COVID-19 Resources | Practicing DPMs | APMA
MIPS 2020
Overview

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. 

Webinar: How Your Practice Can Survive COVID-19

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.

Watch the webinar

Frequently Asked Questions

APMA has compiled answers to members' frequently asked questions.

FAQ

APMA Recommendations

In the News

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.

RELATED NEWS: APMA has canceled the 2020 House of Delegates Meeting and The Coding Seminar.

Well-Being Resources

Considering the current environment surrounding the COVID-19 pandemic, be sure you take stock of your personal health and well-being. APMA has many resources available to help you.

Be Well
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Financial Assistance for Practices

July 2 Update—Congress Extends PPP Application Loan Deadline to August 8, 2020.

June 4 Update—Congress Passes PPP Flexibility Act.

May 18 UpdateSBA 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.

  • Paycheck Protection Program (PPP)–Purpose is to help small businesses with their payroll and related costs for an eight-week period. Loan forgiveness available for small businesses that maintain their workforce. 
  • Economic Injury Disasters Loan and Loan Advance (EIDL)–Program provides small businesses with working capital loans of up to $2 million that can provide vital economic support to small businesses to help overcome the temporary loss of revenue they are experiencing. Small businesses can access a $10,000 loan advance that is not repaid.

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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

Paycheck Protection Program (PPP)

Eligibility
All businesses with 500 or few employees, including sole proprietorships, self-employed individuals, and independent contractors.

Loan Amount
Loans can be for up to two months of your average monthly payroll costs from last year plus an additional 25 percent of that amount. Payroll costs will be capped at $100,000 annualized for each employee. Loan cannot exceed $10 million. Review the FAQ to find out how to calculate your maximum loan amount.

Loan Purpose
Proceeds of the loan may be used for:

  • payroll costs, including benefits;
  • interest on mortgage obligations, incurred before February 15, 2020;
  • rent, under lease agreements in force before February 15, 2020;
  • utilities, for which service began before February 15, 2020;
  • interest payments on any other debt obligations that were incurred before February 15, 2020; and/or
  • refinancing an SBA EIDL loan made between January 31, 2020 and April 3, 2020.

NOTE: 60 percent of the loan proceeds must be used for payroll costs. Review the FAQ to learn what is included in the payroll costs.

Application Dates

  • Small businesses and sole proprietorships can apply starting April 3, 2020.
  • Independent contractors and self-employed individuals can apply starting April 10, 2020.
  • Loans must be submitted by August 8, 2020.

Approved Lenders
Any existing SBA lender, federally insured depository institution, federally insured credit union, and Farm Credit System institution that are participating can service the loan.  Podiatrists should consult with their local lender to determine whether it is participating.

Application Procedures
Use this application to apply directly with an approved lender. You will need to provide a lender with payroll documentation. Review the FAQ for a list of documentation you will likely need to apply.

Loan Forgiveness Criteria

  • You must submit a request for loan forgiveness with the lender that is servicing the loan.
  • Include documents that verify the number of full-time equivalent employees and pay rates.
  • Include payments on eligible mortgage, lease, and utility obligations.
  • Lender must make a decision within 60 days.

Loan Forgiveness Amount

  • The loan will be fully forgiven if the funds are used for payroll costs, interest on mortgages, rent, and utilities. At least 60 percent of the funds must be used for payroll costs.
  • Forgiveness will be reduced if full-time headcount is reduced.
  • Forgiveness will be reduced if you decrease salary and wages by more than 25 percent for any employee who made less than $100,000 annualized in 2019.

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 thmarce number of full-time equivalent employees if the borrower, in good faith:

  • can document that the borrower is: i) unable to rehire individuals who were employees of the borrower on February 15, 2020; and ii) unable to hire similarly qualified employees for unfilled positions on or before December 31, 2020; or
  • can document an inability to return to the same level of business activity as that which existed prior to February 15, 2020, due to compliance with COVID-related health and safety guidance (e.g., standards for sanitation or social distancing) during the period from March 1, 2020 through December 31, 2020.

Loan Terms
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. 

  • 1.0-percent fixed interest rate
  • Loans issued after June 5 have a 5-year maturity time period and loans issued before then are due in two years unless the lender and borrower agree to new terms.
  • Lenders are required to provide complete payment deferment relief for “impacted borrowers” until the loan forgiveness is determined or in ten months if the loan forgiveness application is not submitted within ten months of the loan origination date. This includes interest and fees. Impacted borrowers are presumed to have been impacted adversely by COVID-19, and all recipients are presumed to be “impacted borrowers.”

Loan Forgiveness Application

SBA released the loan forgiveness application and instructions on May 15. The following points provide important information and key takeaways for borrowers.

