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Provider Relief Funds: The Hottest RAC Audit Subject

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.

Update on Medicare/Medicaid Audits in the Wake of COVID-19

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:

  1. Those exceptions published by CMS to apply to all health care providers
  2. Those special, verbal exceptions given directly to an individual provider that were not published by CMS
  3. 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.

Coronavirus: The Latest Court Closings

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Article courtesy of Law360. Updated April 1, 2020.

Notice the article does not expound on the closings or openings of administrative law courts across America. If you are defending a Medicare or Medicaid overpayment, tentative notice of overpayment, or other alleged penalties, you will, most likely, be in administrative court.

At least, here, in NC, the administrative courts are open for Motions. Physically, the courts are closed except for a clerk. No in-person hearings are being held. But emergency, telephonic hearings can be heard.

FEDERAL APPEALS COURTS


U.S. Supreme Court
The high court postponed oral arguments scheduled for this month’s session running March 23 to March 25 and March 30 to April 1. The court’s regularly scheduled order list will be posted on the court’s website at 9:30 a.m. March 23. Hard copies will not be released. Opinions will be issued by the court at 10 a.m. the same day.

The court closed to tourists on March 12 until further notice, but the building will remain open for official business.

The deadline to file any petition for a writ of certiorari due on or after March 19 is extended to 150 days from the date of the lower court judgment, order denying discretionary review or order denying a timely petition for rehearing. The court said it will generally grant motions for time extensions if parties have difficulties related to the coronavirus.

Federal Circuit Court of Appeals
All cases scheduled for argument during the April 2020 sitting will be conducted remotely and no in-person hearings will be held. All existing deadlines in cases are still in effect. All requirements to provide paper copies of documents submitted electronically are suspended for all documents filed on or after March 2 until further notice. Pro se parties are permitted to submit case-initiating documents by fax or email.

The public is prohibited from entering the National Courts Building complex unless preauthorized by court staff and only as necessary to conduct or support essential court functions, effective March 16. Those who have tested positive for the coronavirus or had possible exposure to the virus are prohibited from entering the courthouse.

D.C. Circuit Court of Appeals
The court of appeals for the D.C. Circuit has suspended all in-person onsite oral arguments until further notice.

The Court of Appeals for the D.C. Circuit is limiting access to its courthouse to “judges, court staff, members of the media, and visitors with official business with the courts,” effective Friday. The court asked that those who have tested positive for the coronavirus, have had contact with someone who has been exposed to the virus, been asked to self-quarantine or are experiencing flu-like symptoms not enter the courthouse. Pro se litigants may email filings to ProSeFilings@cadc.uscourts.gov as PDF files and should not send duplicate paper copies to the court.

First Circuit Court of Appeals
Oral arguments scheduled for the month of April are canceled.

Second Circuit Court of Appeals
All filing dates and other deadlines between March 16 and May 17 are extended by 21 days.

Those who do not have business with the court will not be admitted until further notice. Arguments may be conducted remotely.

Lawyers or pro se parties scheduled to argue before the court should contact the clerk of court if they: visited or have been in contact with someone who was in China, Iran, Italy, Japan or South Korea in the past two weeks, have been asked to self-quarantine, have tested positive for the coronavirus or have been in contact with someone who has tested positive, or if they have a verifiable health condition.

Third Circuit Court of Appeals
Oral arguments will continue as scheduled pending further order of the court. The merits panel will determine the manner of argument. Parties may file a motion requesting to appear by audio conference. The majority of staff in the clerk’s office will be working remotely. The three-day time limit for requesting extensions is relaxed until the clerk’s office resumes normal operations. The filing of paper copies of briefs and appendices is deferred until further notice.

The Third Circuit Judicial Conference scheduled for May 13-15 in Philadelphia has been canceled.

Fourth Circuit Court of Appeals
Cases previously scheduled for argument during the March 17-20 and April 7 argument sessions will be heard at a later session, heard remotely or submitted on the briefs, at the direction of the assigned panels. The court temporarily suspended its oral argument requirement for published opinions.

The Powell Courthouse in Richmond, Virginia, is closed to the public. Papers may be filed in the courthouse lobby, but those who have tested positive for the coronavirus, those with symptoms of COVID-19 and those who may have been exposed to the virus are prohibited from entering the building.

Fifth Circuit Court of Appeals
All requirements to file paper copies are suspended until further notice. Extensions with justification may be requested from the clerk’s office. All outstanding deadlines for incarcerated and nonincarcerated pro se filers are extended for 30 days after their due dates. The court canceled in-person oral arguments scheduled for March 30 to April 2 in New Orleans.

Sixth Circuit Court of Appeals
All nonessential court functions are postponed until further notice. Judges, parties, attorneys and some court staff are allowed to appear via video conference. The requirement that nonprisoner pro se litigants file exclusively in paper format is temporarily suspended until April 17.

Those who have tested positive for the coronavirus or come into contact with someone who has tested positive are barred from entering any courtroom. That restriction also applies to those who have been asked to self-quarantine, are exhibiting cold or flu symptoms, have visited Italy, Iran, China or South Korea in the past two weeks, or have had close contact with someone who has visited those countries in the past two weeks.

Seventh Circuit Court of Appeals
All cases scheduled for oral argument from March 30 through the end of April will be argued via telephone. The courtroom in Chicago will be closed to the public, and the court is operating with reduced staff. Arguments will be recorded and posted on the court’s website. If all parties agree among themselves to waive oral argument, they may jointly file a motion with the court seeking permission to do so.

Eighth Circuit Court of Appeals
The public is not being admitted to the Eighth Circuit Clerk’s Office. Those who come to the Burger Courthouse in St. Paul, Minnesota, or the Eagleton Courthouse in St. Louis to file may leave their documents at the front door to the office.

Ninth Circuit Court of Appeals
Ninth Circuit courthouses are closed to the public during noncourt weeks until further notice. The court is evaluating arguments currently scheduled for March, April and May and will give orders to the cases individually. Panels may exercise their discretion to submit cases without argument, postpone argument to a later date or hold argument via telephone or video. Arguments will be livestreamed for the public.

Tenth Circuit Court of Appeals
The Tenth Circuit closed its sole courthouse to the public from March 17 until further notice. The Denver courthouse will be restricted to judges, court staff, court security officers and service providers with official business with the court. All filings should be made electronically or via mail until further notice.

Eleventh Circuit Court of Appeals
In the Eleventh Circuit, only judges, court staff, members of the media and visitors with official business with the court will be allowed into the two Eleventh Circuit buildings. Paper filing requirements are temporarily waived. Panels can hear oral arguments remotely, and those hearings will be livestreamed for the public when feasible. Recordings of oral arguments will also be available on the court’s website. Anyone who is experiencing flu-like symptoms or who has had a known contact with a person who tested positive for the coronavirus will not be allowed inside.

The court has canceled its judicial conference, which had been scheduled for May 6 through May 9 in Atlanta.

FEDERAL DISTRICT COURTS AND STATE COURTS


Alabama
The Northern District of Alabama is prohibiting those who have tested positive for the coronavirus and those who may have been exposed to the virus from entering its courthouses. Also prohibited are those who have visited China, Italy, Japan, Iran or South Korea in the past two weeks.

In the Middle District of Alabama, no jurors will be summoned for civil or criminal jury trials for 30 days as of March 17. All jury trials and trial-specific deadlines scheduled during that period are postponed for 30 days, as are all grand jury proceedings. Initial appearances, arraignments and detention hearings before the magistrate judges will continue remotely. Any proceedings that can’t be conducted remotely will be coordinated with the duty magistrate judge. Case-by-case exceptions to the procedures may be ordered for nonjury matters at the discretion of the court after consultation with counsel.

All the Middle District’s bankruptcy court, hearings will be held by telephone through May 31

The Middle District is prohibiting those who have tested positive for the coronavirus and those who may have been exposed to the virus from entering its courthouses. Also prohibited are those who have visited China, Italy, Japan, Iran or South Korea in the past two weeks.

The Southern District of Alabama is prohibiting those who have tested positive for the coronavirus and those who may have been exposed to the virus from entering its courthouses. Also prohibited are those who have visited Europe, China, Italy, Iran or South Korea in the past two weeks.

In the state court system, all in-person court proceedings are suspended through April 16, with exceptions for jury trials in progress as of March 13 and other essential and emergency matters. Any court deadlines set to expire before April 16 are extended to April 20, excluding statutes of limitation.

Alaska
In the District of Alaska, all civil and criminal jury trials set to begin on or before May 1 are postponed until further notice. Trial-specific deadlines in civil and criminal cases set to begin before May 1 are postponed until further notice. All noncase-related activities scheduled in the James M. Fitzgerald U.S. Courthouse in Anchorage and the U.S. Courthouses in Fairbanks and Juneau are canceled until further notice. All grand jury proceedings scheduled to be held from Feb. 18 through May 1 are postponed. No hearings in bankruptcy appeals pending before the court scheduled from March 23 through May 1 will go forward, except for emergency time-sensitive matters.

In Alaska’s state court system, all Superior Court and District Court proceedings are suspended through April 3 except for certain priority hearings, including arraignments, felony first appearances and bail hearings. All trial court proceedings are suspended through May 1 except for certain priority hearings. Criminal jury trials are suspended through May 1, but trials underway as of March 23 may continue. Filing deadlines are extended to May 1 in suspended cases. The court is encouraging those with COVID-19 symptoms or possible exposure to the virus not to come to any state courthouses.

Arizona 
The District of Arizona has postponed all civil and criminal jury trials scheduled to begin on or before May 4 until further notice. All trial-specific deadlines in criminal cases scheduled to begin before May 4 are postponed until further notice, and judges may postpone deadlines for civil cases at their discretion. All grand juries that were scheduled to convene on or before April 17 are suspended. For those charged with felonies during this time, the period of time for presenting the case to the grand jury is extended 30 days from the indictment deadline. All court proceedings in the Tucson division through March 29 are postponed. Judges will conduct proceedings remotely where feasible. Noncase-related activities at courthouses in Phoenix, Tucson and Yuma, including naturalization ceremonies, are canceled until further notice.

The Flagstaff Courthouse will be closed to the public, except for necessary court appearances, through at least April 10. The public admitted to the courtroom will be limited to no more than two people in the public seating area at any time.

The court is asking those who recently traveled from an area with widespread COVID-19 — and those who are exhibiting symptoms of the disease — not to visit its courthouse.

In the state court system, no new petit juries will be empaneled through April 17.

Arkansas
In the Eastern District of Arkansas, all civil jury trials scheduled between March 18 and April 20 are canceled. All criminal jury trials scheduled to take place between March 23 and April 30 are postponed until further notice. All grand jury proceedings scheduled between March 18 and April 30 are postponed until further notice. Attorneys and parties must provide notice of potential exposure to the coronavirus. The court will use videoconferencing in preliminary criminal proceedings as needed. All large scale public events scheduled for March and April are postponed.

In the Western District of Arkansas, all civil and criminal bench and jury trials are postponed and will be rescheduled to a date after May 1. Other civil and criminal matters that can be resolved without oral argument or handled remotely are unaffected. Those who have tested positive for the coronavirus or may have been exposed to it are prohibited from entering any courthouse.

In the state court system, in-person proceedings in the appellate, Circuit and District courts are suspended until April 17. Exceptions include certain emergency, time-sensitive and other necessary proceedings. All summonses for people to participate in jury panels are suspended until May 1.

California
In the Southern District of California, civil and criminal jury trials are postponed until April 16. For the district’s bankruptcy court, all hearings will be conducted by telephone through April 16.

