Just before COVID-19 gobbled up global attention, the MACs posted an FAQ document answering several common questions about standard written orders (SWO) established by the CY 2020 ESRD Prospective Payment System Final Rule (Final Rule). Even still, the guidance on order dates and non-essential order elements remains incomplete.

Order Date and Timeliness Remain Fuzzy

The Final Rule only requires a dated order before submission. In doing so, it provides maximum supplier flexibility to accept a verbal order, deliver product, generate the SWO, and hold the claim until the supplier receives the completed order.

The FAQs, however, introduce four different dates that may factor into SWO validation:

1. Communication date (the date the referral contacts the supplier to fill an order).
2. Service date (the date the supplier delivers product).
3. Practitioner signature date (the date the doctor signs an order).
4. Claim submission date (the date the MAC receives a claim for payment).

FAQ items three and four attempt to guide suppliers in determining which date serves as the order date. Specifically, FAQ three states:

“Ideally it should be reflective of when the order was first communicated to the supplier, in order to support the dates of service on the claim.”

The FAQ goes on to state that, when multiple dates appear on the order, the MACs will use the earlier communication date in lieu of a later signature date. As such, the guidance suggests the order may not support the date of service if it comes before the date on the order. While the Final Rule alters longstanding policy that order dates must come before service dates, the MACs’ answers leave us uncertain that claim processing logic will adapt to the Final Rule’s intention.

We expected the MACs to instruct reviewers to verify the timeliness of order dates using the claim’s date of receipt. Surprisingly, the answers do not acknowledge submission date.

To be safe, suppliers who deliver product prior to securing a billable SWO should add a start date to the order form. Since the start date will always come before date of service and the submission date, doing so will support both the MAC interpretation and the Final Rule.

MACs Continue to Recommend Suppliers Capture Nonessential Elements

The Final Rule significantly slims down the required elements for a valid SWO, eliminating several non-essential elements like:

• Length of need (LON),
• Frequency of replacement,
• Number of refills,
• Dosage, and
• Strength.

While the MACs affirm CMS no longer requires these elements on the SWO, the FAQ answers contain several backhanded recommendations that create doubt. For example, answer five states:

Frequency is no longer a required order element … but suppliers/providers are permitted to add elements that may provide clarity for issues such as LON, frequency of use, dosage form/strength, refills frequency, etc. Suppliers may also wish to consult state law or regulation since some states may have additional requirements for the elements of an order/prescription.

Doesn’t suggesting suppliers add additional items for clarity effectively make the element required? 

If a claim denies for a nonessential element, the QIC or ALJ will likely apply the Final Rule regulations as intended. Unfortunately, challenging unfavorable findings in the interim is costly. Given conflicting and fuzzy guidance, suppliers are understandably wary of scaling back order forms and templates.

While we believe several of the FAQs contradict the Final Rule’s intent, it will take time to test the MACs interpretations, policies, and payment decisions. Nonetheless, we remain optimistic suppliers will see important revisions to these initial interpretations.

SOURCE LINKS
https://cgsmedicare.com/jc/help/faqs/current/swo.html
https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis
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The OIG recently reported that 96% of SC Medicaid telehealth visits paid in error. The findings highlight the need for provider education, especially as reliance on telemedicine skyrockets during the COVID-19 public health emergency.

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The OIG reviewed 100 South Carolina Medicaid fee-for-service telemedicine payments between July 1, 2014, and June 30, 2017, finding only three met Federal and State requirements. Substantially all of the errors related to technical deficiencies where the practitioner did not:

• Log start and stop times, and/or
• Identify the consulting site location.

Based on the 100-claim sample totaling approximately $27,000, the OIG projected overpayments relative to all payments for telemedicine visits during the audit period and recommended South Carolina refund $1.5 million to the federal government. Cavalier extrapolation only increases the risk to practitioners, and suppliers, scrambling to incorporate telehealth visits into patient care.

With so many providers using telehealth for the first time in response to state lockdowns and other social distancing protocols, mistakes are bound to occur. Suppliers must monitor for these oversights and educate referring providers on proper telehealth documentation to avoid significant recoupments. Suppliers should:

• Familiarize themselves with all federal, state, and other third-party contractual rules related to telemedicine visit substantiation and reimbursement.
• Create a standard intake checklist to monitor referring providers’ telehealth documentation used to support DME orders, including:
  • Documentation of start and stop times, and
  • Despite COVID-19 related removal of site restrictions, descriptions of the patient and practitioner’s locations during the telemedicine visit.
• Provide education to referral sources with documentation errors.

SOURCE LINKS
https://oig.hhs.gov/reports-and-publications/oas/cms.asp
https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Several suppliers recently logged in to find substantial, though unexpected, deposits to their bank accounts. The deposits are from Optum Bank with a vague description “HHSPAYMENT.”  These funds are part of the Provider Relief Fund included in the CARES Act. Providers that have not yet received their share should practice patience, not panic.

We contacted the CARES Provider Relief line operated by the UnitedHealth Group, and the associates we spoke to stated distributions from the fund will continue over the next two weeks. They hope to complete direct deposits by the first week of May … but this is $30 billion dollars that has to be doled out to hundreds of thousands of eligible providers across the country.