  • Borrowers must submit the loan forgiveness application to the lenders servicing the loan. The application has four components: 1) the PPP Loan Forgiveness Calculation Form; 2) PPP Schedule A; 3) the PPP Schedule A Worksheet; and 4) the (optional) PPP Borrower Demographic Information Form. All borrowers must submit (1) and (2) to their lender. Options are available for borrowers to calculate payroll costs using an “alternative payroll covered period” that aligns with borrowers’ regular payroll cycles.
  • Flexibility exists to include eligible payroll and non-payroll expenses paid or incurred during the eight-week period after receiving the PPP loan. 
  • For loans made before June 5, a borrower may elect an eligible period of eight weeks. For all other loans, the eligible period is 24 weeks or until December 31, 2020, whichever comes first.

We encourage borrowers to contact their accountants to assist with preparing the appropriate documentation.

For more information: Access the Borrower Guidance from the Department of the Treasury and the SBA.


Additional Resources from APMA Partners

Paycheck Protection Program (PPP) FAQ

Economic Injury Disaster Loan (EIDL) and Emergency EIDL Loan Advance

Eligibility

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.

Loan Amount
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)

Loan Forgiveness
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)

  • How do I apply for this grant?
    The SBA has launched a streamlined application process via its website, so small businesses can submit applications for both the EIDL and Emergency EIDL simultaneously. If you had previously submitted an application for an EIDL prior to the emergency loan’s availability, you can still submit an application for the Emergency EIDL.
  • How much?
    Up to $10,000 in a cash advance is available.
  • How quickly can I receive this money?
    The SBA anticipates paying the cash advance within three days of a successful application. 
  • What can I use the emergency EIDL cash advance for?
    The grant can be used to provide paid sick leave to employees; maintain payroll; meet increased production costs due to supply chain disruptions; or pay business obligations, including debts, rent, and mortgage payments.
  • Is the cash advance forgivable?
    This advance is forgivable if it is spent on any of the items listed above. The emergency loan is also forgivable even if the grantee is subsequently denied an EIDL.

Loan Purpose
Proceeds of the overall EIDL may be used for:

  • Payroll and other costs
  • Increased costs due to supply chain interruption
  • Mortgage or lease payments
  • Obligations that cannot be met due to revenue loss and for other uses.

Application Dates
Applications for an EIDL and Emergency EIDL can be submitted from January 31–December 31, 2020. 

Application Procedures
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 disastercustomerservice@sba.gov. Eligible businesses should expect a disbursement of monies within five business days of a successful application.

Loan Terms
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).

Economic Injury Disaster Loan (EIDL) and Emergency EIDL (Cash Advance) FAQ

Marcum, LLP Articles for Podiatric Practices

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

Article 2: Accessing Various Forms of Capital for Your Practice

Article 3: Building a Path Forward for Your Podiatry Practice

Article 4: Tools to Help Your Podiatry Practice Survive and Thrive

Additional Assistance and Resources

APMA has compiled resources on other SBA loans, state loans for small businesses, private resources and consumer assistance available to podiatric practices. 

Webinar: How Your Practice Can Survive COVID-19

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.

Podcast: Applying for SBA Loans

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.

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Telemedicine

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:

  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
  2. Use G2012 when a virtual check-in is provided to a Medicare Part B or Medicare Advantage patient
  3. Telephone E/M services for patients with any insurance
  4. Online digital E/M services for patients with any insurance
  5. Watch a video summarizing this information
  6. Listen to a podcast about this information

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.

  • For Medicare patients, providers can use this option for office/other outpatient E/Ms (CPT 99201–99215) and all services listed here
  • Must use a communication tool that has interactive audio and video
  • Communication tool must allow real-time communication
  • Providers are permitted to reduce or waive cost-sharing for these services if they wish
  • Use modifier 95
  • Use the Place of Service that would have been used had the service been rendered in person (e.g., POS 11 for CPT 99213 and POS 32 for CPT 99307)
  • These services will be paid at the regular rate
  • This waiver is in place as long as the public health emergency lasts
  • Postoperative global periods apply
  • Document a progress note just like one would do when this service is provided face-to-face. This interaction is an E/M service and the same documentation requirements apply. The level is selected based on the 1995 or 1997 CMS guidelines for evaluation and management services, except when using CPT 99202-99215. When using CPT 99202–99215 for telehealth, the level may be selected based on “Medical Decision Making alone or total time alone."