In the Eastern District of California, all civil and criminal jury trials are postponed until May 1. All courthouses are closed to the public. All civil matters will be decided on the papers or by remote hearings, if necessary. All criminal initial appearances, arraignments and other essential proceedings will proceed before magistrate judges unless the parties agree to postpone them. Proceedings should be conducted remotely when possible. District judges may postpone criminal matters to a date after May 1.

In the Central District of California, all courthouses are closed to the public through May 1, except for certain criminal hearings. Courthouse tours are canceled. No civil hearings will go forward, except for emergency time-sensitive matters. Any hearings on emergency civil matters will only proceed by telephone. All matters before the bankruptcy court will proceed by telephone.

In the Northern District of California, all civil and criminal jury trials are postponed until May 1. Anyone with symptoms should not appear in court. As of March 24, the San Jose courthouse was closed to both staff and the public until at least April 7 after a visitor was treated for COVID-19. All other district courthouses are closed to the general public until at least April 7. Essential courthouse operations for the Oakland, San Jose and Eureka/McKinleyville courthouses will be consolidated and relocated to the San Francisco courthouse until April 7.

The Central District and Eastern District of California are prohibiting anyone who visited China, South Korea, Japan, Italy or Iran in the past two weeks from entering any of their courthouses. The restriction also applies to those who have had close contact with someone who has visited those countries in the past two weeks, those who have tested positive for the coronavirus or have been in contact with someone who has tested positive, those who have been asked to self-quarantine and those experiencing fever, cough or shortness of breath.

The California Supreme Court suspended in-person oral argument sessions until further notice. Counsel will only appear remotely. All oral argument sessions will be held in the court’s San Francisco headquarters courtroom with limited seating. More information on California state court restrictions is available here.

Colorado
In the District of Colorado, all civil and criminal trials set to start from March 27 through May 1 are postponed. All grand jury proceedings are suspended through May 1. Hearings will be held remotely when possible. Only those with official court business are allowed to enter the district’s courthouses and probation offices. Those who have tested positive for the coronavirus or may have been exposed to it are prohibited from entering any courthouse.

In the state court system, all jury calls are suspended through April 3 except those for criminal trials facing imminent speedy trial deadlines.

Connecticut
The District of Connecticut said Wednesday that all civil and criminal jury trials and jury selections scheduled to start before April 10 are postponed until further notice. The courthouses will remain open for all other business. The clerk’s office is closed to the public until further notice, and all manual court filings can be made at a designated box in the entrance lobby of each courthouse.

The court is also prohibiting visitors who have been to China, South Korea, Japan, Italy, Iran, or any locale that is quarantined in the past two weeks. The court specified that those who have visited New Rochelle, New York — other than in a car or train — are also prohibited from visiting courthouses and probation offices.

All scheduled hearings and conferences in the district’s bankruptcy court will be conducted by telephone, unless the matter is withdrawn, resolved, postponed or the court determines the proceeding is not necessary.

In the state court system, all civil and criminal jury trials are suspended. The courts will only schedule and hear certain high-priority matters. The Connecticut Supreme Court postponed oral arguments in cases scheduled to have been heard between March 24 and April 2. The Supreme Court and Appellate Court have suspended the time requirements for all filings until further notice and have requested that no paper briefs be filed until further notice. On March 13, the court ruled that no appellate preargument conferences will be held for the next 30 days.

Delaware
In the District of Delaware, the J. Caleb Boggs U.S. Courthouse and Federal Building  in Wilmington is closed until further notice. All civil and criminal jury selections and trials scheduled to begin before April 30 are postponed until further notice. Sitting grand juries are authorized to continue to meet, but no new grand juries will be empaneled before April 30. All changes of plea, sentencings and supervised release violation hearings scheduled before April 30 are postponed unless otherwise ordered by the presiding judge.

Attorneys are asked to inform the appropriate court if they have appeared in court and have since developed symptoms or tested positive for the coronavirus and to inform the courts about any scheduled proceedings that will require the attendance of a person who has tested positive for coronavirus or has been in contact in the past 14 days with a person who has tested positive for coronavirus.

Also, the courts will conduct conferences and hearings by phone when possible and will consider any request to change a scheduled in-person proceeding to a telephone proceeding.

The Delaware Bankruptcy Court has halted all nontime-sensitive proceedings until at least April 15. Unless otherwise ordered by the presiding judge, all court hearings held prior to April 15 will be held via telephone or video conference.

In the Delaware Chancery Court, all hearings and trials will be conducted remotely for 30 days beginning March 16.

The Delaware Supreme Court canceled all in-person oral arguments through May.

All state trial courts will have the discretion to postpone for 30 days both civil and criminal trials and hearings. Proceedings will be conducted by telephone when possible and the court will consider all requests for in-person hearings to be conducted by phone. Attorneys and self-represented parties scheduled for trial must notify the court if the trial will require the attendance of a person who has tested positive for coronavirus or has been in contact in the past 14 days with a person who has tested positive for coronavirus.

Florida
In the Florida Southern District Court, all jury trials scheduled to begin March 16 through March 30 are postponed until further notice. All trial-specific deadlines in criminal cases scheduled to begin before March 30 are also postponed until further notice. All grand jury sessions are postponed until April 27.

Court security officers are screening people who enter the federal courthouse and denying entry to anyone who has recently visited Italy, Iran, South Korea or China. Anyone who resides with or has had recent close contact with someone who has traveled to one of those countries, has been asked to self-quarantine, has tested positive for the coronavirus or had contact with someone tested positive also will not be able to enter any of the federal courthouses in the district.

In the Middle District of Florida, those with symptoms of COVID-19 and those who may have been exposed to the coronavirus are prohibited from entering any courthouse. All jury trials in the Orlando Division scheduled to begin before June 30 are postponed, as are all trial-specific deadlines in criminal cases scheduled to begin before June 30.

In the Northern District of Florida, jury trials and grand jury proceedings have been canceled for the month of March, and naturalization ceremonies have been canceled for the months of March and April. Proceedings will be held remotely when possible.

In the state court system, the Florida Supreme Court ruled that all grand jury proceedings, jury selection proceedings, and criminal and civil jury trials are suspended through April 17. Proceedings that already began may continue if the presiding judge and chief judge determine it is required “by the interests of justice.” All time periods involving the speedy trial procedure in criminal and juvenile court proceedings are suspended through April 20. Time periods for those charged with first-degree murder are suspended through April 17. The chief judges of each state Circuit Court were ordered to cancel or postpone nonessential court proceedings, unless the proceedings can be conducted remotely.

Georgia
The Northern District of Georgia said Wednesday it is denying entry to anyone who has visited China, South Korea, Japan, Italy or Iran in the past two weeks. The restriction also applies to those who have had close contact with someone who has visited those countries in the past 14 days, has tested positive for the coronavirus, been in contact with someone who has tested positive or been asked to self-quarantine by any hospital or health agency. Those denied entry may appear by teleconference with approval of the presiding judge.

In the Middle District of Georgia, no jury trials will be held for 60 days. Grand juries are not affected by the moratorium. All criminal hearings are canceled through May 16 except for certain proceedings, including initial appearances, arraignments and detention hearings. Those who have tested positive for the coronavirus or may have been exposed to the virus are prohibited from entering any courthouse.

In the Southern District of Georgia, only those with official court business will be admitted into the courthouse. Those who have symptoms of COVID-19, have tested positive for the coronavirus or may have been exposed to the virus are prohibited from entering the building. Any jury trials between March 17 and April 17 may be postponed. Grand juries will continue to meet. Criminal matters before magistrate judges will continue to take place as usual.

In the Georgia Supreme Court, filing deadlines are suspended through April 13. After that, attorneys will have the same amount of time to file their documents that they had when the court order went into effect on March 14. The court encourages attorneys to file briefs and other documents where practical, since the court is still working on cases.

The Georgia Supreme Court asked all attorneys, parties and other visitors to stay away from the court if they have a fever or symptoms of respiratory illness or if they have been exposed to anyone tested positive for the coronavirus or has the flu.

Guam
In the District of Guam, all jury selections and trials set to begin before April 26 are postponed until further notice. Criminal matters before the magistrate judge will proceed as usual. All grand jury proceedings are postponed to April 26, but the U.S. attorney may schedule proceedings for emergency or essential matters. All sentencing and revocation hearings scheduled to be heard on or before April 3, and any related deadlines, are postponed until further notice.

The court and the U.S. District Pretrial and Probation Office are closed to the public from March 20 through April 3. All naturalization ceremonies and noncourt-related events scheduled for March and April are canceled. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering the district court.

Hawaii
In the District of Hawaii, all civil and criminal trials scheduled to start between March 17 and May 3 are postponed. All civil hearings, including settlement conferences, scheduled for that time period will either be conducted remotely or taken off the court’s calendar. Nonessential criminal matters will be postponed to a date after May 3, but the court will continue to conduct initial appearances, arraignments, detention hearings and other time-sensitive matters. The court is generally closed to the public, but there is limited seating for in-person hearings, available by request.

The court is prohibiting those who have visited China, Iran, Italy, Japan and South Korea within the past two weeks from entering the courthouse, as well as those who have had contact with someone who has been in those countries, tested positive for the coronavirus, been in contact with someone who has been exposed to the virus or have been asked to self-quarantine.

In the state court system, all ongoing trials will be postponed to a date after April 30, as will civil trials and hearings. Criminal trials, grand jury proceedings and hearings will be postponed to a date after April 30 to the extent possible. In the courts of appeal, all oral arguments scheduled before April 30 will be rescheduled or the matter resolved without oral argument. Those who have symptoms or may have been exposed to the coronavirus are prohibited from entering judiciary facilities.

In the state court system, all in-person appearances for civil and criminal dockets are excused, except for emergency matters, child protection hearings, domestic violence hearings and evidentiary hearings in criminal cases. The state Supreme Court ordered that all civil trials, hearings and motions should be postponed and rescheduled for a later date unless the assigned judge finds the proceedings can be held remotely. Any civil trial or hearing currently in progress shall be postponed or completed at the discretion of the presiding judge.

Idaho
In the District of Idaho, all jury trials scheduled to begin on or before May 11 are postponed until further notice. All grand jury proceedings set to begin before May 11 are suspended. No in-person bankruptcy or civil proceedings will take place until further notice. Various criminal hearings before district judges will be postponed until after May 11, and all preliminary felony and post-conviction proceedings conducted by a magistrate judge will be conducted remotely.

The federal courthouse in Pocatello was closed until April 6 after a person working in the building tested positive for the coronavirus. All in-person evidentiary hearings in civil, criminal and bankruptcy cases scheduled before any judge in the Pocatello courthouse are postponed.

Those with symptoms of COVID-19 and those who may have been exposed to the virus are prohibited from coming to court.

In the state court system, all in-person appearances for civil and criminal dockets are excused, except for emergency matters, child protection hearings, domestic violence hearings and evidentiary hearings in criminal cases. The state Supreme Court ordered that all civil trials, hearings and motions be postponed and rescheduled for a later date unless the assigned judge finds the proceedings can be held remotely. Any civil trial or hearing currently in progress shall be postponed or completed at the discretion of the presiding judge. All criminal jury trials scheduled to be heard from March 26 through April 30 are postponed for at least 30 days.

Illinois
In the Northern District of Illinois, all civil case deadlines are extended by 21 days. Civil case hearings, trials and settlement conferences scheduled from March 17 through April 3 are canceled and will be rescheduled by the presiding judge on or after April 6. All criminal case proceedings in any division that can’t be postponed will be conducted in the Eastern Division by district judges serving in emergency capacity.

The court is still accessible for electronic filing and phone and video conferencing in emergency situations.

