For healthcare providers looking to avoid any of the traps stemming from PRF (Provider Relief Funds) compliance, RACmonitor is inviting you to sign up for Knicole Emanuel’s upcoming webcast on January 21st, 2021. It is titled: COVID-19 Provider Relief Funds: How to Avoid Audits. You can visit RACmonitor download the order form for the webcast to save yourself a spot.
If your facility accepted Provider Relief Funds (PRFs) as a consequence of the coronavirus pandemic, you need to be aware of the myriad of rules and regulations that are associated with this funding or else face penalties and takebacks. A word of caution: expect to be audited. In Medicare and Medicaid, regulatory audits are as certain as death and taxes. That is why your facility needs to arm itself with the knowledge of how to address documentation requests from the government, especially while the Public Health Emergency (PHE) is in effect.
This exclusive RACmonitor webcast, led by healthcare attorney Knicole Emanuel, discusses the PRF rules that providers must follow and how to prove that funds were appropriately used. There are strict regulations dictating why, how, and how much PRFs can be spent due to the catastrophic, financial impact of COVID-19. Register now to learn how to avoid penalties and takebacks related to PRFs.
- Rules and regulations relative to receiving and spending funds provided by the COVID-19 PRF
- Exceptions to COVID-19 PRF and relevant effective dates
- PRF documentation and reporting requirements
- The importance of the legal dates of PHE
- How to prove your facility’s use of funds is germane to COVID-19
Who Should Attend:
- RAC and appeals specialists
- RAC coordinators
- Compliance officers
- Directors and managers
About Knicole C. Emanuel, Esq.
Healthcare industry expert and Practus partner, Knicole Emanuel, is a regular contributor to the healthcare industry podcast, Monitor Mondays, by RACmonitor. For more than 20 years, Knicole Emanuel has maintained a health care litigation practice, concentrating on Medicare and Medicaid litigation, health care regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards.
She has successfully obtained federal injunctions in numerous states. This allowed health care providers to remain in business despite the state or federal laws allegations of health care fraud, abhorrent billings, and data mining. A wealth of knowledge in her industry, Knicole frequently lectures across the country on health care law. This includes the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers.
If you are accused of Medicare fraud, your Medicare reimbursements will be immediately cut off without any due process or ability to defend yourself against the allegations. If you accept Medicare and Medicaid then you are held to strict regulations, some of which are highly, Draconian in nature without much recourse, legally, for providers. Many, many a provider have gone bankrupt and been forced out of business due to “credible allegations of fraud.” You see, legally, “credible allegations of fraud” is a low standard to meet. The definition of “credible” is “an indicia of reliability.” “Indicia” is defined as “signs, indications, circumstances which tend to show or indicate that something is probable. It is used in the form of “indicia of title,” or “indicia of partnership,” particularly when the “signs” are items like letters, certificates, or other things that one would not have unless the facts were as the possessor claimed. It can be a disgruntled worker. I am sure that none of the listeners here today have ever dealt with a disgruntled employee. Yes, that is sarcasm.
42 CFR § 405.372 is the regulation outlining the requirements for suspending Medicare payments. 42 CFR § 455.23 is the regulation mandating suspension of Medicaid payments upon credible allegations of fraud.
Pursuant to Medicare regulations, CMS must suspend Medicare reimbursements to a healthcare provider “in whole or in part” if it has been “determined that a credible allegation of fraud exists against a provider or supplier.” 42 C.F.R. § 405.371(a)(2). A credible allegation of fraud is “an allegation from any source, including … civil fraud claims cases, and law enforcement investigations.” 42 C.F.R. § 405.370(a). The decision to suspend Medicare payment or continue a payment suspension is made at the discretion of CMS – not the MAC. If you receive a letter from a MAC alleging fraud, be sure to check whether the letter states that the decision was made in collaboration with CMS. The MACs do not have the authority.
The suspension, however, is not indefinite, although the length is normally a year, which is financially devastating. The regulations allow CMS to maintain the suspension until a “legal action is terminated by settlement, judgment, or dismissal, or when the case is closed or dropped because of insufficient evidence to support allegations of fraud.” 42 C.F.R. §§ 405.370(a) and .372(d)(3); see also § 405.371(b)(3)(ii) (CMS may extend the suspension of payment if the Department of Justice submits a written request that “suspension of payments be continued based on the ongoing investigation and anticipated filing of criminal or civil action or both or based on a pending criminal or civil action or both.”).
When you receive a fraud accusation of any type – it is imperative to send it to your counsel. If you opt to litigate the suspension by asking the Court to enjoin the suspension, your first legal obstacle will be to argue that you do not have to exhaust your administrative remedies before appearing for the injunction. Cases have been decided both in the favor of providers and their suspensions have been lifted and against the providers. These cases usually win or lose on the argument that the suspension of reimbursements is an ancillary subject from the actual investigation of fraud. It is a jurisdictional argument.
It is my opinion that the federal regulations that allow for suspension of payments upon credible allegations of fraud need to be revised. Any of you with lobbyists, we need to revise the regulations to require due process – notice and an opportunity to be heard – prior to the government suspending Medicare and Medicaid reimbursements based on a spurious accusation from an anonymous source.
Back in 2015, I am sure that you all recall the case in New Mexico where NM accused 15 BH care provider of credible allegations of fraud. The providers constituted 87.5% of the BH in NM. I was one of the attorneys representing the larger BH cos. Prior to my involvement, all 15 providers requested good cause. All were denied. Lawmakers think that the good cause exception written into the regulation is enough defense for providers. But when the good cause is almost always denied, it isn’t much help. Write to your congress people. Amend the regulations to require due process.
Reporting the use of PRFs will be an ongoing issue due to the fraud and abuse implications of misusing PRFs.
The federal Provider Relief Fund (PRF) was created under the provisions of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was passed to address the economic harm suffered by healthcare providers that have incurred (or will incur) additional expenses and have lost (or will lose) significant revenue as a result of the COVID-19 pandemic. PRF payments have been made from either the “general distribution” tranche or via various “targeted distributions.” PRF payment amounts and whether the providers complied with the terms and conditions will be a hotly contested topic in Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits for years to come. If Centers for Medicare & Medicaid Services (CMS) auditors put out a monthly magazine, like Time, PRF would be on the cover. This will be the hot topic of RAC audits, come Jan. 1, 2021.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) will audit Medicare payments made to hospitals for COVID-19 discharges that qualified for the 20-percent add-on payment under the CARES Act, according to a new item on the agency’s work plan.
To use the PRF funding from either the general or targeted distributions, providers must attest to receiving the funds and agree to all terms and conditions. However, what constitutes a “healthcare-related expense” or how to calculate “lost revenue” is not clearly defined. Similarly, how you net healthcare-related expenses toward lost revenue is also vague and undefined. On Nov. 2, HHS issued a clarification to post-payment reporting guidance for PRF funds.
The current guidance, issued Oct. 22, includes a two-step process for providers to report their use of PRF payments. The guidance specifically cites:
- Healthcare-related expenses attributable to COVID that another source has not reimbursed and is not obligated to reimburse, which may include general and administrative (G&A) or “healthcare-related operating expenses;” and
- PRF payment amounts not fully expended on healthcare-related expenses attributable to coronavirus are then applied to lost revenues associated with patient care, net of the healthcare-related expenses attributable to coronavirus calculated under the first step. Recipients may apply PRF payments toward lost revenue, up to the amount of the difference between their 2019 and 2020 actual patient care revenue.
