Healthcare Providers

Executive Order GA-40

On June 19, 2020, the Texas Department of Insurance adopted final rules specifying patient notice and election requirements in order for out-of-network providers to balance bill. The final rules replace similar emergency rules that were adopted on December 18, 2019.

Under the new rules, which are meant to implement legislation passed in 2019 by the Texas Legislature, out-of-network providers are prohibited from Balance Billing for nonemergency services unless a patient elects, in writing, to obtain the service from the out-of-network provider. The patient’s election is only effective if the provider satisfies the following notice and disclosure requirements: (1) the patient is provided with a “meaningful choice between an in-network provider and an out-of-network provider,” (2) the patient is not “coerced” into choosing the out-of-network provider, and (3) the patient is provided with a written notice and disclosure. The notice and disclosure statement must be signed by the patient at least 10 business days before receiving any care.[1]

CARES Act Reporting

Under new guidance from the U.S. Department of Health and Human Services (HHS), hospices and other providers who received CARES Act Provider Relief Fund payments can hold off on filing their first quarterly compliance report, slated to be due on July 10, 2020.[1] Instead, HHS states that it will develop its own report and this report itself will contain “all information necessary for recipients of Provider Relief Fund payments to comply with” the quarterly reporting requirements under the Relief Fund Terms and Conditions.

On June 9 the Department of Health and Human Services announced that it will distribute $15 billion to Medicaid and Children’s Health Insurance Program (“CHIP”) providers. HHS spokesman Eric Hargan noted that this distribution will be focused on the approximately 275,000 providers who care for Medicaid and CHIP recipients but who did not receive funds in HHS’ April distribution of $50 billion. Mr. Hargan specifically mentioned providers such as dentists, pediatricians, assisted living facilities and behavioral health provider such as opioid treatment programs. Medicaid/CHIP providers can apply for the funds through the enhanced Provider Relief Portal by providing data that will determine their payments, including information concerning their payer mix to inform future distributions to providers who serve a large portion of Medicaid patients or provide a large amount of uncompensated care.

After the U.S. Department of Health and Human Services (“HHS”) automatically distributed $30 billion to providers as Tranche #1 Relief Fund payments based on 2019 Medicare fee-for-service payment data, HHS subsequently released a new formula that was based on 2018 “program service revenue” and intended to calculate providers’ payments under Relief Fund Tranches #1 and #2 cumulatively.  For providers whose Tranche #1 payments alone exceeded their expected payment under the new “program service revenue” formula, there have been ongoing questions about whether such providers were “overpaid” and needed to reject and return their Tranche #1 payments.

Economic Hardship Covid19

On May 12, 2020 the Centers for Medicare & Medicaid Services (CMS) issued additional 1135 blanket waivers which are applicable to a wide variety of healthcare providers. These COVID-19 Emergency Declaration Blanket Waivers for Healthcare Providers are retroactively effective from March 1, 2020 through the end of the public health emergency (PHE). The waivers in this issuance do not require a request be sent or a notification be made to any of the CMS regional offices.  Each waiver must be consistent with the state’s emergency preparedness or pandemic plan.

Due to expanded COVID-19 diagnostic testing availability, the Missouri Department of Health and Senior Services (MDHSS) is encouraging providers to test both symptomatic and asymptomatic individuals, if the clinician’s medical judgment determines it is necessary. At the same time, MDHSS also posted words of caution regarding the use of serological testing, which is not considered diagnostic for COVID-19 but rather detects antibodies which could reveal exposure to SARS-CoV- 2 (the virus which causes COVID-19) or a different  infection, including other strains of coronavirus, altogether. The recent MDHSS COVID-19 Serological Testing Quick Facts (Quick Facts) cautions that:

Although Wisconsin hospitals have remained busy providing COVID-related treatment and services for the last two months, many Wisconsin health care providers chose to postpone elective surgeries and procedures in compliance with CMS guidance. Notably, Wisconsin never expressly prohibited elective surgeries or procedures at any point during the last few months; however, Emergency Orders #12 and #28 specified that individuals may obtain services at ambulatory surgery centers for response to urgent health issues or related COVID-19 activities. Further, guidance from the Wisconsin DHS Division of Public Health issued on March 20 recommended that dental practices postpone all elective and non-urgent care treatment.  With the issuance of the Badger Bounce Back Plan (the “BBB Plan”), Wisconsin facilities and providers have expressed their intent to prep for elective services and procedures. 

On March 13, 2020 the COVID-19 pandemic was declared a National Emergency by President Trump. This declaration set in motion the availability of FEMA Public Assistance (PA) disaster relief funds to support nonprofit healthcare and higher education organizations, among others, during the recovery. On March 27, 2020, additional FEMA PA disaster relief funds of approximately $45 billion were appropriated through the CARES Act to address the public health emergency. Further, many of the longstanding FEMA policies and procedures are being loosened to streamline and expedite funding for nonprofit healthcare organizations such as hospitals and hospice, as well as certain higher education institutions.

The CARES Act (P.L. 116-136) was passed to provide emergency assistance for individuals, families, and business achieved through two divisions. “Division A” focuses on supporting workers and families as well as the United States healthcare system and economy as a whole through tailored programs. Provisions under Division A provide targeted relief efforts such as the Paycheck Protection Program, Student Loan Relief, Health Coverage for COVID-19 testing, Liability Immunity for Health Care volunteers, Recovery Rebates for Individuals, among many other assistance provisions.

The California Attorney General recently published an opinion  (No. 15-301) clarifying when a report under California Business and Professions Code section 805 must be filed.  Section 805 requires hospitals and other entities to file a report with the relevant state healing arts agency “within 15 days after the effective date” of certain adverse actions taken…