The court said on March 12 that all civil jury trials and jury selections scheduled to start before April 3 are postponed until further notice. Second chance reentry court proceedings, veterans treatment court proceedings and non-telephone settlement conferences scheduled before April 3 are also postponed. The courthouses will remain open for all other business, including criminal case proceedings, and grand juries will continue to meet.

The court suspended all mass public gatherings outside of court proceedings at the federal courthouses in Chicago and Rockford, Illinois, and limited deliveries to the court. Judges are encouraged to conduct proceedings by phone or video conference where practicable.

In the Central District of Illinois, all civil and criminal jury trials scheduled to begin before May 18 are postponed and will be rescheduled by the presiding judge. All petty offense proceedings are postponed and will be rescheduled by the presiding judge. All civil hearings, including settlement conferences, should be conducted by telephone or video conference. Criminal sentencing hearings and hearings on the revocation of supervised release are postponed until after May 18. Those who have symptoms or may have been exposed to the virus should contact the court before appearing.

In the Southern District of Illinois, all in-person civil matters are postponed until further notice. All civil case deadlines are extended by 30 days. Grand jury proceedings are unaffected. Only essential in-person criminal matters will occur. Any emergency hearing required before April 7 in a criminal case will be held remotely. Those who have tested positive for the coronavirus or may have been exposed to the virus are prohibited from visiting the courthouse. All scheduled bankruptcy hearings will be held by telephone.

For the Cook County Circuit Court, all matters are postponed for 30 days from their originally scheduled date, but some proceedings will continue, including certain criminal matters, juvenile detention hearings, temporary custody hearings and mental health hearings, among others. Discovery in civil matters will continue, and emergency civil hearings may be conducted in-person or remotely.

Indiana
In the Southern District of Indiana, all jury trials are postponed through May 1. All other civil court proceedings will continue, although they may be done remotely at the judge’s discretion. Naturalization ceremonies through May 1 are canceled. Those with symptoms and those who may have been exposed to the coronavirus are prohibited from visiting courthouses.

The Indianapolis Division, Terre Haute Division and New Albany Division are closed to the public as of March 18.

In the Northern District of Indiana, the Fort Wayne, Hammond, Lafayette and South Bend divisions, as well as the district’s bankruptcy court and probation office, are closed to the public. The court will conduct necessary proceedings remotely as ordered by the presiding judge in each case. Necessary criminal proceedings will continue to be held before magistrate judges unless the parties agree to postpone them. Those proceedings will be conducted remotely as much as possible.

The Indiana Supreme Court has tolled all deadlines for appellate filings through April 6. Various matters in the Circuit, Superior and Municipal courts have been tolled, including all laws and procedures setting time limits for speedy trials in criminal and juvenile proceedings; public health, mental health and appellate matters; judgments and other orders; and statutes of limitation. Those restrictions apply to the Indiana Tax Court as well.

Iowa
In the Northern District of Iowa, those who have tested positive for the coronavirus are prohibited from entering the courthouse, as are those who have been asked to self-quarantine, those experiencing symptoms and those who may have been exposed to the virus.

In the Southern District of Iowa, all civil and criminal jury trials set from March 16 to May 4 are postponed until further notice. Any further grand jury proceedings for the month of March are canceled.

In the state court system, any criminal trial that is not in progress is postponed and will be rescheduled for after April 20. All civil jury trials that haven’t started as of March 13 but were scheduled to begin before May 4 are postponed. All civil bench trials and other hearings set to start before May 4 are postponed until May 4 at the earliest or should be conducted by telephone, at the discretion of the judge. As of March 17, statutes of limitation for filing an action in district court are extended by 48 days.

The Iowa Supreme Court ordered that attorneys and parties notify their opposing counsel and appropriate clerk of court’s office if they suspect a participant in any proceeding has an elevated risk of transmitting the novel coronavirus. No one who has an elevated risk can attend any state court proceeding in person without court authorization. Attorneys must also ask their clients and witnesses whether they have an elevated risk of transmission, the order said.

Potential state court jurors must notify the jury manager if they have an elevated risk of transmitting coronavirus, and the jury manager must reschedule them to a new service term. The court said it will also promptly consider requests from parties to change in-person proceedings to remote proceedings.

Kansas
In the District of Kansas, all criminal cases and matters scheduled for nonemergency hearings are postponed until further notice. Grand jury proceedings are postponed for at least 30 days. Those who have tested positive for the coronavirus, have symptoms or were potentially exposed to the virus are prohibited from coming to court.

In the state court system, all civil and criminal jury trials scheduled to begin on or after March 18 are postponed until further notice. Trials in progress as of March 18 may continue to conclusion at the discretion of the presiding judge. All district and appellate courts will be restricted to emergency operations until further notice.

Kentucky
In the Eastern District of Kentucky, civil and criminal trials scheduled to begin on or before May 1 are postponed for at least 30 days. Grand jury proceedings will continue.

All currently scheduled hearings in criminal cases and in-person hearings in civil cases scheduled on or before May 1 are postponed, with some exceptions for emergency matters. All hearings in emergency matters will be conducted remotely “absent exceptional circumstances,” according to a district order.

In the Western District of Kentucky, civil and criminal trials scheduled to begin before April 17 are postponed for at least 30 days. All trials in progress will be completed at the discretion of the presiding judge. With certain exceptions, grand jury proceedings are also postponed.

In the state court system, all in-person appearances for civil and criminal dockets are canceled through April 24 except for emergency and time-sensitive matters. All scheduled civil trials, hearings and motions are postponed, and any civil trial or hearing currently in progress will be postponed or completed at the discretion of the presiding judge.

Louisiana
In the Eastern District of Louisiana, all civil and criminal bench and jury trials are postponed until May 1 and will be rescheduled by each presiding judge. The postponements do not include deadlines other than the trial dates. Civil and criminal in-person hearings scheduled before May 1 are postponed. All grand jury proceedings are suspended until May 1. The clerk’s office will not accept sealed paper documents for filing through May 1. All noncase-specific events, including naturalization ceremonies, scheduled before May 1 are canceled and will be rescheduled later.

The court is prohibiting those who have traveled to China, South Korea, Japan, Iran or Italy in the past two weeks from entering the New Orleans courthouse. The restriction also applies to those who have had close contact with someone who recently traveled to those countries, those who have tested positive for the coronavirus, those who have come into contact with someone who has tested positive, those who have been asked to self-quarantine and those with symptoms of COVID-19.

In the Middle District of Louisiana, all criminal and civil trials are postponed until at least May 1. All in-person civil hearings scheduled through April 10 are postponed and will be rescheduled by the presiding judge. All grand jury proceedings are postponed until further notice. Criminal matters before magistrate judges will take place remotely or in-person. Rearraignments and sentencing hearings scheduled before April 10 are postponed. Statute of limitations deadlines are interrupted until April 13. No in-person filings will be accepted before April 13. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from the courthouses.

In the Western District of Louisiana, all jury trials set to begin before May 1 are postponed and will be rescheduled by each presiding judge. Grand jury proceedings will continue. Judges may hold in-person hearings, and parties are encouraged to participate in nonsentencing hearings remotely. Noncase-related events scheduled through May 1, including naturalization ceremonies, are canceled. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from courthouses.

Public access to the Louisiana Western District Clerk of Court Offices in the Alexandria, Lafayette, Lake Charles, Monroe and Shreveport divisions is suspended. Any court filings may be time-stamped and placed in the drop box located in each division.

For state courts, all legal deadlines are suspended until at least April 13. All jury trials scheduled to start before April 13 are postponed until at least April 14. All civil trials, hearings and court appearances scheduled before April 13 are postponed, except for certain emergency proceedings. Essential court functions will be conducted remotely when possible.

Maine
In the District of Maine, all jury selections and jury trials set to begin before any district or magistrate judge are postponed until further notice. All grand jury proceedings are also postponed until further notice.

Public access to scheduled hearings will be permitted only with the prior permission of the presiding judge. The clerk’s office will be open by appointment only. In-person court proceedings are limited to, among other things, certain criminal matters; the issuance of search warrants; motions seeking immediate, emergency relief; and essential administrative functions.

In the state court system, the courts will schedule and hear only certain proceedings, including arraignments and first appearances of defendants held in custody; requests and hearings related to protection from abuse; child protection petitions and hearings; and hearings granted on motion. Other proceedings will not be scheduled or heard before May 1, and all previously scheduled cases are postponed.

Maryland
The District of Maryland has postponed until further notice all civil and criminal jury selections scheduled to begin before April 24. All nonemergency proceedings are postponed through April 24, and all filing deadlines between March 16 and April 24 are extended by six weeks. The court will remain open for emergency criminal, civil, and bankruptcy matters related to public safety, public health and welfare, and individual liberty. All misdemeanor, traffic and petty offense proceedings scheduled through May 31 are postponed until further notice.

As of March 31, all in-court proceedings will be heard on Mondays, Wednesdays or Fridays unless a presiding judge orders otherwise. Emergency proceedings may be heard on Tuesdays or Thursdays when necessary.

As of March 27, the requirement to deliver paper courtesy copies to the clerk’s office is temporarily suspended, unless otherwise ordered by a presiding judge.

All in-court proceedings in the Southern Division U.S. Courthouse in Greenbelt, Maryland, are suspended until further notice. All emergency matters in the Southern Division will be heard in the U.S. Courthouse in Baltimore.

Courthouse access is limited to litigants with scheduled proceedings, counsel, investigators or employees of counsel and credentialed press. The court is also prohibiting those who have visited China, Iran, Italy, Japan, South Korea, Egypt, Washington State and New Rochelle, New York, within the past two weeks from entering the courthouse, as well as those who have had contact with someone who has been in those areas, tested positive for the coronavirus, been in contact with someone who has tested positive or have been asked to self-quarantine.

On the state side, the Court of Appeals has ordered that all courts in the Maryland Judiciary, court offices, administrative offices, units of the judiciary, and clerk’s offices of the Circuit Courts are closed to the public on an emergency basis, effective March 16. Certain matters scheduled to be heard between March 16 through April 3 are postponed until further notice.

Massachusetts
The Massachusetts District Court announced that while the courthouses in Boston, Worcester and Springfield will remain open, all jury trials scheduled to begin before April 27 are postponed until further notice.

The court said that while trial-specific deadlines before April 27 in criminal cases are also postponed, judges can delay trial-specific deadlines for civil cases at their own discretion. Individual judges can continue to hold hearings, conferences and bench trials if they want, but the court is encouraging them to do so by telephone or video conference.

The court will continue to hold criminal proceedings involving personal liberty or public safety issues. Other criminal proceedings will be postponed 60 days as of March 16 with exceptions for certain proceedings, including initial appearances, detention hearings and arraignments. Those proceedings may be conducted remotely when feasible. Pretrial deadlines are also extended by 60 days. Grand jury proceedings are postponed until April 27.

The court is prohibiting visitors who recently traveled to China, Italy, Japan, Iran and South Korea from entering any courthouse or probation office in the district. Those who have had close contact with someone who visited those countries — as well as those who have symptoms of COVID-19, have tested positive for the virus or have been instructed by a doctor to self-quarantine — are also prohibited from visiting.

In the state court system, the only in-person proceedings that will be held in state courthouses through at least April 6 are emergency matters that can’t be handled remotely. Only essential parties can enter courthouses, and only up to three members of the news media will be allowed in for an emergency in-person proceeding. All civil and criminal jury and bench trials scheduled to begin before April 17 are postponed until at least April 21, unless the proceeding is a civil bench trial that can be conducted remotely. All statutes of limitation are tolled through April 21. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any state courthouse.

The state appeals court has ordered that all cases scheduled for oral argument during the remainder of March will be held by telephone.