The provider relief deposit represents each supplier’s share of a $30 billion pot of money. Any supplier that received Medicare reimbursement in 2019 for covered services is eligible. Our back-of-the-napkin math suggests that Medicare is paying suppliers just over six cents for every dollar they paid for reimbursable services in 2019.  For suppliers that want a rough estimate of the one-time payment for their company, multiply 2019 Medicare receipts by $0.06.

This is not a loan.  So long as suppliers sign an attestation statement agreeing to the 10-page terms and conditions and then use the funds for intended purposes, suppliers do not need to repay the money.

Having said that …

It is foolhardy to think this money doesn’t come with responsibility. Before spending any of it, suppliers should read the terms and conditions carefully to be sure they can comply. Suppliers have 30 days from the date of the deposit to review the terms and conditions and upload an attestation statement.  We recommend holding off on submitting the attestation until CMS clarifies some vague terms and spending restrictions in the current agreement.

We suggest suppliers segregate these funds in a separate bank account and internally request them for specific purposes.  Doing so will prompt management to revisit the terms and conditions with each dollar spent to ensure accountability and avoid problems down the road. We expect CMS will perform audits and ask pointed questions about the use of funds during the crisis.

Additionally, any supplier that receives more than $150,000 in total aid from any relief program will have to issue quarterly reports on the use of those funds.  Suppliers must prepare for this eventuality.

In summary, suppliers that have not yet received funds need not worry, and those that have should take care to understand the fine print related to their use.

SOURCE LINKS
https://www.hhs.gov/provider-relief/index.html
https://www.hhs.gov/sites/default/files/relief-fund-payment-terms-and-conditions-04132020.pdf
https://myservices.optumhealthpaymentservices.com/registrationSignIn.do

The COVID-19 healthcare crisis is hobbling the provision of healthcare. Many state and local governments are joining federal agencies recommending against, if not outright forbidding, visits to hospitals and doctors’ offices for non-critical care. DME suppliers are already seeing declines in new orders. Hospitals are furloughing thousands of employees nationwide, and many doctors’ offices are closed altogether until the COVID-19 crisis subsides. While part of the US healthcare system is overheating, the majority managing chronic and long-term care sits idle.

In spite of all that …

DME suppliers that track their sales pipeline carefully may be able to mitigate their own losses by offering insightful assistance to their patients and referral sources. Suppliers can send work to referral sources.

For example, DME sales orders that are stopped or holding for compliance reasons often require a doctor visit to resume billing. Suppliers can use their sales order pipeline analysis to query these patients and coordinate telehealth visits with the physician and the patient. Physicians can bill for a regular visit, and patients get the care they need.

Surprisingly, many physicians don’t know that, not only can they bill the same amount for a telehealth encounter as a commensurate office visit, they can now use freely-available applications like Apple’s Facetime, Microsoft’s Skype, Google Hangouts, and Zoom to conduct telehealth with both practitioner and patient in the safety and comfort of their respective homes.

Building a Sales Order Pipeline Analysis (SOPA)

At MiraVista, we built an Excel model that allows us to measure new sales orders by week and stratify the weekly data into comparable groups:

• The quarter ended December 31, 2019, is our baseline, or normal volume, measurement.
• 2020 calendar weeks 1-11 are the normal-to-COVID-19 transitional period.

COVID-19-related declines usually surface after week 11 or mid-March. The following SOPA example shows the decline (over and above typical first quarter dips):

From there, we see trends specific to key referral sources:

We also see orders that are stopped or held due to compliance, opportunities to collaborate with referring physicians to generate telehealth visits:

Collaborate With Referring Physicians

DME suppliers can initiate a collaborative dialogue in two ways:

• Provide a list of patients that need telehealth visits for continued DME compliance.
• Educate physicians on telehealth options during the outbreak.

The first list comes straight from the sales order pipeline analysis. For telehealth education, suppliers should build a toolkit and talking points to assist physicians in resuming patient visits. The following resources provide a good starting point:

• Press Release: https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak
• FAQ: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
• Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
• Approved Services for Telehealth: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes 
• The Office of Civil Rights HIPAA Waivers for Telehealth: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Collaborate With Patients

Many patients worry about access to care during this time; the need is significant even if it is not immediately life-threatening. Consider communicating telehealth options to them as well through available communication modes:

• Patient billing statement inserts.
• Telehealth educational mailings for talking to physicians about telehealth options during COVID-19.
• Temporary call centers staffed by sidelined sales and marketing employees.

These are difficult times, to be sure, but DME suppliers have an opportunity to use their experience and resources to play a significant role in providing overall patient care. Suppliers, armed with data from a simple sales order pipeline analysis, can:

• Identify physicians with declining referral orders related to COVID-19 lockdowns,
• Query lists of those practitioner’s patients in need of a telehealth visit to satisfy compliance and resume DME billing,
• Educate physicians on the revised telehealth options, and
• Collaborate with referral sources to salvage both businesses during a very difficult time.