HHS’s newest clarification came from its response to a FAQ, in which it said that healthcare-related expenses are no longer netted against the patient care lost revenue amount cited in the second portion. HHS indicated that a revised notice would be posted to remove the “net of the healthcare-related expenses” language in the guidance. Of course, as of now, we have no guidance regarding when this clarification is to be put into place officially. Yet another moving target for auditors.
Anticipate audits of the use of your PRF payments. CMS is choosing a sample of hospitals across the country that have received PRF payments to verify that such expenditures were for healthcare-related expenses. For each audit, OIG will obtain data and interview HHS/PRF program officials to understand how PRF payments were calculated, and then review actual PRF payments for compliance with CARES Act requirements. OIG will also review whether HHS’s controls over PRF payments ensured that payments were calculated correctly and disbursed to eligible providers.
Audits will also focus on how providers initially applied to receive PRFs, including calculations utilized and how COVID-19 patients are defined. When each hospital ceased netting expenses against lost revenue will now be another hot topic.
Balance billing is another area of interest. The terms and conditions require providers that accept the PRFs not to collect out-of-pocket payments from patients for all care for a presumptive or actual case of COVID-19 that exceeded what they would pay an in-network provider.
More havoc may ensue with any purchases or sales transactions that occur in the next year or so. Providers will need to know how to navigate compliance risks associated with any accepted or transferred PRFs. Tracking and reporting use of the PRFs will also be an ongoing issue due to the fraud and abuse implications of misusing PRFs, and there is limited guidance regarding how use will be audited. Many questions remain unanswered. Many terms remain undefined.
Programming Note: Knicole Emanuel, Esq. is a permanent panelist on Monitor Mondays. Listen to her RAC Report every Monday at 10 a.m. EST.
While the Coronavirus pandemic is horrible and seems to be getting worse. COVID has forced slight, positive changes in the telehealth arena and, perhaps, in the widening of the ambiguous definition of “medical necessity” or, as I call it – the undefined, definition of “medical necessity.” Medical necessity is the backbone of rendering health care services. Without it, services should not be provided. Yet, medical necessity is the most litigated topic in all of audits.
On September 1, 2020, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule that will codify a definition of “medical necessity” for Medicare purposes. So far, the definition of medical necessity varies, depending on the source. The MACs have been given long rein in defining the term on an individual and separate basis, creating disparity in definitions and criteria. The proposed rule’s comment period ended November 2, 2020.
All this to say medical necessity is in the eye of the beholder. Much like beauty. Why then, can RAC and MAC auditors who are not doctors, not firsthand, treating providers, not nurses or LCASs, decide that medical necessity does or does not exist for a patient that they have never seen?
Black’s Law Dictionary (the most prominent legal dictionary) has a super, unhelpful definition of medical necessity: “If not carried out the patient’s situation could worsen. For a patient’s treatment found to be necessary is this specific type of procedure or treatment.”
The American Medical Association (“AMA”), on the other hand, has a more detailed definition, probably unintended to make it all the more confusing:
“Our AMA defines medical necessity as: Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”
CMS’ proposed rule codifies a definition of what makes an item or service medically “reasonable and necessary” under the Social Security Act 1861(a)(1)(A). The rule, if finalized, would codify in regulations a definition of “reasonable and necessary” items and services based on a definition currently used by Medicare Administrative Contractors (MACs), with an additional element that potentially would include coverage determinations by commercial insurers as a factor in making Medicare coverage determinations.
The Proposed Definition (To be Codified in 42 CFR 405.201)
“We are proposing to codify the longstanding Program Integrity Manual definition of “reasonable and necessary” into our regulations at 42 CFR 405.201(b), with modification. Under the current definition, an item or service is considered “reasonable and necessary” if it is (1) safe and effective; (2) not experimental or investigational; and (3) appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is—
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member;
- Furnished in a setting appropriate to the patient’s medical needs and condition;
- Ordered and furnished by qualified personnel;
- One that meets, but does not exceed, the patient’s medical need; and
- At least as beneficial as an existing and available medically appropriate alternative.” See Proposed Rule.
In addition, CMS adds that it will also utilize commercial payor standards or have an objective panel determine medical necessity if criteria #1 and #2 were met, but not #3. This additional commentary is another example of how subjective and fact-specific determining medical necessity can be. The LCDs will also be consulted.
If adopted, these proposals would arguably lead to the most wide-ranging changes in Medicare’s coverage standards and procedures in decades. The proposal to codify the definition of “reasonable and necessary” applies to all items and services. The inclusion of commercial payor standards may be a wild card.
The definition of medical necessity has not been officially revised – yet. One could imagine that, in the midst of a RAC or MAC audit, auditors and providers will disagree as to the true definition of medical necessity.
Going forward, when you get audited, immediately look and see whether your claim denials were denied due to “lack of medical necessity.” Ask yourself, “Really? Is there no medical necessity in this case…even in the era of COVID?” Because the auditors may be wrong.
Secondly, ensure that the RAC and MAC entity is CMS-certified to review those certain CPT codes for medical necessity. CMS limits audits on medical necessity because of the vagueness of the definition. When auditors find no medical necessity, then providers must push back. And you should push back, legally, of course!
No one is free from audits. Even auditors get audited.
When the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audits auditors, however, the auditors get recommendations for changes, not the million-dollar penalties that healthcare providers receive.
In September 2020, OIG released an audit report of the Accountable Care Organizations (ACOs). There were 472 ACOs in America as of 2017, per the report. To those ACOs that were not audited for this September 2020 OIG report, expect audits to come. The Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) auditors, Unified Program Integrity Contractors (UPICs), and Recovery Audit Contractors (RACs) to audit ACOs.
These audits for monetary penalties will be dissimilar from audits by OIG, which wielded recommendations. ACOs are large entities: groups of doctors, hospitals, and other providers that come together to give coordinated high-quality care to Medicare beneficiaries.
In 2017, ACOs served approximately 9 million beneficiaries under the Medicare Shared Savings Program (MSSP). Of all the ACOs, 159 were eligible for shared savings payments, and received approximately $799 million. Of the remaining ACOs, 11 were liable for shared losses, and 302 were neither eligible to receive shared savings payments nor liable for shared losses, because they generally did not reduce healthcare costs (or they chose not to participate).
OIG found weaknesses in the oversight of ACOs, which are required to report data on 31 quality measures through three methods of submission:
- A patient experience-of-care survey (eight measures);
- Claims and administrative data (eight measures); and
- The designated CMS web portal (15 measures).
For the September 2020 OIG Report, 159 ACOs were required to select a CMS-certified vendor of their choice. You can learn more about this by listening to my recent webcast: “SNFs & COVID-19: New Audits Coming Soon.”
These CMS-certified vendors would contact the ACOs’ patients for a survey or poll, kind of like the follow-up surveys that you get after a seminar. Sometimes the students rating the teachers marks the best truth-teller of effectiveness.
