March 2023 DZA Newsletter

The End Approaches (for the PHE)

On January 30, 2023, it was announced simultaneously that the Public Health Emergency (PHE) period would be renewed for an additional 90 days AND it would be the final renewal – meaning the PHE is officially set to expire on May 11, 2023. As we’ve mentioned in the past, the Secretary of HHS promised they would give us at least a 60-day notice if they did not intend to renew the PHE any further, so I guess we can consider this additional 30-day notice a gift from the Secretary.

Since it’s unlikely your facilities have not in some way taken advantage of the flexibilities offered during the PHE, we have compiled the following list of flexibilities that could impact your facilities. The list has been organized to first include items that could impact any type of facility, followed by those specific to facility types. These are a selection out of a much longer list. We’re focusing on these ones because we frequently see these impacting many of the facilities we work with. Hopefully, this can help prepare you for what comes next.

All Facilities

Let’s begin with some good news.

• Some telehealth waivers were extended by Congress through December 31, 2024! (But not all of them.)
  • These telehealth waivers will remain through the December date:
    • Expanded list of eligible practitioners (i.e. physical therapists, speech therapists, and occupational therapists)
    • RHCs as distant site providers
    • Audio-only services
    • No in-person visit required for newly-covered mental health encounters (which includes RHCs) provided via audio only. Under the current rules, these require an in-person visit every six-months.
    • The flexibility to bill telehealth services provided in the patient’s home, as if the service was provided in an approved originating location,
  • This telehealth waiver will expire with the end of the PHE
    • Payment for telehealth services provided in the patient’s home will no longer be paid as if the patient is seen in the clinic.

Now for some not-as-good news.

• During the PHE, hospitals could send a patient for a skilled nursing facility stay without meeting the three-day qualifying stay requirement. This waiver will end with the PHE. Moving forward, for Medicare to pay for a skilled level of care (whether in a nursing home or swing bed), the patient needs to have a medically necessary stay for at least three days in an acute care hospital before admission to the swing bed or nursing facility.
• Extended Medicaid eligibility determinations will be removed, meaning we should expect to see Medicaid beneficiaries losing their coverage. This may also mean additional assistance will be necessary to help beneficiaries re-enroll.
  
• Hospitals without walls (or temporary expansion sites) will end with the PHE. This allowed hospitals to provide care for patients in temporary facilities; now, hospitals will need to revert to compliance with the previously established conditions of participation.
• During the PHE, facilities could set up off-site screening locations to prevent the spread of COVID-19 within the hospital’s facility. Either using these off-site locations should end with the PHE or the location should meet previously established standards.
• COVID-19 testing will need to be included with other standard charges on your website to adhere with price transparency rules.

Prospective Payment System (PPS) Hospitals

PPS hospitals were given some unique flexibilities as a result of the PHE.

• Enhanced DRG payments received for caring for COVID-19 patient will end.
• Inpatient prospective payment hospitals (IPPS) could bill inpatient stays in excluded units. This will end with the PHE.
• Sole Community Hospitals (SCH) were offered flexibilities with some eligibility requirements with regards to increased beds or changes in market share. CMS has instructed the intermediaries to resume testing of these requirements at the end of the PHE.
• Medicare Dependent Hospitals (MDH) were offered flexibilities to increase beds above 100, as well as to fall below 60% Medicare eligible patients. CMS has instructed the intermediaries to resume testing of these requirements at the end of the PHE.
• Remember the occupational mix surveys? These are the reports that show how efficiently your hospital staffs nursing-type employees. The last round of data was collected in 2020, based on 2019 calendar year data; however, several extensions were offered for submission of that data. The next survey will be based on 2022 calendar year data and will be collected in summer 2023.
• Geographical reclassification requests are typically due September 1st. No extensions are expected in the future, so if you benefit from this reclassification or intend to make this request in the future, we should prepare for timely submission.

Critical Access Hospitals (CAH)

CAHs have a few other items to consider that do not apply to other provider types.

• The two 96-hour conditions/rules listed below must BOTH be met by CAHs once the PHE ends.
  • Remember that pesky condition of participation stating inpatient stays must be, on average, less than 96 hours? Expect intermediaries to resume testing of this condition once the PHE ends. If you are not currently monitoring this calculation, we recommend you begin doing so.
  • A Medicare patient’s medical record must state the intent is to discharge or transfer that patient within 96 hours.
• CAHs are limited to 25 set-up beds for inpatient care. Additional beds were approved for the PHE to prepare for an influx of patients, but this flexibility will end with the PHE.
  

Rural Health Clinics (RHC)

Don’t worry RHCs, you haven’t been left out. Whether you operate an RHC that is provider-based to a hospital or a stand-alone RHC, there are a few things you, too, should keep in mind:

• The all-inclusive rate in an RHC is based on the greater of actual visits or a productivity requirement. During the PHE, RHCs had the opportunity to request an exemption, allowing clinics not meeting the productivity requirements to request actual visits be used for this calculation. These exemptions will no longer be available at the end of the PHE. We recommend you review your clinic’s method of capturing provider hours available to see patients now, in preparation for future cost reporting periods. If practitioners are providing fewer than the prescribed visits, changes should be made to their schedule to send them home when not scheduled with patients.
• During the PHE, an RHC that lost its mid-level could remain an RHC. Once the PHE ends, RHCs must have coverage by a mid-level practitioner at least 50% of the time the clinic is open.
• RHCs were also able to expand locations during the PHE. To ensure compliance with previously established conditions, RHCs should discontinue the use of these expanded locations before the PHE ends.
• If the RHC qualifies under for a grandfathered rate and the hospital expanded to more than 50 beds during the PHE, the hospital needs to drop back down or they’ll lose their hospital-specific cap (i.e.. they would revert to the statutory caps).

A more detailed description of the flexibilities included above can be found here or here. 

Preparations should be made now for the end of the PHE to ensure we remain in compliance.

Closing

As always, if you have questions, please let me or your favorite DZA representative know.

Shayna DesJardin, Manager