Michigan
The Eastern District of Michigan is prohibiting people who have visited China, South Korea, Italy and Iran in the last two weeks from entering any district courthouse until further notice. All civil and criminal matters scheduled for in-person appearances are postponed until further notice, as are grand jury proceedings. Case-by-case exceptions to postponements may be ordered for nonjury matters. Criminal matters before magistrate judges will continue to take place as usual.

The Theodore Levin U.S. Courthouse in Detroit closed to the public on March 25, and will remain closed to the public until the building owner can clean the courthouse according to federal guidelines. The district announced on March 27 that 10 court security officers showed COVID-19 symptoms, four were hospitalized, and two tested positive for the virus.

In the Western District of Michigan, judges will handle matters remotely as much as possible. All facilities in the district are closed to public access through April 13, except for the Ford Building in Grand Rapids and the Marquette Facility. Those facilities will be open by appointment only.

The district is also prohibiting: those who have had close contact with someone who has visited those four countries, have recently traveled to U.S. areas with widespread community transmission of the coronavirus, have been asked to self-quarantine, have tested positive for  the virus or who exhibit the symptoms of COVID-19.

In the state court system, trial courts are limiting courtroom access to no more than 10 people at a time, including staff. The courts are practicing social distancing and limiting court activity to essential functions. All criminal jury trials are adjourned until after April 3. Most civil and business court matters, including trials, will be conducted remotely or adjourned until after April 3.

Minnesota
All criminal and grand jury proceedings are postponed until April 16. All jury trials are postponed through April 27, as are trial-specific deadlines. The clerk’s office intake desks will not accept cash payments, and the requirement that the filing party provide courtesy copies to the judge hearing the motion is suspended through April 27. The clerk’s office intake desks in Minneapolis, St. Paul, Duluth and Fergus Falls are closed to the public until further notice.

Video conferencing and telephone conferencing are allowed for several types of proceedings, including detention hearings, initial appearances, arraignments, felony pleas and felony sentencings.

The District of Minnesota is prohibiting those who have visited China, Iran, Italy and South Korea within the past two weeks from entering the courthouse, as well as those who have had contact with someone who has been in those countries, tested positive for the coronavirus, been in contact with someone who has tested positive or been asked to self-quarantine.

In the state court system, appellate courts can grant extensions for deadlines to initiate appeals or requests for review up to 30 days. The appellate courts may determine for any case that oral argument is unnecessary. In district courts, trials that have started as of March 13 will continue unless there is a need to suspend them. No new jury trials will begin before April 22 or until further order of the Minnesota Supreme Court. Public access to courtrooms will be limited.

Mississippi
In the Northern District of Mississippi, all proceedings should be conducted remotely where possible. For petty offenses, the hearing dates set to address misdemeanor citations in April and May will be continued until June and July, respectively. The cases set for the March hearing date will be disposed of at the discretion of the presiding judge. Public access to courthouses is limited to essential business.

In the Southern District of Mississippi, all nonessential matters set for hearing or trial through March 31 are postponed until further notice. Those who have symptoms or have tested positive for the coronavirus must notify the judge and counsel involved if they intend to come to court.

In the state court system, courts are limiting in-person contact through remote proceedings. When remote proceedings are not feasible, the court will conduct certain in-person proceedings, including jury trials currently in progress, emergency child protection matters, and other emergency and time-sensitive matters. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering state courts.

Missouri
In the Eastern District of Missouri, all civil and criminal jury trials scheduled to begin before May 31 are postponed. Proceedings should be held remotely where possible. In-person proceedings that a presiding judge determines are nonessential will be postponed until further notice. Naturalizations are postponed through April 6.

Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from visiting any courthouse. All requirements related to in-person participation in alternative dispute resolution are suspended until May 31.

In the Western District of Missouri, all civil and criminal jury trials and grand juries are postponed through March 29, and trial-specific deadlines are postponed through the same date. All nonemergency criminal and civil hearings are postponed through March 29. Criminal matters before magistrate judges will continue to take place. Bankruptcy hearings and trials through March 29 will be held remotely or postponed.

In the state court system, all in-person proceedings are suspended through April 17, except for certain emergency and essential proceedings. Judges in each Circuit and appellate court will determine how the in-person proceedings are carried out.

Montana
In the District of Montana, all jury trials set to begin on or before May 1 are vacated, to be reset by order of the presiding judge. The order does not vacate any pending deadlines other than trial dates and final pretrial conferences. Grand jury proceedings are also vacated through May 1. Individual judges may hold nontrial proceedings in-person or remotely at their discretion. Group tours, attorney admission ceremonies and naturalization ceremonies are canceled through May 1. Continuance of creditors meetings in bankruptcy court will be suspended through April 16. Section 341 meetings will be postponed or conducted remotely. The court will not accept cash payments until further notice.

In the state court system, the Montana Supreme Court recommended that judges in district courts, the Montana Water Court and courts of limited jurisdiction reset civil jury matters through April 30 at the earliest. Judges should conduct necessary matters remotely whenever possible, the Supreme Court recommended. Priority must be given to necessary work in criminal matters, requests for orders of protection, and child abuse and neglect proceedings, the court said.

Nebraska
All jury trials set to begin in March are postponed until further notice, as are all grand jury proceedings scheduled for the month of March. The District of Nebraska has ordered that those who have recently visited China, South Korea, Japan, Italy or Iran should not attend in-person proceedings without court authorization.

The restriction also applies to those who have had contact with someone who has been in those countries, have tested positive for the coronavirus, been in contact with someone who has tested positive, have been asked to self-quarantine or exhibit symptoms of an infectious respiratory illness.

Nevada
In the District of Nevada, all trials and their associated deadlines are postponed until April 10. All noncase events are postponed. Naturalization ceremonies through March are postponed. The court is trying to conduct hearings remotely whenever possible. The clerk’s office is closed to the public as of March 20, but all filing deadlines are still in effect unless otherwise ordered by the presiding judge.

Those who have tested positive for the coronavirus, may have been exposed to it or show symptoms of COVID-19 are prohibited from visiting any courthouse.

In the district’s bankruptcy court, all hearings will be conducted remotely.

In the state court system, the Nevada Supreme Court and appellate courts have postponed all oral arguments until further notice.

New Hampshire
The New Hampshire District Court has postponed all civil and criminal jury trials scheduled to begin before May 1 and all grand jury proceedings scheduled before May 1. All criminal hearings scheduled before April 13 are postponed. All civil hearings and conferences scheduled to occur after March 20 will be conducted remotely. The court will conduct in-person hearings at the Rudman Courthouse in Concord on Tuesdays and Thursdays, with certain restrictions regarding the number of people who can be in a courtroom.

The court has also canceled all naturalization events that were scheduled before May 1.

Prospective jurors experiencing any flu-like symptoms, coughing, sneezing or fever should contact the district court before appearing. The court said it will make reasonable accommodations and reschedule appearances and hearings as needed.

In the state court system, all in-person proceedings in the Circuit, Superior and Supreme courts are suspended through April 6. Exceptions include certain emergency and essential proceedings.

New Jersey
For the New Jersey District Court, all civil and criminal jury selections and trials scheduled to begin before April 30 are postponed until further notice. Judges can continue to hold proceedings at their discretion and are encouraged to conduct proceedings remotely. No new grand juries will be empaneled before April 30, but sitting grand juries may continue to meet. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any district courthouse.

Both district courthouses in Newark were closed from March 26 through April 6 after several employees tested positive for the coronavirus. No one is permitted to enter the buildings during the closure except for authorized cleaning staff.

For New Jersey state courts, new jury trials are suspended until further notice. Proceedings will be conducted remotely where possible. Time constraints for discovery will be relaxed and extended from March 16 through March 30. Pending motions will be subject to telephone conferencing as of March 18. All municipal court sessions are suspended through March 27.

Schedules for nonjury proceedings such as landlord-tenant and small claims hearings will be staggered to prevent large groups of people from gathering in a confined area. Out-of-state travel has been suspended for staffers, and nonessential court events like student tours have been canceled.

New Mexico
The District of New Mexico postponed all civil and criminal jury trials set to begin on or before April 10 until further notice. It also postponed all trial-specific deadlines in criminal cases scheduled to begin before April 10. All grand jury proceedings are postponed until further notice.

In the state court system, no more than 15 people will be allowed in each courtroom. Judges must conduct civil and criminal proceedings remotely except when an emergency requires an in-person appearance. Civil and criminal jury trials that have not started yet are suspended, and payment deadlines for fines and fees between March 19 and May 29 are extended by 30 days.

New York
The Southern District of New York has postponed until further notice all civil and criminal jury trials that were scheduled to begin before April 27. While case-related activities and naturalizations will continue, other noncase activities such as Continuing Legal Education events and school visits are canceled until further notice. All bankruptcy hearings and conferences scheduled to be held in the courthouses of the Manhattan Division, White Plains Division and Poughkeepsie Division of the bankruptcy court will be conducted by telephone unless the presiding judge decides otherwise.

The court urges= counsel to check individual judges’ webpages for possible orders, including orders extending time in civil matters and adjourning conferences.

The Thurgood Marshall Courthouse in Manhattan is closed for all district activities, except grand jury matters, through at least April 11. The Daniel Patrick Moynihan Courthouse in Manhattan is open only for certain urgent matters.

The Southern District is prohibiting those who have visited China, Italy, Iran, Japan or South Korea along with a slew of European countries, according to signs posted at courthouse entrances on March 12. The Eruropean countries are Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Vatican City, Iceland, Liechtenstein, Latvia, Lithuania, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Sweden, Switzerland, San Marino and Spain.

The court is also barring those with a fever, cough or shortness of breath, and the executive office in that district will not be issuing new attorney service passes until further notice. Access to courthouses is restricted to certain groups, including those with official court business, courthouse employees, certain contractors, mail carriers, law enforcement, credentialed press, family members of criminal defendants and jurors in ongoing trials.

In bankruptcy court, debtors with Chapter 13 cases before Chief Judge Cecelia G. Morris and Judge Sean H. Lane are waived from in-person court appearances. Attorneys and unrepresented debtors who are showing signs of illness must adjourn their cases. The contact for Judge Morris is Vanessa Ashmeade, (845) 451-6367. The contact for Judge Lane is Arturo Tavarez at (914) 467-7094.

The Eastern District of New York has postponed until further notice all civil and criminal jury trials that were scheduled to begin before April 27. All naturalization ceremonies are suspended for 45 days, as of March 16. All petty offense proceedings scheduled to begin before April 27 are postponed until further notice. In-person attorney admission ceremonies at all courthouses are suspended until further notice. For all criminal matters that had preliminary hearings before magistrate judges scheduled for March 18 through April 27, preliminary hearing deadlines are extended 60 days after the initial appearance.

The district is allowing video or telephone conferencing for several types of proceedings, including detention hearings, initial appearances and arraignments.

Access to court buildings is restricted to “those whose presence is essential,” according to an order. The court is prohibiting those who have traveled to China, Italy, Iran, Japan or South Korea and a slew of European countries in the past two weeks. Also prohibited are those who have come into close contact with anyone who has traveled to those countries within the past two weeks, have been asked to self-quarantine, tested positive for the coronavirus or have come into contact with someone who has tested positive.

In the Northern District of New York, all civil and criminal jury selections and trials — including for grand juries — scheduled to begin through April 30 are postponed until further notice. Other criminal matters before magistrate judges will continue to take place as usual. All mass public gatherings, including naturalization ceremonies, are suspended. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any courthouse.

In the Western District of New York, all civil jury trials and grand jury selections are postponed for 60 days as of March 16. The court encouraged judges to reduce personal appearances for all other proceedings as much as they can. No naturalization ceremonies will be conducted for 60 days as of March 16. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any courthouse.