The patient survey reported eight points of quality measures to CMS on the ACOs’ behalf. The vendors collected the data through mail and telephone surveys. The auditors would mail a questionnaire, and if that went unanswered, they would place a follow-up telephone call.
Twelve auditors conducted the 2017 audit of the ACOs’ patients. They surveyed approximately 400,000 beneficiaries and reported all patient survey data for those who responded.
Prior to 2019, non-medical home care agencies did not have a role in the Medicare Advantage (MA) landscape. After a variety of policy chances, they now have an opportunity to contract with MA plans through two major pathways.
The OIG report found the following weaknesses in CMS’s supervision of ACOs:
- CMS did not ensure that its contractor provided feedback reports in time to enable survey vendors to include and evaluate quality assurance plans regarding all of the changes implemented to address issues identified.
- CMS did not ensure that its contractor reviewed survey instruments translated into other languages.
OIG recommended that CMS increase supervision to confirm changes and collect client feedback. It is my opinion that ACO audits will increase.
Programming Note: Knicole Emanuel, Esq. is a permanent panelist on Monitor Mondays. Listen to her RAC Report every Monday at 10 a.m. EST.
Even though the public health emergency (“PHE”) for the COVID pandemic is scheduled to expire July 24, 2020, all evidence indicates that the PHE will be renewed. I cannot imagine a scenario in which the PHE is not extended, especially with the sudden uptick of COVID.
Center for Medicare and Medicaid Services (CMS) has given guidance that the voluminous number of exceptions that CMS has granted during this period of the PHE may be extended to Dec. 1, 2020. However, there is no indication of the RAC, and MAC audits being suspended until December 2020. In fact, we expect the audits to begin again any day. There will be confusion when audits resume and COVID exceptions are revoked on a rolling basis.
Remember the emergency-room physician whom I spoke about on the June 29 on Monitor Mondays? The physician whose Medicare enrollment was revoked due to a computer error or an error on the part of CMS. What normally would have been an easy fix, because of COVID, became more difficult. Because of COVID, he was unable to work for three months. He is back up and running now. The point is that COVID really messed up so many aspects of our lives.
The extension of PHE, technically, has no bearing on RAC and MAC audits coming back. Word on the street is that RAC and MAC audits are returning August 2020.
This month, July 2020, CMS released, “Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs).” (herein afterward referred as “CMS July 2020 FAQs”).
The question was posed to CMS: “Is CMS suspending most Medicare-Fee-for-Service (FFS) medical review during the PHE for the COVID-19 pandemic? The answer is, according to CMS, “As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on Aug. 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.” See CMS July 2020 FAQs.
Monday, July 13, 2020, we began our fourth “COVID-virtual trial.” The Judges with whom I have had interaction have taken a hard stance to not “force” someone to appear in person. It appears, at least to me, that virtual trials are the wave of the future. This is the guidance that conveys to me that RAC and MAC audits will begin again in August. Virtual audits may even be the best thing that ever happened to RAC and MAC audits. Maybe now the auditors will actually read the documents that the provider gives them.
Another specific issue addressed in the CMS’ July 2020 FAQs is that given the nature of the pandemic and the inability to collect signatures during this time, CMS will not be enforcing the signature requirement. Typically, Part B drugs and certain Durable Medical Equipment (DME) covered by Medicare require proof of delivery and/or a beneficiary’s signature. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19. This exception may or may not extend until Dec. 31, 2020.
The upshot is that no one really knows how the next few months will unfold in the healthcare industry. Some hospitals and healthcare systems are going under due to COVID. Big and small hospital systems are in financial despair. A RAC or MAC audit hitting in the wake of the COVID pandemic could cripple most providers. I will reiterate my recommendation: In the re-arranged words of Roosevelt, “Speak loudly, and carry a big stick.”
Programming Note: Knicole Emanuel is a permanent panelist on Monitor Mondays. Listen to her live reporting every Monday at 10 a.m. EST.
As of now, the public health emergency (PHE) for the COVID-19 pandemic will expire July 24, 2020, unless it is renewed. Fellow contributor David Glaser and I have both reported on the potential end date of the PHE. Recent intel from Dr. Ronald Hirsh is that the Centers for Medicare & Medicaid Services (CMS) may renew the PHE period. Each time the PHE period is renewed, it is effective for another 90 days. Recent news about the uptick in COVID cases may have already alerted you that the PHE period will probably be prolonged.
CMS has given guidance that the exceptions that it has granted during this period of the PHE may be extended to Dec. 1, 2020. There is no indication of the Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits being suspended until December 2020. In fact, we expect the audits to begin again any day. There will be confusion when audits resume and COVID exceptions are revoked on a rolling basis.
I witnessed some interesting developments as a health care attorney during this ongoing pandemic. Three of my physician clients were erroneously placed on the Medicare exclusion lists. One would think that during the pandemic, CMS would move mountains to allow a Harvard-trained ER doctor to work in an ER. Because of the lack of staff, it was actually difficult to achieve an easy fix. This doctor was suspended from Medicare based on an accidental and inadvertent omission of a substance abuse issue more than 10 years ago. He disclosed everything except an 11-year-old misdemeanor. He did not omit the misdemeanor purposely. Instead, this ER physician relies on other hospital staff to submit his Medicare re-credentialing every year, as he should. It just happened that this year, the year of COVID, this doctor got caught up in a mistake that in normal times would have been a phone call away from fixing. We cleared up his issue, but not until he was unable to work for over two months, during the midst of the PHE.
At the time of the announcement of the public health emergency, another company, a home health provider, was placed on prepayment review. I am not sure how many of you are familiar with prepayment review, but this is a Draconian measure that all States and the federal government may wield against health care providers. When you are on prepayment review, you cannot get paid until another independent contracted entity reviews your claims “objectively.” I say objectively in quotes because I have yet to meet a prepayment review audit with which I agreed.
Mostly because of COVID, we were forced to argue for a preliminary injunction, allowing this home heath provider to continue to provide services and get paid for services rendered during the PHE. We were successful. That was our first lawsuit during COVID. I believe we went to trial in April 2020. We had another trial in May 2020, for which we have not received the result, although we have high hopes. I may be able to let you know the outcome eventually. But for now, because of COVID, with a shortage of court reporters willing to work, we will not receive the transcript from the trial until over four weeks after the trial.
Tomorrow, Tuesday, we begin our third COVID trial. For the first time since COVID, it will not be virtual. This is the guidance that conveys to me that RAC and MAC audits will begin again soon. If a civil judge is ordering the parties to appear in person, then the COVID stay-at-home orders must be decreasing. I cannot say I am happy about this most recent development (although audits may be easier if they are conducted virtually).
The upshot is that no one really knows how the next few months will unfold in the healthcare industry. Some hospitals and healthcare systems are going under due to COVID. Big and small hospital systems are in financial despair. A RAC or MAC audit hitting in the wake of the COVID pandemic could cripple most providers. In the rearranged words of Roosevelt, “speak loudly, and carry a big stick.”
