended its declaration under the Public Readiness and Emergency Preparedness Act (PREP Act) on January 28 to add additional categories of qualified persons authorized to prescribe, dispense, and administer COVID-19 vaccines authorized by the US Food and Drug Administration. APMA recommends that podiatrists contact their state licensing board (e.g., board of podiatry/board of medicine) for a determination on state law.
As of March 2, 2021, APMA is aware of eight states that authorize podiatrists to administer vaccines:
Each state’s requirements are different. You will need to contact the state department of health for more information or to ask questions. If your state is not listed, please contact your state component for more information.
More information is available in a February 1 news story: Update: APMA Advocates for Podiatrists in Plans for COVID-19 Vaccine Distribution.
If you are able to vaccinate, the CDC has materials for preparing your practice for COVID-19 vaccination, including the CDC's Vaccine Training Modules and a printable "Facts about COVID-19 Vaccines" resource you can provide to your patients.
Q: Can podiatrists require their office staff to receive the COVID-19 vaccination?
Generally, you can require your employees to get vaccinated if by not getting the vaccine they pose a direct threat to customers or other employees. In the context of a physician's office, it is probably easy to demonstrate that employees would pose a direct threat to patients if the employee was not vaccinated.
However, any policy that requires employees to receive the COVID-19 vaccine must comply with the Americans with Disabilities Act, Title VII of the Civil Rights Act of 1964, and other workplace laws. The Equal Employment Opportunity Commission has provided guidance to employees in Section K of What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws.
Note: See Sections K.5, K.6 and K.7 on when employers must provide a disability or religious exemption or a reasonable accommodation to employees.
More information is also available from the Society for Human Resource Management regarding what employers can do if workers refuse a COVID-19 vaccination and when employers can require COVID-19 vaccinations.
Lesions and other dermatologic manifestations have been observed as a potential symptom of COVID-19. These lesions can appear in several places, including the feet. This "COVID Toes" phenomenon requires further study.
APMA is working closely with the American Academy of Dermatology (AAD) on its established COVID-19 registry, www.aad.org/covidregistry. Listen to this message from APMA President Seth Rubenstein, DPM, about the value of your participation.
APMA encourages its members to report cases of lesions on the feet associated with COVID-19 through this registry because it could have immediate and long-term strategic benefits for our profession.
“The emergence of so-called 'COVID Toes' is an opportunity for our profession to both contribute meaningful data as well as assist with research, publish papers, and collaborate with another medical specialty in education and research opportunities. Developing peer-to-peer relationships with the house of medicine can also open other doors for advocacy and education,” APMA President Seth Rubenstein, DPM, said. The Principal Investigator of the AAD Registry, Esther Freeman, MD, PhD, shared that, “We have seen a broad range of cutaneous manifestations in COVID-19, many of which involve the extremities and acral surfaces. We look forward to collaborating with our colleagues from the APMA.”
The AAD COVID Registry is HIPAA-compliant and Institutional Review Board (IRB)-approved.
Watch as Tracey Vlahovic, DPM, reviews dermatologic manifestations of viral diseases, including those recently associated with COVID-19. Dr. Vlahovic will discuss the current scientific literature related to dermatologic manifestations and how they are related to podiatric medicine.
"Addressing the Question of Dermatologic Manifestations of SARS-CoV-2 Infection in the Lower Extremities: A Closer Look at the Available Data and its Implications"
Letter to the Editor, JAPMA, April 20, 2020. Rami Basatneh, DPM, and Tracey Vlahovic, DPM
"Foot Manifestations in a COVID-19 Positive Patient: A Case Study"
Clinical Correspondence, JAPMA, May 4, 2020. Michael Nirenberg, DPM, and Maria del Mar Ruiz Herrera
CDC/WHO Guidance for Health-Care Professionals
Recommendations for Clinical Practice
Practice, Legal, and Financial Resources