​This morning, several of our (K)notes Plus clients in Jurisdictions B and C reported large up-ticks in Medicare CO-151 denials on capped rental items.  During our research, a CGS customer service representative confirmed a systemwide issue causing erroneous denials since yesterday. The company has not yet resolved the issue.

Keep an eye on the Claims Payment Alert page for updates. We expect CGS will soon post confirmation of the issue, as well as any future solutions, to the site.

Unfortunately, 151 denials are medical necessity denials which normally preclude resubmission. For now, we recommend setting these aside because resubmitted claims will deny as duplicate. We hope CGS will automatically reprocess affected claims after correcting the underlying issue.

If you have any questions, give us a shout.

As the country waits for the next development in the COVID-19 public health emergency (PHE), suppliers are not alone in wondering, “What exactly is the difference between a waiver and a flexibility?” We explored the question for our (K)notes subscribers back in August, and I thought I would share it here today.

CMS creates administrative relief during any PHE through 1135 blanket waivers and program flexibilities. According to page 3 of the Medicare Fee for Service Emergency and Disaster Related Policies and Procedures document:

• An 1135 waiver or modification changes or suspends a statutory requirement or implementing regulation using Section 1135 or Section 1812(f) of the Social Security Act.
• A flexibility changes agency policy or procedures using CMS’s current authority. The agency can generally adjust these policies without reprogramming CMS’s systems.

If the change overrides a statute or law, it’s a waiver; if it overrides CMS policy, it’s a flexibility. They are pretty much the same thing from the supplier’s perspective.

How Long do Waivers and Flexibilities Last?

CMS has the authority to extend waivers and flexibilities to the end of the applicable PHE. If, however, the Secretary determines the PHE no longer impedes beneficiary access or supplier compliance, CMS can terminate waivers and flexibilities before the PHE ends.

Recent expirations signal CMS believes fewer process modifications are necessary to maintain patient access and compliance. As waivers and flexibilities expire, suppliers must adapt their own policies and procedures to comply with changing CMS and contractor instructions.

SOURCE LINKS
https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf
https://www.phe.gov/Preparedness/legal/Pages/1135-waivers.aspx

Did you see that CMS updated the Provider Enrollment FAQ in July affecting several flexibilities for DME suppliers? They modified:

• Question 20 (accreditation and re-accreditation).
• Question 21 (supplier standards 7, 9, and 30 for physical facility, business telephone, and minimum hours, respectively).
• Question 22 (site visits).

Accreditation and Re-Accreditation Resume

On August 21, 2020, the NSC resumed enforcement for new and re-accreditation survey applications. Moreover, the agency is notifying suppliers that received extensions at the onset of the public health emergency (PHE) they have 30 days (from the date of the notice) to submit required documentation and resume the process. Those suppliers enrolled during the waiver period can expect to hear soon of rescheduled deadlines to produce documentation. Suppliers that do not comply risk loss of billing privileges.

Site Visits Resume

On August 6, 2020, the NSC announced it resumed site visits in accordance with the expiration of the standard 7 waiver. Standard 7 requires suppliers to occupy an appropriate site and post hours of operation.

Suppliers should ensure they:

• Post accurate hours of operation visible to the public and site inspectors.
• Take care to answer the business telephone during those hours.

Failure to do so could result in PTAN revocation.

Continued Waivers for On-Site Business Phone and Minimum Hours of Operation

Question 21 of the CMS FAQ contains incorrect information related to the enforcement of Standard 9 (primary on-site business phone, e.g. not a mobile or forwarded number) and Standard 30 (minimum hours of operation). The answer prematurely suggests CMS expired this waiver, when in-fact, the NSC continues to waive standards 9 and 30 for new and existing suppliers. As of this publication date, the CMS FAQ remains uncorrected.

Public Access Expectations Under Active Waivers

Despite continuation of the waivers for standards 9 and 30, the NSC expects suppliers to staff business phone lines during normal business hours. While the waivers persist, suppliers can forward calls to a remote office or cell phone, if necessary. As for retail hours open to the public, the NSC will not penalize locations with limited hours while waiver protection remains in force. Nonetheless, suppliers’ posted hours of operation should accurately reflect any temporary changes for the location.

Watch for Enforcement Changes

CMS continues to phase out waivers and flexibilities when the agency believes the climate no longer necessitates them. As such, suppliers should subscribe to NSC newsletters and check the NSC website for updated news on enforcement actions and waiver termination dates. We encourage suppliers to monitor conditions and self-impose a return to normal when feasible for each of their locations. When suppliers proactively phase out their reliance on waivers, they experience less disruption when the contractor announces a termination date. 

SOURCE LINKS
https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf
https://palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~National%20Supplier%20Clearinghouse~Articles~General~BS8KN64417?open
https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/BSPMJP5722?opendocument
newsletters
https://palmettogba.com/palmetto/providers.nsf/News_New?OpenView&RestrictToCategory=National%20Supplier%20Clearinghouse

Suppliers may be surprised to learn that within weeks of launching the Paycheck Protection Program, the Department of Justice (the DOJ) filed its first criminal charges against applicants for such offenses as making false statements to a financial institution and bank fraud. In fact, the DOJ announced 25 separate PPP fraud cases totaling nearly $120 million between May 5 and August 21.

Sure, everyone expects the DOJ to pursue the most nefarious offenders. In many of these cases, applicants petitioned funds for fake or inactive companies. In others, they misappropriated funds for cars, jewelry, personal entertainment, and real estate. In all cases, the DOJ is questioning the legitimacy of the business or alleging misuse of funds.

[Feeling isolated by remote work? Need answers to those pesky reimbursement questions that pop up? (K)notes Plus gives you access to our research team and unlimited email consulting.]

Why Should Suppliers Care?

While most suppliers used funds for legitimate businesses and actual employees – not Rolexes, Lamborghinis, and golf trips – many legitimate borrowers may have used funds inadvertently for unauthorized purposes. For example, the DOJ is alleging in one case that transfers from a borrowing company to a personal brokerage account for “personal benefit” constitutes fraud. Fraud issues aside, the ambiguous definition of personal benefit puts all payments to owners from borrowing companies in dangerous territory.

Strings Attached

Like it or not, the government is going to have an opinion on how companies use borrowed funds. Suppliers can avoid trouble by matching every incoming PPP dollar to an outgoing PPP-eligible expense. And before authorizing management bonuses or big investments, ask “Would this have been a good idea if we didn’t receive stimulus money to cover our payroll?”

SOURCE LINKS
https://www.justice.gov/news?keys=PPP&items_per_page=50
https://www.justice.gov/opa/pr/washington-tech-executive-charged-covid-relief-fraud-and-money-laundering