Published in Today’s Wound Clinic:
When I was asked to draft an article for Today’s Wound Clinic, it was approximately two weeks ago. I was asked to write about the current state of Medicare and Medicaid audits. Specifically, I was asked to provide a legal analysis about CMS suspending audits un-related to COVID-19. In the month of April, we have seen the spike of COVID-19, which has overturned our everyday world. We have been instructed by President Trump to “stay home” and “social distance” to decrease the spread of the virus. This “stay at home” instruction is unprecedented and has uprooted many of our most reliable and commonplace businesses, such as hairdressers, bowling alleys, and tattoo parlors.
Here is the answer: The current state of Medicare/Medicaid audits, at the moment, is dictated by COVID-19.
We can divide the post-COVID-19 audit rules into 3 categories:
- Those exceptions published by CMS to apply to all health care providers
- Those special, verbal exceptions given directly to an individual provider that were not published by CMS
- Effective immediately, new guidelines that CMS will follow until CMS believes it no longer needs to follow (by its own choice, of course).
An example of an “effective immediately” guideline is our current state of Medicare/Medicaid audits in the wake of COVID-19. CMS has not suspended all Medicare/Medicaid regulatory audits. But CMS has suspended most audits.
Effective immediately, survey activity is limited to the following (in Priority Order):
- All immediate jeopardy complaints (cases that represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm) and allegations of abuse and neglect;
- Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses;
- Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities);
- Any re-visits necessary to resolve current enforcement actions;
- Initial certifications;
- Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years;
- Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy.
See CMS QSO-20-12-ALL. You can see that these “effective immediately” guidelines are usually published on CMS letterhead. The “effective immediately” guidelines explain why CMS is taking the stated action, the stated action, and that the action is temporary and due to COVID-19.
Here are a few recent “effective immediately” guidelines due to COVID-19:
- On April 27, 2020, CMS said it would no longer expedite Medicare payments to doctors and be more stringent about accelerating the payments to hospitals as Congressional relief aimed at providers reaches $175 billion.
- The agency is not accepting any new applications for the loans from Part B suppliers, including doctors, non-physician practitioners and durable medical equipment suppliers. CMS will continue to process pending and new requests from Part A providers, including hospitals, but be stricter with application approvals.
- CMS expanded the Accelerated and Advance Payment Programs in late March as the pandemic continued to gain strength in the U.S. Since then, the agency has approved over 21,000 applications making up $59.6 billion in accelerated payments to Part A providers and almost 24,000 applications making up $40.4 billion in payments for Part B suppliers.
The $2.2 trillion Coronavirus Aid, Relief, and Economic Security stimulus package passed by Congress in March benchmarked $100 billion in funds for hospitals. On Friday, President Donald Trump signed legislation with a second round of emergency funding, called the Paycheck Protection Program and Health Care Enhancement Act, that allocates another $75 billion for providers — roughly three-quarters of what major provider trade associations requested.
An initial $30 billion from the fund was distributed between April 10 and April 17 based on Medicare fee-for-service revenue, sparking criticism that put facilities with a smaller proportion of Medicare business, such as children’s and disproportionate share hospitals, at a disadvantage. HHS on Friday began releasing an additional $20 billion in CARES payments to providers based on their 2018 net patient revenue, with more funding to roll out “soon,” the agency said, including $10 billion for hard-hit areas like New York.
How RAC/MAC auditors are compensated dictates their actions and/or aggressiveness.
RAC Auditors are paid by contingency. They are usually compensated approximately 13%, depending on the State. Imagine what 13% is of 1 million. It is $130,000 – more than most people make in a year. If you do not believe that 13% contingency is enough to incentivize a company, which, in turn, incentivize the employees, then you are sorely mistaken.
RACs were established through a demonstration program under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (“MMA”), piloted between 2005 and 2008, and were later made permanent under the Tax Relief and Health Care Act of 2006, which required CMS to establish Recovery Auditors for all states before 2010.
MACs are not compensated by contingency, per se. CMS decided to structure the MAC contracts with 1-year base performance periods and four, optional, 1-year performance periods at the time. The MMA required that these contracts be recompeted at least once every 5 years. The recent enactment of the Medicare Access and CHIP Reauthorization Act of 2015 amended this requirement to authorize a maximum 10-year performance period before MAC contracts must be recompeted. The amendment, which applies to MAC contracts in effect at the time of enactment or entered into on or after enactment, would permit CMS to modify existing MAC contracts or enter into future MAC contracts for 1-year base performance periods and nine optional 1-year performance periods. See Pub. L. No. 114-10, § 509(a)- (b) (April 16, 2015). Therefore, while MACs are not compensated on contingency, MACs are compensated on performance. The less a MAC spends, the more services a MAC allows, the strict oversight a MCA ensues on its providers…all these “performance-based” measures may not be a contingency compensation relationship, but it’s pretty close. Saved money becomes profit for MACs.
Medicare and Medicaid auditors love rules. Even if the rules that auditors are instructed to follow really are not required by actual law. It goes without saying that auditors are not lawyers. Auditors are not trained to decipher whether statutes, regulations or policy are superseded by federal statutes and regulations. The fact is that, more times than one would hope, the auditors are wrong in their assessments that a claim should be denied, not out of malice, but because of a basic misunderstanding of what the law actually requires.
I have all kinds of stories about auditors claiming money is owed, when, really it was not owed because the RAC/MAC auditor failed to follow the actual, correct procedure or misconstrued a regulation. For example, I had a durable medical equipment provider, DME ABC, who was informed by the NSC Supplier Audit and Compliance Unit of Palmetto GBA that it owed $1,075,548.64. Palmetto is one of the MACs for Medicare – durable medical equipment. There was no demand letter. The alleged overpayment amount came to fruition in a telephone conference between the CEO of the company and an employee of Palmetto. Let’s call her Nancy. Nancy told CEO that company owed $1,075,548.64 based on an alleged violation of 42 C.F.R. § 424.58,
Even more disconcerting, was the fact that Palmetto claimed that its alleged, oral overpayment against DME ABC arose from a normal, reoccurring validation process pursuant to 42 C.F.R. §424.57, approved by CMS and in accordance with the requirements of 42 C.F.R. §424.58. No formal letter was necessary was Palmetto’s retort. Not correct; a formal demand letter is always required.
In this case, Palmetto began to backtrack once we pointed out that Palmetto nor Nancy ever sent a formal demand letter with any reconsideration review appeal rights or administrative appeal rights. We knew this was procedurally incorrect because federal law dictates that you receive a formal demand letter with appeal rights and notice of how many days you have to appeal. But out of fear of retribution, DME ABC was willing to write a check without pushing back. Obviously, we did not do so.
I tell this story as an example of how intimidating, scary, and overwhelming auditors can be. If someone off the street asked you for a million dollars, you would laugh them off your doorstep, right? After you tell them to don a mask and maintain social distancing.
But in the new-age world of COVID-19, rules have been broken. This behavior would not be acceptable pre-COVID-19. But this provider honestly was going to pay.
The Trump Administration is issuing an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic.
Pre-COVID-19 if you were to state “paperwork over patients,” everyone in the industry would agree. There would be snickers and eyes rolling, because no one wanted paperwork to be over patients. But it was. Now the mantra has flipped upside down – now the mantra is: Patients over Paperwork.
Post-COVID-19, if documents are lost or misplaced, or otherwise unusable, DME MACs have the flexibility to waive replacements requirements under Medicare such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.