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

  • G2012: Brief communication technology-based service (e.g., virtual check-in) by a physician or other qualified health-care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion
  • Can be any type of telecommunication tool, including telephone
  • CANNOT relate to any service in the last seven days
  • CANNOT result in patient coming in within the next 24 hours or soonest available appointment
  • No modifiers needed
  • Providers are permitted to reduce or waive patient cost-sharing for these services if they wish

3. Telephone E/M services for patients with any insurance

  • This interaction is an E/M service and documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as possible, and some form of medical management.
  • Must be initiated by patient or the patient’s guardian
  • Provider may educate patients about this option
  • Not reimbursed by some payers
  • CANNOT report if call results in decision to see patient within 24 hours or next available urgent appointment
  • CANNOT report if call refers to E/M service performed by same provider within previous seven days
  • CANNOT report if call refers to a problem for which a patient is in a global period
  • CANNOT report if provider performed a telephone E/M or online digital E/M for the same patient for the same problem in the last seven days
  • CANNOT report if the call is part of Home Care Oversight Services, Care Plan Oversight Services, Home/Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services
    • CPT 99441 - Telephone evaluation and management service by a physician or other qualified health-care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion
    • CPT 99442– ; 11–20 minutes of medical discussion
    • CPT 99443– ; 21–30 minutes of medical discussion

 4. Online digital E/M services for patients with any insurance

  • This interaction is an E/M service and documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as possible, and some form of medical management.
  • Examples of digital platforms:
    • Electronic health record
    • Email
    • Text message
    • Other two-way digital communication
  • Must be initiated by patient via a digital platform
  • Provider may educate patients about this option
  • Not reimbursed by some payers
  • Providers are permitted to reduce or waive patient cost-sharing for these services if they wish
  • CANNOT report if service refers to a problem for which a patient is in a global period
  • CANNOT report if service is initiated within seven days of any E/M for same problem
  • CANNOT report if performed on same day as in-person E/M service
  • CANNOT report if service is part of Home Care Oversight Services, Care Plan Oversight Services, Home/Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services
  • Time spent is cumulative time over seven days starting with review of the request
  • Can only report once per seven-day period
  • Time includes:
    • Review of inquiry
    • Review of patient records
    • Interaction with other staff
    • Development of management plan
    • Rx
    • Ordering tests
    • Communication with patient
  • Add time if multiple providers in same practice perform this service for the same patient over the same seven-day period
  • If within seven days of the initiation of an online digital E/M service, a separately reported E/M visit occurs, then the provider work devoted to the online digital E/M service is incorporated into the separately reported E/M visit
  • CPT 99421: Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes
  • CPT 99422  ; 11–20 minutes
  • CPT 99423  ; 21 or more minutes

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.

5. Watch a video summarizing this information

6. Listen to a podcast about this information

We have recorded a special episode of The APMA Podcast about providing telemedicine services. Listen below.

References:

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

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

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.

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CARES Act

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 advocacy@apma.org.

Read Summary

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APMA Advocacy

APMA has been working to protect you and your practice since the COVID-19 public health practice began.

Comment Letters Related to COVID-19

Other Efforts

  • APMA and its state components signed on to two coalition letters led by the American Academy of Dermatology along with more than 72 other medical societies asking America's Health Insurance Plans and Blue Cross Blue Shield Association to harmonize the disparate requirements its member companies have provided regarding telemedicine by asking them to align with CMS guidelines, reimburse telehealth at in-office rates, and mirror CMS guidance coding guidance for these services.
  • APMA signed a coalition letter led by the American College of Physicians along with 40 other societies asking CMS to pay telephone E/M services at the same rate that office/outpatient E/M services pay and to ensure that the MACs are following guidance from CMS to pay telephone E/M services.
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CMS Updates

Get MIPS 2020 PY COVID-19 Hardship Exception Information

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

Medicare

  • General CMS COVID-19 Resource Page
  • Suspension of Medicare Sequester Through December 31, 2020
    Section 3709 of the CARES Act temporarily lifts the Medicare sequester, which reduces payments to providers by 2 percent, from May 1 through December 31, 2020, boosting payments for hospital, physician, nursing home, home health, and other care. The Medicare sequester would be extended by one year beyond current law to provide immediate relief without worsening Medicare’s long-term financial outlook. Read APMA's full CARES Act summary.
  • CMS announced on April 26 its decision to reevaluate the amounts that will be paid under the Accelerated Payment Program and to suspend its Advance Payment Program to Part B suppliers.
  • Provider Relief Fund
    On April 10, 2020, the Department of Health and Human Services (HHS) began distributing the initial $30 billion in relief funding to Medicare fee-for-service (FFS) facilities and providers. These are grants, not loans, and do not have to be repaid. The funds you will receive from this fund will be in direct proportion to your practice’s share of Medicare fee-for-service spending. 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.

    If you have not yet received the funds directly in your bank account, check with the bank account associated with your practice’s TIN. The automatic payments will come to the organizations via Optum Bank with "HHSPAYMENT" as the payment description. Within 30 days, you must sign and submit an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13 and will be linked from hhs.gov/providerrelief.