For state courts, new civil and criminal jury trials will be suspended starting on March 16. Jury selection will also be halted, and grand juries will not be empaneled “absent exceptional circumstances,” although current grand juries will remain on duty along with some trial jurors. An executive order from Gov. Andrew Cuomo tolled all proceeding deadlines through April 19. No nonessential filings, paper or electronic, will be accepted by the courts until further notice. New York City Criminal Court will start holding proceedings through videoconferencing on March 25 and New York City Family Court will start holding remote proceedings on March 26.

New York state announced on March 11 that it is prohibiting anyone who has traveled to China, South Korea, Japan, Italy or Iran in the past 14 days from its 350 state-run courthouses.

Also banned from state courts are people who live with or have come into close contact with anyone who has been in one of those countries during that period, been asked to self-quarantine, and those who have either tested positive for the coronavirus or come into contact with someone who has tested positive.

The U.S. Court of International Trade in Manhattan is prohibiting entry to those who have visited China, Italy, Iran or South Korea in the past two weeks, as well as those who have been asked to self-quarantine. The restriction also applies to those who have tested positive for the coronavirus or have come into close contact with someone who has tested positive. The court is allowing teleconferencing and video conferencing with the approval of a presiding judge.

North Carolina
In the Eastern District of North Carolina, all civil and criminal jury trials set to begin on or before May 1 are postponed until further notice. All other hearings are subject to the presiding judge’s discretion. Grand jury proceedings will continue as usual, until further notice. Parties are encouraged to participate in proceedings remotely. Noncase events scheduled before May 1 are canceled. Those who have tested positive for the coronavirus, have symptoms of COVID-19 or may have been exposed to the virus are prohibited from visiting any courthouse without permission from the chief judge.

In the Middle District of North Carolina, all civil trials scheduled to begin before April 16 are postponed until further notice. All criminal cases are postponed to a date on or after April 16. Grand jury proceedings scheduled for March are canceled. Only those with official business are permitted to enter the district’s courthouses unless they have prior permission from the chief judge. Those who have tested positive for the coronavirus, have symptoms, or may have been exposed to the virus are prohibited from visiting any courthouse without permission from the chief judge.

In the Western District of North Carolina, judges are staggering their hearings, and hearings will be held in the largest courtroom available. Nonevidentiary hearings should be conducted remotely where possible.

In the state court system, the filing deadlines for documents previously due between March 16 and April 17 are extended to the end of the day on April 17. The order does not apply to the appellate courts. All civil and criminal District and Superior Court matters are postponed unless they are essential for constitutional or public safety reasons.

North Dakota
In the District of North Dakota, all jury trials scheduled before April 10 are postponed, as are trial-specific deadlines. Trial-specific deadlines in civil cases remain but may be postponed by individual judges. Criminal matters before magistrate judges will take place as usual. Grand jury proceedings scheduled through April 21 are postponed.

The North Dakota Supreme Court suspended all state jury trials until after April 24, but state courts are holding nonjury proceedings to the extent possible.

Northern Mariana Islands
In the District of the Northern Mariana Islands, all scheduled civil and criminal jury selections and trials are postponed until further notice. All grand jury proceedings are postponed unless otherwise ordered by the chief judge. The schedule for all other civil and criminal hearings will be determined on a case-by-case basis by the presiding judge. All noncase proceedings, including naturalization ceremonies, are postponed. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering the courthouse.

Ohio
In the Southern District of Ohio, certain in-court proceedings will continue but on a limited basis. The court will not have additional jury trials for 30 days beginning March 17. Proceedings that don’t require in-person meetings will continue at the discretion of each judge. Naturalization ceremonies are postponed until at least April 13.

In the Northern District of Ohio, all civil jury trials, reentry court proceedings and petty offense proceedings scheduled to begin before May 1 are postponed until further notice. Criminal trials will not proceed unless absolutely necessary, and grand juries will not meet unless absolutely necessary. Judges may conduct pretrial proceedings remotely where practical. All mass public gatherings, including naturalization ceremonies, are suspended until at least May 1. All courthouses in the district are closed to the public until May 1. Cash payments will not be accepted in the court until May 1.

The Ohio Supreme Court has provided guidance for state courts, including waiving appearances for pretrial hearings and using video conferencing or other technology to conduct proceedings including arraignments, hearings, pretrial hearings and probation meetings.

Oklahoma
In the Northern District of Oklahoma, all civil and criminal matters scheduled for in-court appearances are postponed until further notice, as are their related deadlines. All grand jury proceedings are postponed until further notice. Case-by-case exceptions to nonjury matters may be ordered. Civil and criminal motions that can be resolved without oral argument are unaffected.

In the Western District of Oklahoma, jury trials on the April docket are postponed. The presiding judge will address trial-related deadlines. Three grand jury sessions scheduled for March and April are canceled.

In the Eastern District of Oklahoma, all jury trials, grand jury sessions and naturalization ceremonies scheduled to start on or before April 17 in the Ed Edmondson Federal Courthouse in Muskogee are postponed. Those who have COVID-19 symptoms, have tested positive for the coronavirus or may have been exposed to the virus are prohibited from entering the courthouse.

On the state side, the Oklahoma Supreme Court and Court of Criminal Appeals ordered on March 16 that all state courts cancel all jury terms for 30 days and release jurors from service. All deadlines in any civil, criminal and juvenile cases are also suspended for 30 days. The statute of limitations is extended by 30 days in all civil cases, and judges will handle emergency matters and required proceedings on a case-by-case basis. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any courtroom or other facility used by the state courts.

Oregon
In the District of Oregon, civil and criminal jury selections and trials scheduled to begin before April 26 are postponed until further notice. All grand jury proceedings scheduled before that date are postponed. All other civil and criminal matters scheduled for an in-court appearance before April 26 are postponed unless they can be resolved remotely or without oral argument. The District Clerk’s Office is closed to the public in all locations but available by phone. Filings will be processed electronically and by mail.

In the state court system, trials and hearings scheduled to start between March 19 and March 27 are postponed, with limited exceptions. The Oregon Court of Appeals has canceled oral arguments scheduled between March 17 and March 27. Trial courts throughout the state are reducing the number of people summoned as jurors. Potential jurors who are in high-risk categories for severe illness can contact the court to reschedule their jury service.

Pennsylvania
In the Eastern District of Pennsylvania, all civil and criminal jury trials and grand jury selections are postponed until April 13.

In the Western District of Pennsylvania, all civil and criminal jury trials and grand jury selections are postponed until April 26.

In the Middle District of Pennsylvania, all hearings and proceedings in civil and criminal cases are postponed for 60 days as of March 13, with exceptions for certain individual cases.

The Supreme Court of Pennsylvania ordered all trial and intermediate appellate courts, with exceptions for certain essential functions, to close their doors entirely through April 3 at the earliest. The state Supreme Court’s argument session scheduled for April 20 through April 22 is canceled, and cases listed for that session will be decided on the briefs.

Puerto Rico
In the District of Puerto Rico, all civil and criminal nonjury trials, hearings and conferences are postponed until further notice, but certain ongoing trials will continue. Grand jury proceedings will continue as scheduled. All deadlines set from March 16 through April 9 are extended until April 10.

The bankruptcy court will not be open to the public through March 30. All hearings scheduled from March 16 through March 30 are postponed and will be rescheduled individually.

Rhode Island
In the District of Rhode Island, the courthouse building at One Exchange Terrace, Providence, is closed to the public until further notice. The court operations in the John O. Pastore Building in Providence will be closed Tuesdays and Thursdays and will be open for limited purposes only on Mondays, Wednesdays and Fridays. The presiding judge’s case manager will cancel all in-person civil matters and arrange remote hearings where possible. All grand jury proceedings and ongoing criminal hearings are postponed unless the person’s liberty interests are involved.

Those who are required to appear in Rhode Island’s district court, including those who are called as jurors, must contact the court before appearing if they are experiencing any flu-like symptoms. Those who have traveled to China, Italy, Iran and South Korea in the past two weeks are prohibited from entering the courthouse, as are those who may have been exposed to the virus.

In the state court system, all Superior Court jury trials are postponed until after April 17. All Superior Court grand jury proceedings are suspended until after April 17. All other matters in the state courts are postponed until after April 17 except for emergency and essential matters. All payment dates and filing deadlines are extended for 30 days as of March 17. The courts will entertain requests for extensions to statutes of limitation after the 30 days if they arise from the current health crisis.

South Carolina
In the District of South Carolina, all civil and criminal jury selections and trials scheduled to start through May 8 are postponed until further notice. All grand jury proceedings scheduled through May 8 are postponed unless otherwise noted by the chief judge. In all civil cases, deadlines are extended 21 days, but statutes of limitation are not tolled. All other civil and criminal matters scheduled for an in-court appearance before May 8 and their associated deadlines are postponed, unless the matter can be resolved remotely.

In the state court system, all oral arguments scheduled before appellate courts as of March 20 are canceled until further notice. Parties do not need to file additional document copies with the South Carolina Supreme Court or the Court of Appeals. In the Circuit Courts, only emergency hearings shall be held at the discretion of each chief administrative judge. All jury trials are postponed, and all large gatherings are canceled until further notice. Hearings that can be held by video may be held remotely.

South Dakota
In the District of South Dakota, all civil and criminal jury trials scheduled to begin on or before April 24 are postponed until further notice. Nonjury matters will proceed as scheduled unless otherwise ordered by the presiding judge, and parties are encouraged to participate remotely where possible. All grand jury proceedings scheduled before April 24 are postponed until further notice.

The South Dakota Supreme Court declared a judicial emergency and authorized the presiding judges of the state’s seven judicial circuits to adopt rules and orders regarding court operations. Each circuit put forward policies to address requests from high-risk individuals to be excused from in-person court appearances.

Tennessee
In the Eastern District of Tennessee, civil and criminal jury trials set to begin on or before April 24 are postponed. Cases not scheduled for a trial will proceed as scheduled, but oral proceedings will be conducted remotely where possible. Grand jury proceedings in Greeneville and Chattanooga are suspended through April 24. All misdemeanor, petty offense and traffic dockets scheduled through April 24 are postponed. Tours and naturalization ceremonies are canceled until further notice.

In the Western District of Tennessee, all civil judicial proceedings currently scheduled are postponed until after April 17. Criminal proceedings that don’t require in-person appearances are postponed until after April 17. All civil and criminal jury selections and trials scheduled to begin on or before April 17 are postponed until further notice. All grand juries already selected will not meet until after April 17. The federal courthouse at 111 S. Highland Ave. in Jackson is closed to the public until further notice.

The Middle District of Tennessee has postponed civil and criminal jury selections that were scheduled to begin March 17 through March 30. All grand jury proceedings scheduled to take place between March 17 and April 30 are postponed, as are related deadlines.

Tennessee’s state and local courts have suspended all in-person proceedings from the close of business on March 13 through April 30, with certain exceptions including: bond-related matters for criminal defendants, plea agreements for incarcerated people, civil and criminal jury trials that are in progress as of March 13, and proceedings related to relief from abuse, emergency child custody orders, petitions for temporary injunctive relief, emergency mental health orders, emergency protection of elderly or vulnerable people and proceedings related to COVID-19.

Deadlines — including statutes of limitations, orders of protection and temporary injunctions — that are set to expire between March 13 and May 5 are extended through May 6.

Texas
The Northern District of Texas has postponed all civil and criminal bench and jury trials scheduled to begin through May 1 until further notice. The postponement does not include other deadlines besides the trial date. All grand jury proceedings through May 1 are postponed, and all deadlines, including the statute of limitations, are suspended through May 1. Public tours and naturalization ceremonies scheduled through May 1 are canceled and will be rescheduled later.