Post-COVID-19, CMS is pausing the national Medicare Prior Authorization program for certain DMEPOS items. CMS is not requiring accreditation for newly enrolling DMEPOS and extending any expiring supplier accreditation for a 90-day time period. CMS is waiving signature and proof of delivery requirements for Part B drugs and Durable Medical Equipment when a signature cannot be obtained because of the inability to collect signatures. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.
Post-COVID-19, in order to increase cash flow to providers impacted by COVID-19, CMS has expanded the current Accelerated and Advance Payment Program. An accelerated/advance payment is a payment intended to provide necessary funds when there is a disruption in claims submission and/or claims processing. CMS may provide accelerated or advance payments during the period of the public health emergency to any two Medicare providers/suppliers who submits a request to the appropriate MAC and meets the required qualifications. The process of obtaining the funds is a MAC-by-MAC process. Each MAC will work to review requests and issue payments within seven calendar days of receiving the request. Traditionally repayment of these advance/accelerated payments begins at 90 days, however for the purposes of the COVID-19 pandemic, CMS has extended the repayment of these accelerated/advance payments to begin 120 days after the date of issuance of the payment. Providers can get more information on this process here: www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf
The Future of Medicare/Medicaid Audits
The beauty of predicting the future is that no one can ever tell you that you are wrong. These are my predictions:
Auditors will deny claims for not having prior authorizations. Auditors will deny claims because the supplier accreditation expired after the 90-day time period. Auditors will deny claims because the percentage of face-to-face time was not met as described per CPT codes.
Obviously, these would be erroneous denials if the denials are within the dates that the COVID-19 pandemic occurred. The problem will be that the auditors will not be able to keep up with all the exceptions, not because the auditors are acting out of malice or dislikes providers. They will be simply trying to do their job. They will simply not be able to take into consideration all the exceptions that were given during the virus. Because, while we do have many written exceptions, if you call CMS with a personal and individualized problem, CMS will, most likely, grant you a needed exception. As long as the exception has the best interest of the consumer at heart. However, this personalized exception will not be written on CMS’s website. In five years, when you undergo a MAC or RAC audit, you better have proof that you received that exception. It will not be enough proof for you to state that you were given the exception over the phone.
So how can you protect yourself from future, erroneous audits?
Write everything down. When you speak to CMS, document concurrently the date, time, name of the person to whom you are speaking, the summary of your conversation, the COVID-19 regulatory exception, sign it and date it.
It is a hearsay exception. Writing down everything does not magically transform your note into the truth. However, writing down everything concurrently does magically allow that note that you wrote to be allowed in a court of law as an exhibit. Had you not written the note contemporaneously with the conversation that you had with CMS, then the attorney on the other side of the case would move to exclude your handwritten or typed note as hearsay.
Hearsay is defined as a statement that (1) the declarant does not make while testifying at the current trial or hearing; and (2) a party offers in evidence to prove the truth of the matter asserted in a statement. There are too many hearsay exceptions to name in this article.
Just know, for purposes of this article, that any health care provider who is relying on an exception to a normally required regulatory mandate – regardless what it is – either be able to: (1) cite the written exception that was published by CMS to the public; or (2) produce the written or typed contemporaneously written note that you wrote to memorialize the conversation.
2 years ago – Hindsight is 20/20. #COVID19
The United States currently spends more per person on health care than any other developed country. So when my daughter and I recently vacationed the “Highlights of Europe” tour, I was interested in learning about the varied health care systems, country-by-country. We visited England, France, Switzerland, Austria, Germany, the Netherlands, and Italy. It was awesome!! She turned 13 during the trip, and she starts 8th grade next week. Where does the time go?
While I do not protest to know all the answers, during our vacation, I researched the diverse countries’ healthcare system and methods of payment, but, most importantly, I interviewed people. I interviewed people who were begging for money. I interviewed my taxi drivers. I interviewed the bus drivers. I interviewed people on the streets. I interviewed shop owners. I interviewed the hotel concierge. I interviewed bartenders and waiters.
This blog is intended to memorialize my findings. It has not been fact checked. In other words, if a person told me something about the healthcare system and their personal experiences, I did not go back and review that country’s laws to determine whether that person was telling the truth or that the person’s rendition of their experience was compliant with the law. I did this for a reason. Sometimes what the laws dictate as to healthcare is not what actually occurs in reality. I wanted personal perspectives. I wanted an opinion from citizens of other countries as to how healthcare was or was not working in their country. I did not want to meet health care policy, rules, regulations. I wanted the cold, hard, real truth.
At least one person in every country – Austria, The Netherlands, France, England, Germany, Switzerland, and Italy told me, “[Country name] has the best health care in the world.” Obviously, they cannot all be right. And I certainly heard the worst case scenarios in country’s that claimed to be the best in the world.
This is what I learned:
England has the best health care system in the world! England’s healthcare system is drastically different from the USA’s. England’s National Health Service (NHS) is a free healthcare program for all permanent residents of United Kingdom. Reading the fine print, however, the NHS is not completely free. There are charges associated with eye tests, dental care, prescriptions, and many aspects of personal care.
England relies on primary care more so than specializations. Mental health services, for example, are largely treated by the general practitioners (GPs). Provider trusts, fed by taxes, compensate most health care, the main examples in the hospital trust and the ambulance trusts which send the money allocated to them by commissioning trusts. Hospitals normally receive the lion’s share of NHS funding as hospital’s have the most expenses.
Our taxi driver (Jim) told me that paperwork is minimal with the NHS, which makes it super easy to use. Although he was quick to point out that the health care system in England does vary in quality and timeliness depending on where you live, but I believe we can say the same about the USA. Jim also told me that he and his family has had problems with wait-times to be seen by specialists. Jim’s wife suffered persistent and serious acid reflux. Her general practitioner referred her to a gastroenterologist. However, she could not get an appointment until 20 weeks later. But, in the end, she was seen, and had no waiting period on the day of her appointment. Generally, Jim is happy with the NHS. The costs are minimal, and, he believes that the quality of care is high.
The hotel concierge (let’s call him Blake) was extremely open about his experiences with the health care system in England. It appears from his enthusiasm that health care is just as big of a political issue in England than it is in the US. He told me that he has never waited more than four hours in an emergency room. Apparently, his children frequent it. However, I do place an asterisk on Blake’s comment. You will see below that Alice from France waited for 7 hours at the ER in the UK with her husband. Some of the stories that I heard contradicted each other.
Blake also told me that for traumatic experiences, such a broken arm due to a car accident, which his youngest daughter recently endured, the wait time is significantly less than when his best buddy got drunk at the pub and broke his finger. Blake also told me that, for day-to-day, general, “I have a tummy ache” appointments, English citizens do not get to choose appointment times. You leave a voice mail message for the nurse and the nurse informs you when you need to present yourself. While this may sound inconvenient, Blake stated that there are no wait times. I know that I have waited many an hour to see my general practitioner.
Dental insurance, on the other hand, is a whole new can of worms. Basically, general practitioners are free, but dentists are not. The wait times to see a dentist are extensive, and, if you do not have private dental insurance, the wait times can be even longer. My take-away? If I were a dentist, I’d move the the UK. This also explains a lot about English actors and actresses.