    APMA strongly encourages members to read the terms and conditions closely before attesting, and seek guidance from their legal counsel if necessary.
  • Expansion of Covered Telehealth Services in Response to COVID-19
    Please visit APMA’s full resource page on updates to providing non-face-to-face services.
    The OCR has also issued additional guidance on relaxed enforcement discretion for telehealth remote communications during the COVID-19 public health emergency:
      - OCR Bulletin: 2020 HIPAA and Novel Coronavirus (PDF, February 2020)
  • Provider Enrollment Relief Information
    The March 22 FAQ includes toll-free hotlines available to provide expedited enrollment and answer questions about COVID-19 enrollment requirements. As noted in the FAQs, CMS is exercising its 1135 waiver authority in the following ways:
Physicians and Non-Physician Practitioners
  1. Establish toll-free hotlines to enroll and receive temporary Medicare billing privileges
  2. Waive the following screening requirements:
    1. Criminal background checks associated with fingerprint-based criminal background checks (FCBC)—42 C.F.R 424.518 (to the extent applicable)
    2. Site visits—42 C.F.R 424.517
    3. Postpone all revalidation actions
All Other Providers and Suppliers (including DMEPOS)
  1. Expedite any pending or new applications
  2. All clean web applications will be processed within seven business days and all clean paper applications in 14 business days
  3. Waive the following screening requirements for all enrollment applications received on or after March 1, 2020:
    1. Criminal background checks associated with the FCBC – 42 C.F.R. 424.518 (to the extent applicable)
    2. Site-visits – 42 C.F.R. 424.517
    3. Postpone all revalidation actions

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.

  • Changes for 2019 MIPS PY Reporting
    For 2019 MIPS, CMS is extending the data submission deadline from March 31, 2020 to April 30, 2020 - Read APMA's response to this announcement here.

    After the initial announcement on March 22, CMS released additional guidance on March 27, 2020:
      - CMS MLN Memo Exceptions and Extensions for 2019 Quality Reporting Requirements (PDF)
      - Quality Payment Program – COVID-19 Response (PDF)

    2019 Performance Year: MIPS eligible clinicians reporting as individuals who have not submitted any MIPS data or submitted for only one performance category by April 30, 2020, will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year. Clinicians reporting as individuals who have reported at least two performance categories or reporting as groups will need to proactively request the extreme and uncontrollable circumstances hardship, via the re-opened the 2019 extreme and uncontrollable circumstances application

    2020 Performance Year: For 2020 MIPS, CMS is evaluating options for providing relief around participation and data submission. 

  • CMS Adult Elective Surgery and Procedures Recommendations
    During the COVID-19 crisis, CMS provided guidance to limit non-essential adult elective surgery and medical and surgical procedures in order to better conserve critical resources such as ventilators and Personal Protective Equipment (PPE). This guidance also ensures limiting exposure of patients and staff to the SARS-CoV-2 virus.

Medicaid

  • General CMS Medicaid COVID-19 Resource Page
  • Medicaid Telehealth
  • States Currently Approved for 1135 Medicaid Waivers
    CMS has approved a number of 1135 Medicaid Waivers in recent days, offering states new flexibility to focus their resources on combating the outbreak and providing the best possible care to their Medicaid beneficiaries.
Alabama Illinois Montana Rhode Island
Alaska Indiana Nebraska South Carolina
Arizona Iowa  Nevada South Dakota 
Arkansas Kansas New Hampshire Tennessee
California Kentucky New Jersey Texas
Colorado Louisiana New Mexico Utah (no COVID-19 waiver to date)
Connecticut Maine New York Virginia
Delaware Maryland North Carolina Vermont
District of Columbia Massachusetts North Dakota Washington
Florida Michigan Oklahoma West Virginia
Georgia Minnesota Ohio (no COVID-19 waiver to date) Wisconsin (no COVID-19 waiver to date)
Hawaii Mississippi Oregon Wyoming
Idaho Missouri Pennsylvania

Some states have not yet applied for or received their 1135 Medicaid waivers. CMS has issued an FAQ to address this situation.

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Provider Relief Funds

Page last updated on June 9, 2020.

June 9 Update – HHS Announced Distribution of Provider Relief Funding for Medicaid Providers.

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.

Jump to Section
$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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Reopening Your Practice

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.

Jump to Section
Risk Management Resources and Checklists
Employee Issues
Elective Procedures and Non-Emergent Non-COVID-19 Health Care
State-by-State Issues
Additional Resources 

Risk Management Resources and Checklists

Employee Issues

Elective Procedures and Non-Emergent Non-COVID-19 Health Care

State-by-State Resources

Additional Resources

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.

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COVID Toes

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.

AAD COVID-19 Registry

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.

Webinar

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.

Download a PDF of the presentation.

Academic Sources

"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

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