The Southern District of Texas said Thursday that it is suspending all jury trials until April 1. The federal courthouse in Houston will remain open for other matters, including matters scheduled for hearing in bankruptcy court, the district said.

In the Eastern District Court, attorneys and parties were ordered to communicate if court proceedings could cause someone to come into contact with an individual exposed to or infected with the virus.

The Western District of Texas postponed all civil and criminal bench and jury trials scheduled to begin before May 1. Each presiding judge will reset those dates, and the postponement does not apply to any pending deadlines other than the trial dates. Grand jury matters will proceed normally. Parties are encouraged to participate in nonsentencing proceedings by telephone or video. Other matters such as tours and naturalization ceremonies that were scheduled to take place before May 1 are canceled.

The Western District of Texas postponed scheduled proceedings in all civil and criminal bench and jury trials set to begin before May 1, with the exception of pleas, sentencings, criminal matters before magistrate judges and the issuance of warrants. All deadlines in a scheduling order, besides the trial date, remain in effect unless modified by the assigned judge. Parties are encouraged to participate in nonsentencing proceedings by telephone or video. Other matters such as tours and naturalization ceremonies that were scheduled to take place before May 1 are canceled.

On the state side, the Texas Supreme Court issued guidance Thursday calling on courts to suspend proceedings or schedule them to avoid gatherings of large groups of people until at least April 1, including jury trials and large docket calls. It is encouraging courts to implement remote appearances by phone or video for all proceedings that may occur remotely.

The Harris County Civil District Court, serving the Houston area, has suspended civil jury trials for the rest of March and has suspended criminal jury trials through March 20.

Dallas County has canceled all jury trials through May 8.

Collin County District Courts are rescheduling all nonessential court matters from March 16 to April 1. All in-person hearings and trials will be rescheduled during this time, unless designated as “essential,” a list that includes temporary restraining orders, temporary injunctions and any suits or hearings with jurisdictional deadlines. Attorneys must contact each court regarding each setting. No uncontested matters will be heard. The courts are developing a plan for electronic appearances.

U.S. Virgin Islands
In the District of the Virgin Islands, all civil and criminal jury and bench trials scheduled from March 18 through April 16 are postponed until further notice. Sitting grand juries are not authorized to meet before April 16, and no new grand juries will be empaneled during that time. The 30-day time period for filing an indictment is tolled through April 16. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from visiting the courthouses.

The Supreme Court of the Virgin Islands ordered that all nonessential functions of the judicial branch be suspended until further notice. In the Supreme Court, deadlines in appeals pending as of March 20 are extendedeither by 14 days or to April 27, whichever is longer. Deadlines in original proceedings, such as for mandamus or other writs, are still in effect unless the presiding judge has ordered otherwise. The time to file a notice of appeal or other initiating document is tolled through April 26, and the period from March 23 through April 26 is excluded from the 120-day period for the Superior Court to rule on post-judgment motions.

In the Superior Court, all deadlines in cases pending as of March 20 are extended either by 14 days or to April 27, whichever is longer. All previously scheduled depositions may occur as scheduled, and new depositions may be scheduled, but parties are encouraged to agree to postpone depositions if possible.

Utah
In the District of Utah, all civil and criminal jury trials scheduled to begin before May 1 are postponed until further notice. All trial-related deadlines in criminal trials scheduled to begin before May 1 are postponed until further notice, but criminal trials already underway as of March 16 will continue. Judges can postpone trial-related deadlines in civil cases at their discretion. All grand jury proceedings are suspended through May 1.

All currently scheduled hearings in criminal cases are postponed, but the assigned judge in each case may proceed with the hearings remotely.

In the state court system, those with symptoms of COVID-19 and those who may have been exposed to the coronavirus are not allowed to enter any courthouse. The Utah Supreme Court directed state court judges to grant motions for extensions of time liberally. Hearings will be conducted remotely or on the papers, “absent exigent circumstances,” according to the state Supreme Court’s order. District Court and Justice Court judges were directed to suspend all criminal and civil jury trials until after June 1.

Vermont
In the District of Vermont, all civil and criminal matters scheduled for in-person court appearances are postponed until further notice. The court’s order does not affect motions that can be resolved remotely or without oral argument. All grand jury proceedings are postponed until April 23.

In the state court system, all nonemergency superior court hearings, including jury trials, are postponed until at least April 15. The courts will only schedule and hear certain emergency matters. Parties may participate in nonevidentiary proceedings remotely.

Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering state courthouses.

Virginia
In the Eastern District of Virginia, all civil and criminal proceedings scheduled to occur through March 31 are postponed and will be rescheduled for a later date. The grand jury is not meeting, but the district is permitted to seek documents and testimony for return dates after March 31. All filing deadlines between March 17 and March 31 are extended by two weeks unless otherwise ordered by the presiding judge. The court’s order does not apply to the statute of limitations.

The Eastern District of Virginia has postponed all naturalization ceremonies for the remainder of March and has suspended all noncase-related events, tours and other gatherings in the courthouses.

In the Western District of Virginia, all in-person civil, criminal and bankruptcy proceedings scheduled on or before May 1 are postponed and will be rescheduled at a later date. All civil and criminal jury trials scheduled on or before May 1 are postponed and will be rescheduled. All misdemeanor, traffic and petty offense dockets on or before May 1 are postponed, and all Veterans Treatment Court, Reentry Court and Drug Treatment Court sessions on or before May 1 are canceled. Grand jury proceedings scheduled on or before April 17 are postponed.

In the state court system, the Virginia Supreme Court and Rose Lafoon Building in Richmond are closed to the public until further notice. All filings related to appeals to the Court of Appeals that are filed in a Circuit Court are extended by 21 days, as of March 16. The Court of Appeals will conduct remote arguments at least through June 30.

Washington
In the Western District of Washington, all civil and criminal hearings and trial dates scheduled to occur before June 1 are postponed until further notice. Individual judges may decide to proceed with remote conferences as appropriate. All grand jury proceedings scheduled before June 1 are postponed. All initial criminal appearances and detention hearings will be conducted remotely with the defendant’s permission, unless the court directs otherwise. The bankruptcy court will continue with scheduled nonevidentiary hearings by telephone as posted on www.wawb.uscourts.gov and announced by the individual bankruptcy judge.

In the Eastern District of Washington, all in-court hearings in civil and criminal cases scheduled through April 14 are vacated until further notice, and case-related deadlines are suspended. All grand jury sessions before April 13 are vacated. Magistrate judges can evaluate their essential proceedings on a case-by-case basis. Naturalization ceremonies have been canceled through April 30.

In the state court system, all civil jury trials are suspended until after April 24. Trials already in session may proceed or may be postponed to a later date at the discretion of the judge or by agreement of the parties. All nonemergency civil matters are postponed until after April 24, and emergency matters must be held remotely, if possible. All criminal jury trials are postponed until after April 24. Criminal trials already in session with sworn juries may proceed if public health measures are strictly observed, but may be postponed if the defendant agrees to do so.

Washington, D.C.
All federal civil and criminal jury trials in D.C. federal courts have been put off starting March 17 until at least May 11, while other proceedings are postponed until April 17. Federal trial and bankruptcy courts in D.C. will remain open with limited operations.

The D.C. Superior Court has postponed citation arraignments scheduled for March 17 through April 15 for eight weeks from their originally scheduled date. New jury trials in criminal cases are postponed until at least March 30. The court will hear only emergency matters in the civil, family court, probate and tax divisions and auditor master. In general, all other matters are postponed.

The D.C. Court of Appeals has canceled all oral arguments scheduled through March 31. Filing deadlines on or after March 16 are also being delayed until March 31.

The U.S. Tax Court building is closed until further notice, and various trial sessions through March and April have been canceled.

West Virginia
In the Northern District of West Virginia, those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any courthouse.

In the Southern District of West Virginia, all civil and criminal jury trials and grand jury proceedings are postponed until further notice. Those who tested positive for the coronavirus, have symptoms or may have been exposed to the virus are prohibited from entering any courthouse.

In the state court system, all proceedings and judicial deadlines through April 10 are stayed, except for certain emergency proceedings. Deadlines set to expire before then, including statutes of limitation, are extended to April 11. Proceedings previously scheduled between March 23 and April 10 are postponed and will be rescheduled by the presiding judge. Emergency proceedings should be conducted remotely when possible

Wisconsin
In the Eastern District of Wisconsin, all civil and criminal jury trials scheduled to begin before May 1 are postponed and will be rescheduled for a later date. All petty offense, reentry court and grand jury proceedings are also postponed. Civil hearings should be conducted remotely. Naturalization ceremonies scheduled before May 1 are canceled. Those who are experiencing COVID-19 symptoms or may have come into contact with the virus are prohibited from visiting any courthouse.

In the Western District of Wisconsin, the Kastenmeier Courthouse in Madison will remain open and proceedings will go on as scheduled. Those who feel ill should stay away from the courthouse.

In the state court system, all civil and criminal jury trials scheduled to begin on or before May 22 are postponed and will be rescheduled by the presiding judges. All in-person proceedings in appellate and Circuit courts, with certain exceptions, are suspended through April 30.

Wyoming
In the District of Wyoming, judges are conducting matters remotely where possible. Those who have tested positive for the coronavirus, have symptoms or may have been exposed to the virus — including those who have recently visited Iran, China, South Korea or a host of European countries — are prohibited from entering the courthouse.

In the state court system, all District and Circuit courts have suspended in-person proceedings, with certain exceptions. The Wyoming Supreme Court ordered that all civil trials in state courts be rescheduled and that the courts make reasonable attempts to reschedule criminal trials. The Wyoming Supreme Court building in Cheyenne is closed to the public. The rules requiring paper copies of documents that can be filed electronically are suspended in the Wyoming Supreme Court.

IMMIGRATION COURTS


The U.S. Department of Justice’s Executive Office for Immigration Review has postponed all immigration court hearings for immigrants who aren’t in detention through May 1, although hearings on the docket for detainees are continuing.

Four courts in Miami, San Francisco, Kentucky and New Jersey were fully closed as of April 1.

Filings intended for Miami’s Krome center and San Francisco’s Montgomery St. court can be submitted to other courts in those cities. Filings for the Elizabeth, New Jersey, court can be sent to the Newark court.

The Louisville, Kentucky, immigration court has been closed since August for reasons unrelated to the virus, but filers can submit to the Memphis, Tennessee, immigration court.

Filings in closed courts may also be submitted by email, EOIR announced on March 31.

These 20 courts are fully open: Adelanto, California; Baltimore; Batavia, New York; Conroe, Texas; Eloy, Arizona, El Paso, Texas, Service Processing Center; Falls Church, Virginia, Immigration Adjudication Center; Fishkill, New York; Florence, Arizona; Fort Worth, Texas; LaSalle, Louisiana; Oakdale, Louisiana; Otay Mesa, California; Otera, New Mexico; Pearsall, Texas; Port Isabel, Texas; Stewart, Georgia; Tacoma, Washington; Ulster, New York; and York, Pennsylvania.

The remainder of immigration courts have been kept partially open, and in some cases reopened, for the limited purpose of accepting filings, and if applicable, holding hearings for detained immigrants.

U.S. PATENT AND TRADEMARK OFFICE


All examiner and examining attorney interviews, Patent Trial and Appeal Board and Trademark Trial and Appeal Board oral hearings and other similar in-person meetings scheduled to take place at USPTO offices on or after March 13 will be conducted remotely by video or telephone until further notice.