We cannot analyze any country’s health care system without taking into account the taxes that you must pay in order to maintain such a health care system, no matter how poor or amazing that health care system is. Income taxes in the UK are 40% if you make more than 46,351 pounds. Once you hit 150,000 pounds, then your taxes increase to 45%. Almost half of your wages are taken by the government, but you get, essentially, free health care. Does it balance out?
The Netherlands has the best health care system in the world! Every person that I asked in Amsterdam, informed me that Dutch health care is among the best in the world. It seemed that the Dutch took pride in their health care system. So, I wanted details. If Dutch health care is the best, why doesn’t everyone else mimic it?
I learned that everyone who lives or works in the Netherlands is legally obligated to take out standard health insurance. All insurers offer the same standard package. The standard insurance package includes general practitioners, some medications, dental care until the age of 18, nutritional and dietary care, medical aids, mental health services, and much more. It does not cover over-the-counter aspirin or cosmetic surgery procedures. But neither does insurance in America.
In Amsterdam, my daughter and I rented bicycles for two days. It was an absolute blast. The rental process, however, took a bit longer than expected. The gentleman behind the counter needed our passport numbers, information on our hotel, credit card information, and provided us with an instruction program on how to properly secure the bicycles. Given the length of the process, I took the opportunity to ask him about health care.
Let’s call the bicycle rental agent Stefan.
Stefan explained that the Dutch believe in misery first. According to him, regardless the affliction, general practitioners will tell you to take an aspirin and come back in two weeks if you are not dead. I am fairly sure that he was exaggerating. But I have always been of the opinion that exaggerations have some form of truth.
In the Netherlands, the general practitioners are called huisarts, which are expected to know all aspects of medicine. I liken the huisarts to attorneys who practice general law. What attorney could know all aspects of family law and criminal law? The answer is none. A generalist knows a tad about everything, but nothing much about anything.
Preventive care is rare in the Netherlands, certainly in terms of women’s health. For example, in the US, France, and Spain, it is typical to get a test for cervical cancer at least every 2 to 3 years. Here, in Amsterdam, insurance will only pay for one every 5 years. Hormone replacement therapy is also rare here, as most GPs are still following outdated guidelines, based on a flawed study from 2002.
It seems as though I am overly negative as to the health care in the Netherlands. All I can write is that I began this blog with an open mind because if any country has mastered health care then we should learn from it. I was also swayed by my interviewees.
While other countries maintained high income taxes to pay for “free health care,” the Netherlands does not use tax dollars to pay for health care. Every Dutch resident is required to buy their own health insurance on top of the taxes they pay to the government.
Taxes in the Netherlands is exorbitant. If you make over 66,421 euros, taxes are 52% of your income. These taxes, remember, do not include health insurance.
In Amsterdam, there was a pub across the river from our hotel Movenpick. A group of guys were “celebrating” an upcoming wedding and were drinking bottles upon bottles of wine at the river’s edge. Multiple times members of the group ended up swimming.
So, imagine my surprise when one of the intoxicated gentlemen sat at our table and ensued with a semi-intelligent conversation about health care. We will call him Henry. Henry had recently been married and his wife gave birth last year to a premature baby. I completely related because my daughter was born at 28 weeks and 2 pounds and 2 ounces. I asked Henry about the health care coverage for his premature baby girl’s birth and subsequent surgeries. He told me that, besides the meals that he ate during the two-month stay in the hospital, once his new daughter and wife were free to leave, his hospital bill was zero. His daughter endured a two-month stay in the neonatal department, his wife had a two-month, inpatient hospital stay, his daughter underwent multiple surgeries for her lungs and heart, and his daughter had 24-hour care for 60 days. All for zero euros. All children in the Netherlands are automatically insured by the government.
While I see the downside of paying 52% of your income to the Dutch government and having to pay for health insurance, I do see the benefit of Dutch insurance if you have a medical emergency, like a premature baby.
France has the best health care system in the world! In a 2000 World Health Organization (WHO) comparison of 191 different countries’ health care, France came out at number one. And they are not afraid to tell you. Even though the WHO ranking is from 2000, the French still tout its outcome because there have been no other such rankings since then. The French believe in the universal right to health care.
The entire population must pay compulsory health insurance.
Our two-hour ride on the Eurostar from Paris to London gave me a unique opportunity to ask other passengers about health care, especially since there is bar in one of the cabins. People congregated there to drink, eat, and talk, plus one nosy American asking about health care. The following are summaries of the stories I heard:
Nancy, who is from Devon, England and has lived in France with her family since 2006 thinks that French health care is the best. Since she moved to France her family has, unfortunately, undergone 6 operations. Her husband had cancer a couple of years ago and the Oncopole (oncologist) encouraged alternative therapies and even told him the taxi drivers (bringing patients home from the hospital) often go straight to a rebouteuse (a healer) after radiotherapy. A lot of doctors practice homeopathy, which is fantastic, according to Nancy. She also said that doctors prescribe “sacks full of medicine.” The good news is that Nancy’s husband is in remission.
Alice, a former British citizen, who moved to France told me the French health care system saved her husband’s life. Five years ago, her husband started to feel ill while visiting the UK. They couldn’t get a family/general practitioner to come to their home (I thought, my doctor wouldn’t come to my home in the US either). Over the phone, the general practitioner said, “take an aspirin and rest.” They also went to the ER but gave up after 7 hours waiting as her husband was in extreme pain (Juxtapose Blake’s recount that he never waited over 4 hours in the ER in the UK). A few days later they flew home, and her husband could not walk. Within an hour of arriving in France, her husband was admitted to a hospital. He was diagnosed with stage 4 kidney failure and stage 5 equates to dialysis. Needless to say, Alice is a French health care fan.
My daughter and I used a tour group company for our mommy-daughter vacation, and, while in France, I heard one person tout that health care is free in France. I will contend, from my travels, that French health care is great, but not completely free. I saw a presumably-homeless, elderly gentleman with no legs begging for money. In extremely, broken Frenglish and impromptu sign language, I asked the gentleman why he didn’t have health coverage and was he a French citizen? To the best of my ability, I interpreted his responses to indicate that, yes, he is a French citizen, but that free, French health care does not include prosthetics.
Taxes are approximately 41% if you make over $72,617. Whereas, in the US, if you make over $72,000 your tax bracket is 15.55%, barring extraordinary circumstances.
Italy has the best health care system in the world! From my travels, I gathered that Italians believe that their health care system is the best (over France’s – I believe that there is a bit of a friendly rivalry). In 2000, the World Health Organization (WHO) ranked Italy as the 2nd best health care system in the world, right under France. In 2012, WHO found Italy’s life expectancy to be 82.3 years.
Italy has a regionally organized National Health Service (“SSN” – Servizio Sanitario Nazionale) that provides citizens with free or low-cost healthcare. It’s funded through national income taxes and regional VAT, and generally the standard of care is very high. I was pleased to discover that foreign citizens living in Italy with a regular stay permit are entitled to all the same treatment and rights as Italian citizens. Retirement 2035 – here I come!