INTERNATIONAL COURTS


European Court of Justice & General Court of the European Union

Both the ECJ and the General Court have partially closed their doors. The courts will hear only urgent matters until further notice. All other cases already scheduled until March 27 at the ECJ and April 3 at the General Court will be heard at a later date. The filing deadlines for all cases will not change. The ECJ has also advised staff not to go into the court buildings from March 16 to 27 unless it is necessary for a specific case.

–Additional reporting by Stewart Bishop, Dorothy Atkins, Suzanne Monyak, Matt Chiappardi and Melissa Lipman. Editing by Jill Coffey.

Suspension of Audits During the Coronavirus?

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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.

Obviously, there are so many questions. Providers across the country are asking whether they need to comply with document requests. Are TPE audits continuing? Do they need to comply with ongoing ADRs?

Every bulletin that CMS publishes instigates more detailed and complex questions. With all these relaxed guidelines, won’t RACs, etc. have a field day when this is all over? Of course they will.

General Recommendations:

  • Be proactive.
  • Document everything.
  • Deadlines will be extended.
  • Exceptions will be made.
  • Keep all email correspondence.
  • Maintain copies of everything that you submit. (Do not rely on electronic computer software programs).
  • Keep track of CMS updates.

Email me questions, and I will try to respond.

Also, feel free to reach out to the government: QSOG_EmergencyPrep@cms.hhs.gov.

Effective date: 30 days from the memo, which equals April 3, 2020.

 

 

CMS Revises and Details Extrapolation Rules

Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC).

Extrapolation is a veritable tsunami in Medicare/Medicaid audits. The auditor collects a small sample of claims to review for compliance, then determines the “error rate” of the sample. For example, if 500 claims are reviewed and one is found to be noncompliant for a total of $100, then the error rate is set at 20 percent. That error rate is applied to the universe, which is generally a three-year time period. It is assumed that the random sample is indicative of all your billings, regardless of whether you changed your billing system during that time period or maybe hired a different biller. In order to extrapolate an error rate, contractors must use a “statistically valid random sample” and then apply that error rate on a broader universe of claims, using “statistically valid methods.”

With extrapolated results, auditors allege millions of dollars of overpayments against healthcare providers – sometimes a sum of more than the provider even made during the relevant time period. It is an overwhelming impact that can put a provider and its company out of business.

Prior to this recent change to extrapolation procedure, the Program Integrity Manual (PIM) offered little guidance regarding the proper method for extrapolation.

Prior to 2019, CMS offered broad strokes with few details. Its guidance was limited to generally identifying the steps contractors should take: “a) selecting the provider or supplier; b) selecting the period to be reviewed; c) defining the universe, the sampling unit, and the sampling frame; d) designing the sampling plan and selecting the sample; e) reviewing each of the sampling units and determining if there was an overpayment or an underpayment; and, as applicable, f) estimating the overpayment.”

Well, Change Request 10067 overhauled extrapolation in a huge way.

The first modification to the extrapolation rules is that the PIM now dictates when extrapolation should be used.

Under the new guidance, a contractor “shall use statistical sampling when it has been determined that a sustained or high level of payment error exists. The use of statistical sampling may be used after a documented educational intervention has failed to correct the payment error.” This guidance now creates a three-tier structure:

  1. Extrapolation shall be used when a sustained or high level of payment error exists.
  2. Extrapolation may be used after documented educational intervention (such as in the Targeted Probe-and-Educate (TPE) program).
  3. It follows that extrapolation should not be used if there is not a sustained or high level of payment error or evidence that documented educational intervention has failed.

“High level of payment error” is defined as 50 percent or greater. The PIM also states that the contractor may review the provider’s past noncompliance for the same or similar billing issues or a historical pattern of noncompliant billing practice. This is critical because so many times providers simply pay the alleged overpayment amount if the amount is low or moderate in order to avoid costly litigation. Now, those past times that you simply paid the alleged amounts will be held against you.

Another monumental modification to RAC audits is that the RAC auditor now must receive authorization from CMS to go forward in recovering from the provider if the alleged overpayment exceeds $500,000 or is an amount that is greater than 25 percent of the provider’s Medicare revenue received within the previous 12 months.

The identification of the claims universe was also redefined. Even CMS admitted in the change request that, on occasion, “the universe may include items that are not utilized in the construction of the sample frame. This can happen for a number of reasons, including, but not limited to: a) some claims/claim lines are discovered to have been subject to a prior review; b) the definitions of the sample unit necessitate eliminating some claims/claim lines; or c) some claims/claim lines are attributed to sample units for which there was no payment.”

How many of you have been involved in an alleged overpayment in which the auditor misplaced or lost documents? I know I have. The new rule also states that the auditors must be able to recreate the sample and maintain all documentation pertinent to the calculation of an alleged overpayment.

High-volume providers should face a lower risk of extrapolation if their audited error rate is less than 50 percent and they do not have a history of noncompliance for the same or similar billing issues, or a historical pattern of noncompliant billing practice.

RAC Audits Will Be Targeting Telehealth

Consults by telephone are becoming more and more prevalent. It only makes sense. In an age in which the population has surged, the ratio of physicians to patients has grown more disparate, and the aging and disabled community continues to increase, telehealth is a viable, logical, and convenient resource. I can tell you that when I have to go to a doctor appointment, my whole day is off-kilter. You have to get dressed, drive there, sit in the waiting room, wait for the doctor in the patient room, talk to your doctor, check-out, drive back to work/home and, usually, have a hour-long telephone call with your insurance company. Doctor visits can take up a whole day.

Enter telehealth.

Telehealth allows a patient who needs to see a health care provider to present to a health care provider over the telephone. No getting dressed, driving, or waiting.

According to a FAIR Health White Paper report, “the use of non-hospital-based provider-to-patient telehealth increased 1,393% from 2014 to 2018, from 0.007% to 0.104% of all medical claim lines. There was a 624% increase in claim lines related to any type of telehealth, from 0.0192% to 0.1394% of all medical claim lines. Non-hospital-based provider-to-patient telehealth accounted for 84% of all telehealth claim lines in 2018.”

According to the numbers in the report, the use of telehealth increased in urban areas, rather than rural areas, at a much greater percentage, which, personally, I found surprising, at first. But when you consider the number of people living in urban areas rather than rural areas, the disparate percentages make sense.

Not surprising, 82% of telehealth claims were associated with individuals aged 51+.

Private insurances are jumping on the band wagon, but, more importantly, government insurers are already on the wagon. And the wagon is gaining a wagon train; CMS is expanding the use of telehealth even as you read this.

On April 5, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies that increased plan choices and benefits, including allowing Medicare Advantage plans to include additional telehealth benefits. Before this year, Medicare recipients could only receive certain telehealth services if they live in rural areas. Now Medicare will pay for telehealth across the country…all from your house.

On July 29, 2019, CMS took the first steps toward welcoming opioid treatment programs (OTPs) into the Medicare program and expanding Medicare coverage of opioid use disorder (OUD) treatment services provided by both OTPs and physician practices. CMS is proposing the use of telehealth for opioid services. More specifically, CMS is proposing telehealth substance abuse counseling, telehealth individual/group therapy.

Enter RAC, ZPIC, UPIC, TPE, MAC, and MFCU audits.

Where there is Medicare money to be made or fraud to be had there are the auditors. The alphabet soup.

In April 2019, one of the largest healthcare fraud rings in U.S. history, involving telemedicine companies was busted. At an alleged amount of $1.2 billion. Durable medical equipments (DME) were also targeted, but this blog focuses on telehealth.

Allegedly, the telehealth companies would inform Medicare beneficiaries that they, for example, qualified for a brace. Using telehealth, the physicians wrote prescriptions for braces. DME would file the claim and pay the telehealth provider and the physician.

The government argued that you have to be seen in-person to determine your need for a brace.

It is important to note that the above-referenced scheme was performed prior to the most recent expansion of telehealth.

With this most recent expansion of telehealth, expect the auditors to be drooling.

Warning: Auditors Will Target SNF Patient Conditions, Not Services and Time Rendered

Oct. 1, 2019 marks the beginning of a new era of billing for skilled nursing facilities (SNFs).

Say goodbye to RUG-IV, and hello to the Patient-Driven Payment Model (PDPM).

This is a daunting task, not for the faint of heart. Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to a successful Recovery Audit Contractor (RAC) audit.

In the past, therapy documentation has been the focus of RAC audits. Now, nursing documentation is front and center. Do not try to maximize case mix index (CMI). But remember, certain documentation can easily lead to higher reimbursement. For example, if you document when a patient is morbidly obese, suffering from diabetes, and taking intravenous medication, this can lead to three times the reimbursement over the first three days. This article will explore the intricacies of RAC audits and how to maximize reimbursement while successfully maneuvering through the process.

Here is the million-dollar question: how will PDPM affect your business?

The answer is four-fold, for the purposes of this article, although this list is not exhaustive.

  1. Managing care: Unlike RUG-IV, which incentivizes ultra-high volumes of therapy to capture maximum payment, PDPM requires you to carefully manage how you deliver services in order to provide the right level of care for each patient. This begs the question of whether you’re getting paid to over-deliver services (or practice “defensive medicine”), or you’re getting audits and recoupments for under-delivering due to poor patient outcomes. For this reason, it can seem like you are getting pulled in two directions.
  2. Financial: PDPM is designed to be budget-neutral. Your reimbursements will decrease. SNFs will be able to offset the loss in therapy reimbursement with higher reimbursement for services already being provided.
  3. Staffing: There is less demand for therapists in a SNF setting. But you will be able to retain the best therapy sources.
  4. Billing: Under PDPM, you will bill using the Health Insurance Prospective Payment System (HIPPS) code that is generated from assessments with ARD. You will still be using a five-digit code, as you did with RUG-IV. But the characters signify different things. For example, under RUG-IV, the first three characters represented the patient’s RUG classification, and the last two were an assessment indicator. With PDPM, the first character represents the patient’s physical therapy (PT) and occupational therapy (OT) component. The second is the patient’s speech language therapy (SLP) component. The third is the nursing component classification. The fourth is the NTA component classification, while the fifth is an AI code.

The upshot to this is that different clinical categories can result in significant reimbursement differences. For example, consider the major joint replacement or spinal surgery clinical category. That clinical category is a major medical service, which can translate to a $42-a-day increase in reimbursement. For a 20-day stay, that clinical category would increase reimbursement by $840. You want to pick up on this type of surgery.

I received a question after a recent program segment asking whether swing beds will be affected by PDPM. In most hospitals, the answer is yes. The exception is critical access hospitals (CAHs), which will remain cost-based for their swing beds.

Final Rule: “Accordingly, all non-CAH swing-bed rural hospitals have now come under the SNF PPS. Therefore, all rates and wage indexes outlined in earlier sections of this final rule for the SNF PPS also apply to all non-CAH swing- bed rural hospitals.”

The latest changes in the MDS for swing-bed rural hospitals appear on the SNF PPS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html

Programming Note:

Listen to healthcare attorney Knicole Emanuel every Monday on Monitor Monday, 10-10:30 a.m. EST.

RAC Audits: Alternatives to Litigation

Understanding why there’s a need for auditing the auditors.

I frequently encounter complaints by healthcare providers that when they are undergoing Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), and, more recently, the Targeted Probe-and-Educate (TPE) audits, the auditors are getting it wrong. That’s as in, during a RAC audit, the auditor finds claims noncompliant, for example, for not having medical necessity – but the provider knows unequivocally that the determination is dead wrong. So the question that I get from the providers is whether they have any legal recourse against the RAC or MAC finding noncompliance, besides going through the tedious administrative action, which we all know can take upwards of 5-7 years before reaching the third administrative level.