For a country with the best health care in the world, I saw the most homeless, medically-challenged beggars than any other country. Maybe there are more homeless, medically-challenged beggars in Italy than other country because the weather is so nice, the gelato is so delicious, the population is greater, mental health care is worse, or the food is so amazing…I do not know. But I saw the most homeless, medically challenged beggars in Italy than anywhere else. Oddly, the afflictions were the same. Their feet were misshapen and curled inward to a degree that did not allow them to walk. It was heartbreaking. I googled it and discovered that medical articles have been written on the anomaly of foot deformities in southern Italy.
Taxes in Italy are as follows:
- 23% for amounts up to $36,000
- 33% for the next band from $36,001 to $39,300
- 39% for amounts between $39,301 and $119,200
- 45% for amounts $119,201 and over.
I met Valentina in Roma. Europe has strict hourly limits for bus drivers and our original bus driver, apparently, over-drove. Valentina stepped in and was very chatty, unlike the original bis driver who spoke no English. Considering our group consisted of 21 English-speaking vacationers and one couple fluent in Spanish and English, a bus driver who only spoke French was unhelpful.
Valentina told me that in Italy, mainly in the south, public hospitals are very crowded and offer very limited and sometimes hasty assistance, so that patients are too soon sent to rehabilitation centers, very few of which are public. This almost entirely private field is financially sustained by the National Health Service, which pays a per diem for a patient’s clinic stay. If a patient still needs rehabilitation after 2 months in a rehabilitation clinic or center, reimbursement from the National Health Service will be in any case cut by about 40%. Private insurance is very rare and usually is not involved in rehabilitation.
In private rehabilitation centers, physicians often have to deal with overworked nurses and angry, worried patients and relatives.
Valentina said that her mother went to her general practitioner complaining of frequent headaches, depression, anxiety, dizziness, and recurrent fatigue. Her general practitioner, diagnosed her as “a hysteric neurotic,” and she was prescribed anxiolytics. Her headaches continued. When she finally was able to see a specialist, her magnetic resonance image report showed that she had several cerebral metastatic lesions from an otherwise silent neoplasia – basically, a death sentence.
Switzerland has the best health care system in the world! The Swiss health care system is regulated by the Swiss Federal Law on Health Insurance. There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country) (country #2 on my options for retirement).
Like every country we visited, Switzerland has a universal health care system, requiring all to buy insurance. Switzerland holds a special place in my heart. My mother’s mother, Martha Zuin (imagine an umlaut over the ‘u’), immigrated to the US from Switzerland, so I still have family living in Switzerland.
The plans in Switzerland resemble those in the United States under the Affordable Care Act: offered by private insurance companies, community-rated and guaranteed-issue, with prices varying by things like breadth of network, size of deductible and ease of seeing a specialist. Almost 40% of people get subsidies offsetting the cost of premiums, on a sliding scale pegged to income. Although these plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit basis, providing additional services and more choice in hospitals. For these voluntary plans, insurance companies may vary benefits and premiums; they also can deny coverage to people with chronic conditions. Most doctors work on a national fee-for-service scale, and patients have considerable choice of doctors, unless they’ve selected a managed-care plan.
Both Swiss and German systems cost their countries about 11 percent of GDP.
Mia, the hotel clerk at Lake Maggiore, is a Swiss resident. She informed me that insurance premiums are not adequately adjusted to income, and they have doubled in price since 1996, while salaries have risen by just one-fifth. It comes as no surprise, then, that just over a quarter of the population needed government assistance to pay their premiums in 2014. She says that over 1/2 of Swiss residents owe money for medical bills.
You can be blacklisted from reimbursement for health insurance in Switzerland. Some 30,000 blacklisted patients so far have lost their right to be reimbursed for medical services under basic insurance and can be refused care, save for emergencies. A policy initially designed to encourage people to pay up has instead come under fire for going against the principle of basic health coverage for all. In 2017, EHR became mandatory for most, which increased the costs for many health care visits.
Research told me that Switzerland is the second most expensive country for health care other than USA with The Netherlands, Sweden, Germany, and Denmark closely following.
Germany has the best health care system in the world! The German health care system and Switzerland’s have a lot in common. According to interviewees, Germany has slightly better access to health care, especially with respect to costs. Switzerland has higher levels of cost-sharing, but its outcomes are hard to beat — arguably the best in the world – for real.
A majority of Germans (86%) get their coverage primarily though the national public system, with others choosing voluntary private health insurance. Most premiums for the public system are based on income and paid for by employers and employees, with subsidies available but capped at earnings of about $65,000. Patients have a lot of choice among doctors and hospitals, and cost sharing is quite low. It’s capped for low-income people, reduced for care of those with chronic illnesses, and nonexistent for services to children. There are no subsidies for private health insurance, but the government regulates premiums, which can be higher for people with pre-existing conditions. Private insurers charge premiums on an actuarial basis when they first enroll a customer, and subsequently raise premiums only as a function of age — not health status. Most physicians work in a fee-for-service setting based on negotiated rates, and there are limits on what they can be paid annually.
Though mostly public, the German health insurance system is not a state-run system like the National Health Service in the United Kingdom. In fact, more than 100 different health insurers, known as sickness funds, compete for members in Germany’s comparatively decentralized system. These sickness funds are non-profit, non-governmental organizations that operate autonomously. Most Germans’ health insurance contributions are deducted from their paychecks by their employers. The amount, however, is capped at 14.6% of a person’s salary, split fifty-fifty between the employer and the employee, so 7.3% each way. But coverage is not dependent on the employer, so when Germans change or lose their jobs, nothing changes in their health insurance. Recent changes in health care have allowed the wealthy to obtain higher quality and more efficient health care services. Anyone who makes over 57,600 euros/year can opt out of public health care and pay for private health care. Doctors are more prone to be more attentive of their privately-insured patients.
We met Emma at a beer garden; she was our waitress. Emma was as equally inquisitive about American health care as I was about German health care. She said that she could not get her head wrapped around HIPAA. Privacy, she indicated, is not a hot topic issue in Germany. Emma said that doctors in Germany “get it wrong a lot.” When I asked her what she meant, she said that she went to her general practitioner for chest pain. Whereas, in America, chest pain is considered serious, Emma said that her doctor did not even place a stethoscope on her chest. Instead, he told her to go home, rest, and take an Ibuprofen. Emma’s friend had a baby with a problem in one eye. She went to several doctors and they told her nothing can be done. She finally went to a specialist in Spain and received a concrete diagnostic and special glasses for the 7 month-old-baby, because the eye movement was related to the eye condition.
Austria has the best health care system in the world! If European health care were on a bell curve, Austria would be at the bottom (hmmmmm…..although I have not compared Austria to the US). Dr. Clemens Martin Auer is the President of the European Health Forum Gastein and Director General at the Austrian Federal Ministry of Health.
Dr. Auer is focused on digital health and access to drugs. Talking to people in other European countries, who complained about over prescribing, Austria, apparently, has a high cost issue barring many people from receiving prescriptions.
In Austria, the health care system is largely financed by social security contributions and taxes, to a lesser part also by private sources, such as prescription charges, compulsory personal contributions, per-diem charges for hospital stays or contributions to private health insurance.
Each month a contribution will be taken from your tax payment, which is worked out according to how much you earn. This gives you access to basic healthcare including treatment in hospitals, medication, dental care, and some specialist appointments. If you make over 31,000 euros, you pay 41% tax.
According to Tobias, the man I met in Innsbruck, people wait months to see a specialist. So, if you have a cold, you are good, but of you have cancer, then get on the waiting list. Tobias also told me that people do not go to hospitals unless they have a severe injury or serious surgery. Instead, the general practitioners are heavily relied on. I am not sure I like the idea of going to a generalist for everything. If I have stark knee pain, I want to see an orthopedic, not a general internist. But I am learning that free health care may not equate to the best health care.
Written by my partner, Isaac Mamaysky. This article is germane to health care providers during this COVID19 pandemic.
The governor of Ohio recently made national headlines by telling employers across the state to check employees’ temperatures every day before work. Whenever employers conduct health screenings or otherwise make decisions based on their employees’ health, the Americans with Disabilities Act becomes a key consideration.
The ADA regulates employer-mandated medical examinations, the medical questions employers are allowed to ask employees, and of course, the provision of reasonable accommodations to disabled individuals, including during a pandemic.
During the 2009 H1N1 swine flu pandemic, the U.S. Equal Employment Opportunity Commission published a document called Pandemic Preparedness in the Workplace and the Americans With Disabilities Act. Having faded into relative obscurity in the intervening years, the EEOC’s guidance once again became relevant when COVID-19 was named a global pandemic.
Since that time, employment attorneys have referenced the 2009 guidance and wrestled with its implications for 2020. Last week, the EEOC updated its H1N1 guidance to clarify exactly how the principles apply today. The EEOC also updated a separate guidance document called What You Should Know About the ADA, the Rehabilitation Act, and COVID-19 and released a supplemental webinar titled Ask the EEOC.
Perhaps not surprisingly, the Ohio governor’s request aligns with the EEOC’s compliance guidelines, which help employers navigate ADA considerations while keeping COVID-19 out of the workplace. While medical examinations are normally prohibited under the ADA, the EEOC explains that examinations are appropriate when an employee would pose a “direct threat” to others by transmitting COVID-19.
Taken together, the EEOC’s updated guidance materials provide the following key takeaways for employers.
Employers should not ask questions related to disabilities, such as whether an employee has a compromised immune system or a medical condition that makes the employee more susceptible to COVID-19.
Employers can ask questions about symptoms of COVID-19 to ensure that sick employees stay home. Likewise, when employees call in sick without giving details, employers can ask about symptoms of COVID-19 in order to protect the rest of the workforce. However, employers should not ask these questions of employees who are already working remotely and have not been interacting with customers or coworkers.
Employers can check temperatures and conduct COVID-19 screenings of current employees, and of new employees but only after making a conditional job offer. If an employer has a reasonable belief based on objective evidence that a particular employee might have COVID-19 (due to a hacking cough, for example), the employer may conduct a health screening only of that one employee, rather than the entire workforce.
If an employee refuses to answer COVID-19 screening questions or refuses a temperature check, then the employer may bar the employee from the workplace. The EEOC encourages employers to assure employees that their medical information will remain confidential, which may make employees more likely to comply with employer requests.
Any records resulting from medical screenings should be maintained in a separate medical file (i.e., not as part of an employee’s personnel file) and treated as a confidential medical record. If a manager receives medical information while teleworking, and thus cannot follow the employer’s usual confidentiality protocols, the medical information should be safeguarded to the greatest extent possible until it can be properly filed when the manager returns to the workplace. This may mean documenting medical information using initials or ensuring that laptops and devices cannot be accessed by others in the household.
Likewise, employers who send an employee home should keep the decision confidential. Employers can tell other employees that they were exposed to a coworker with COVID-19, and then send home all employees who worked in close proximity to that person, but employers should not identify the coworker in question.
That person’s identity should only be shared with those who have a need to know, such as a supervisor who interviews the coworker about who might have been exposed to them in the workplace. Likewise, if an employee is teleworking due to having COVID-19, the employer can share the fact that the employee is teleworking but should not share the reason the employee is teleworking.
Employers can delay the start date of an employee who has symptoms of COVID-19. If an employer needs an employee to start working immediately, then the employer can withdraw a job offer to an employee with COVID-19.
Employers can request that employees who recently traveled to affected areas or were exposed to a person with symptoms of COVID-19 stay out of work until a certain number of days passes without symptoms. Employers should not specifically ask employees if they have a family member with COVID-19, which would be prohibited by the Genetic Information Nondiscrimination Act. Employers can ask, more generally, if employees have been exposed to any person with symptoms of COVID-19.
Employers can require a doctor’s clearance prior to allowing an employee to return to work. Note, however, that the Centers for Disease Control and Prevention tells employers not to require a doctor’s note to validate symptoms, because that discourages employees from staying home.
Employers can require employees to adopt infection-control practices in the workplace, such as prohibiting handshakes and requiring frequent hand-washing, wearing masks, maintaining six feet of distance from other employees, and related measures.
For the moment, much of this guidance applies to essential businesses, such as supermarkets and transportation companies, which are still open despite quarantines and other social distancing measures. Many nonessential businesses, which are currently closed, aspire to reopen as soon as possible.
While the exact timeline is still unclear, many businesses will likely reopen while COVID-19 is more controlled than it is today but still a risk, especially for employees with compromised immune systems and other medical conditions (such as lung disease and heart issues).
Since employers cannot ask questions related to disabilities, how can they determine which employees may be unavailable when they reopen? The EEOC explains that an inquiry is not disability-related if it identifies nonmedical reasons for absence on the same footing with medical reasons.
So, for example, an employer is permitted to ask a survey question along the following lines: In the event our business reopens in the near future, would you be unable to come to work for a reason such as your child’s day care center being closed, public transportation being sporadic, other dependents needing care, or having a compromised immune system or other health condition?
In this way, employers can determine which staff will be unavailable without running afoul of the ADA.
Depending on how early a particular business reopens, certain vulnerable employees might need to continue working from home for some period of time. Of course, employers are not absolved of their obligations to provide reasonable accommodations during a pandemic.
The EEOC observes that the rapid spread of COVID-19 has increased the number of requests for reasonable accommodations. This number will continue to increase if businesses reopen while the virus is not fully contained.
If an employer’s usual reasonable accommodation processes are delayed due the volume of inquiries, the EEOC encourages employers to implement temporary solutions that enable employees to keep working while the discussion and potential provision of reasonable accommodations is pending. The EEOC’s webinar provides extensive details on this topic.
Reflecting the general uncertainty surrounding current events, the EEOC is still unsure whether COVID-19 is a disability under the ADA. As the EEOC observes, our knowledge of COVID-19’s spread and containment changes day by day and its status as a disability will become clearer as time goes on.
As employers and their attorneys have seen, federal and state laws and regulations are changing equally fast. For now, while much of the country is on pause, employers should watch the changing landscape closely.
In the coming weeks and months, and especially as businesses reopen, states are expected to implement many new safety protocols. Perhaps a number will even follow Ohio’s lead by beginning each workday with a temperature check.
This article originally appeared in Law 360’s Expert Analysis section on March 31, 2020.
To learn more about the issues raised by this client bulletin, please contact Isaac Mamaysky at email@example.com
Note: This bulletin is for general use and should not be construed to provide legal advice as to particular factual situations.