To which, now, upon a recent discovery in one of my cases, I would have responded that the only other option for relief would be obtaining a preliminary injunction in federal court. To prove a preliminary injunction in federal court, you must prove: a) a likelihood of success on the merits; and b) that irreparable harm would be incurred without the injunction; i.e., that your company would be financially devastated, or even threatened with extinction.

The conundrum of being on the brink of financial ruin is that you cannot afford a legal defense if you are about to lose everything.

This past month, I had a completely different legal strategy, with a different result. I am not saying that this result would be reached by all healthcare providers that disagree with the results of their RAC or MAC or TPE audit, but I now believe that in certain extreme circumstances, this alternative route could work, as it did in my case.

When this particular client hired me, I quickly realized that the impact of the MAC’s decision to rescind the client’s Medicare contract was going to do more than the average catastrophic outcomes resulting from a rescission of a Medicare contract. First, this provider was the only provider in the area with the ability to perform certain surgeries. Secondly, his practice consisted of 90 percent of Medicare. An immediate suspension of Medicare would have been devastating to his practice. Thirdly, the consequence of these Medicaid patients not undergoing this particular and highly specialized surgery was dire. This trifecta sparked a situation in which, I believed, that even a Centers for Medicare & Medicaid Services (CMS) employee (who probably truly believed that the negative findings cited by the RAC or MAC were accurate) may be swayed by the exigent circumstances.

I contacted opposing counsel, who was the attorney for CMS. Prior to this situation, I had automatically assumed that non-litigious strategies would never work. Opposing counsel listened to the facts. She asked that I draft a detailed explanation as to the circumstances. Now, concurrently, I also drafted this provider’s Medicare appeal, because we did not want to lose the right to appeal. The letter was definitely detailed and took a lot of time to create.

In the end, CMS surprised me and we got the Medicare contract termination overturned within months, not years, and without expensive litigation.

(Originally published on RACMonitor)

CMS Revises and Details Extrapolation Rules: Part II

Biggest RACs Changes Are Here: Learn to Avoid Denied Claims

See Part I: Medicare Audits: Huge Overhaul on Extrapolation Rules

Part II continues to explain the nuances in the changes made by CMS to its statistical sampling methodology. Originally published on RACMonitor.

The Centers for Medicare & Medicaid Services (CMS) recently made significant changes in its statistical sampling methodology for overpayment estimation. Effective Jan. 2, 2019, CMS radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC).

The RAC program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans. The RAC auditors review a small sample of claims, usually 150, and determine an error rate. That error rate is attributed to the universe, which is normally three years, and extrapolated to that universe. Extrapolation is similar to political polls – in that a Gallup poll will ask the opinions of 1-2 percent of the U.S. population, yet will extrapolate those opinions to the entire country.

First, I would like to address a listener’s question regarding the dollar amount’s factor in extrapolation cases. I recently wrote, “for example, if 500 claims are reviewed and one is found to be noncompliant for a total of $100, then the error rate is set at 20 percent.”

I need to explain that the math here is not “straight math.” The dollar amount of the alleged noncompliant claims factors into the extrapolation amount. If the dollar amount did not factor into the extrapolation, then a review of 500 claims with one non-compliant claim is 0.2 percent. The fact that, in my hypothetical, the one claim’s dollar amount equals $100 changes the error rate from 0.2 percent to 20 percent.

Secondly, the new rule includes provisions implementing the additional Medicare Advantage telehealth benefit added by the Bipartisan Budget Act of 2018. Prior to the new rule, audits were limited in the telehealth services they could include in their basic benefit packages because they could only cover the telehealth services available under the FFS Medicare program. Under the new rule, telehealth becomes more prominent in basic services. Telehealth is now able to be included in the basic benefit packages for any Part B benefit that the plan identifies as “clinically appropriate,” to be furnished electronically by a remote physician or practitioner.

The pre-Jan. 2, 2019 approach to extrapolation employed by RACs was inconsistent, and often statistically invalid. This often resulted in drastically overstated overpayment findings that could bankrupt a physician practice. The method of extrapolation is often a major issue in appeals, and the, new rules address many providers’ frustrations and complaints about the extrapolation process. This is not to say that the post-Jan. 2, 2019 extrapolation approach is perfect…far from it. But the more detailed guidance by CMS just provides more ways to defend against an extrapolation if the RAC auditor veers from instruction.

Thirdly, hiring an expert is a key component in debunking an extrapolation. Your attorney should have a relationship with a statistical expert. Keep in mind the following factors when choosing an expert:

  • Price (more expensive is not always better, but expect the hourly rate to increase for trial testimony).
  • Intelligence (his/her CV should tout a prestigious educational background).
  • Report (even though he/she drafts a report, the report is not a substitute for testimony).
  • Clusters (watch out for a sample that has a significant number of higher reimbursed claims. For example, if you generally use three CPT codes at an equal rate and the sample has an abnormal amount of the higher reimbursed claim, then you have an argument that the sample is an invalid example of your claims.
  • Sample (the sample must be random and must not contain claims not paid by Medicaid).
  • Oral skills (can he/she make statistics understandable to the average person?)

Fourthly, the new revised rule redefines the universe. In the past, suppliers have argued that some of the claims (or claim lines) included in the universe were improperly used for purposes of extrapolation. However, the pre-Jan. 2, 2019 Medicare Manual provided little to no additional guidance regarding the inclusion or exclusion of claims when conducting the statistical analysis. By contrast, the revised Medicare Manual specifically states:

“The universe includes all claim lines that meet the selection criteria. The sampling frame is the listing of sample units, derived from the universe, from which the sample is selected. However, in some cases, the universe may include items that are not utilized in the construction of the sample frame. This can happen for a number of reasons, including but not limited to:

  • Some claims/claim lines are discovered to have been subject to a prior review;
  • The definitions of the sample unit necessitate eliminating some claims/claim lines; or
  • Some claims/claim lines are attributed to sample units for which there was no payment.”

By providing detailed criteria with which contractors should exclude certain claims from the universe or sample frame, the revised Medicare Manual will also provide suppliers another means to argue against the validity of the extrapolation.

Lastly, the revised rules explicitly instruct the auditors to retain an expert statistician when changes occur due to appeals and legal arguments.

As a challenge to an extrapolated overpayment determination works its way through the administrative appeals process, often, a certain number of claims may be reversed from the initial claim determination. When this happens, the statistical extrapolation must be revised, and the extrapolated overpayment amount must be adjusted. This requirement remains unchanged in the revised PIM; however, the Medicare contractors will now be required to consult with a statistical expert in reviewing the methodology and adjusting the extrapolated overpayment amount.

Between my first article on extrapolation, “CMS Revises and Details Extrapolation Rules,” and this follow-up, you should have a decent understanding of the revised extrapolation rules that became effective Jan. 2, 2019. But my two articles are not exhaustive. Please, click here for Change Request 10067 for the full and comprehensive revisions.

Medicare Reform Proposals Include Eliminating “Incident-to” Rules

There are a lot of concerns related to “incident-to billing. However, for physician practices, “incident-to” billing is a money maker, which, in the world, of sub-par Medicare reimbursement rates is a minute ray of sunshine in an otherwise eclipsed land. Auditors argue that there are fraud and abuse concerns because practices ignore or are confused about the rules and bill everything “incident-toregardless of the conditions being met. This can result in a nasty audit, as well as substantial fines, penalties, and attorneys’ fees. If you bill “incident-to,” just follow the rules…unless those rules are eliminated. Until possible elimination, keep up with the rules, which can differ depending on the auditor in the region.

Recently, people have been pushing for Medicare reform to include disallowing nurse practitioners (NPs) and physician assistants (PAs) from billing “incident-to.” Proponents of the suggested amendment claims that the recommendation would save the Medicare program money — approximately $50 to $250 million annually and just under $1 billion over 5 years.

The number of NPs who bill Medicare has more than doubled, from 52,000 to 130,000 from 2010 to 2017

What is “incident-to” billing?

In colloquialism, “incident-to” billing allows non-physician providers (NPPs) to report services “as if” they were performed by a physician. The NPP stands in the shoes of the physician. The advantage is that, under Medicare rules, covered services provided by NPPs typically are reimbursed at 85% of the fee schedule amount; whereas, services properly reported “incident-to” are reimbursed at the full fee schedule value.

In legalize, “incident-to” services under §1861(s)(2)(A) of the Social Security Act are provided by NPPs as a part of the services provided directly by the physician, but billed as if they were in fact performed by the physician. Several, legal, threshold requirements must be satisfied before billing eligibility for these services is established.

Billing using “incident-to” can be a huge money-maker for providers. If billed incorrectly, it can also be a provider’s financial downfall.

“Incident-to” billing can only apply to established patients. Not new patients. Not consults. The other non-negotiable factor is that the physician who is supervising must be on-site. Not a phone call away. Not grabbing a burger at a local eatery. On-site. Although with hospitals, the cafeteria is a viable option. I foresee, in the future, telehealth and Skype may change this on-site requirement. The incident-to rules also require that the services be part of a patient’s normal course of treatment.  The rules require that the physician remains actively involved in the patient’s course of treatment.  There must be direct supervision.  Direct supervision = on-site. The following services cannot be billed as “incident-to:”

  • new patient visits
  • visits in which an established patient is seen for a new problem
  • visits in which the treatment provided or prescribed is not a part of the treatment plan established by a physician
  • services provided in the hospital or ambulatory surgery center.

Do not confuse “incident-to” with Medicare patients versus Medicaid patients. MediCAID’s regulations for the coverage of MD services vary significantly than Medicare’s rules and requires direct contact with the patient with exceptions.

Here is a question that I often get: “When billing “incident-to,” do you bill “incident to” the physician who is physically on-site that day or the physician who is overseeing that patient’s care? Both physicians are in the same group and it is billed under the Group NPI, but not sure which physician to reference for “incident-to.”

Answer: Bill under the MD who is on-site. This was addressed by the Center for Medicare and Medicaid Services (CMS) in the 2016 Physician Fee Schedule Final Rule.

The Medicare Benefit Policy Manual addresses the “incident-to” rules for each provider type and in any scenario:

  • Section 60 contains policies for services furnished incident to physicians’ services in the physician’s office.
  • Chapter 6, section 20.5 enumerates the policies for therapeutic services furnished “incident-to” physicians’ services in the hospital outpatient setting.
  • Section 80 states the policies for diagnostic tests in the physician’s office
  • Chapter 6, section 20.4 lists the policies for diagnostic tests furnished in the hospital outpatient setting.

Drug Administration under “incident-to”

“The Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs that are furnished “incident to” a physician’s service provided that the drugs are not usually self-administered by the patients who take them.” Medicare Benefit Policy Manual, 50.2. Injectable drugs, including intravenously administered drugs, are typically eligible for inclusion under the “incident-to” benefit.

The Medicare Administrative Contracts (MACs) (or – auditors) must fully explain the process they will use to determine whether a drug is usually self-administered and thus does not meet the “incident-to” benefit category. The MACs must publish a list of the injectable drugs that are subject to the self-administered exclusion. If there is discrepancy amongst the MACs, a lawsuit could help.

In order to meet all the general requirements for coverage under the “incident-to” provision, an FDA approved drug or biological must:

  • Be of a form that is not usually self-administered;
  • Must be furnished by a physician; and
  • Must be administered by the physician, or by auxiliary personnel employed by the physician and under the physician’s personal supervision

The charge, if any, for the drug or biological must be included in the physician’s bill, and the cost of the drug or biological must represent an expense to the physician.

Summary

“Incident-to” billing is subject to elimination. The difference in billing “incident-to” is a 100% reimbursement rate versus an 85% reimbursement rate. That 15% difference cannot be passed onto the Medicare recipients.

While “incident-to” billing continues to be allowed, it is imperative to keep up with the ever changing rules.