Marti Arvin joins us for part three of our series to discuss compliance considerations around the Center for Medicare and Medicaid Services Waivers (CMS) that were issued for hospitals under the Public Health Emergency. In part one of this series, Marti covers a number of the section 1135 waivers issued by CMS to support teaching hospitals, teaching physicians, acute care, and other hospitals. Marti also discusses specific waivers and compliance considerations associated with the waiver.
Links to content:
- Read the fourth half of our blog series “CMS Waivers Under COVID-19: An Overview of Compliance Considerations – Part 4”
- Download our 30/60/90 day checklist, “Planning for Incident Response During the COVID-19 Crisis: Tales on Tackling the Security Debit.”
- For a full repository of COVID-19 crisis resources, visit our CTEK COVID-19 Communications page for news, articles, podcasts, and more.
- Contact us with any questions regarding the regulatory changes during the COVID-19 crisis.
Hello and welcome to CTEK Voices: The Risk Perspective. I’m Lauren Frickle
and I’m back with Marti Arvin, Executive Advisor at CTEK. Today Marti will continue with part 3 of her “CMS Waivers Under COVID-19: An Overview of Compliance Consideration” Series.
Hello Marti. Thanks for joining us and welcome back.
Hi Lauren. Thank you and welcome back everyone. I hope you’ve had the opportunity to listen to part one and two of the podcast. They’re not necessarily in sequential order so you could be listening to this one independently. That’s really up to you.
What I’ve been talking about in this podcast series are the 1135 waivers that CMS has issued for Medicare services for hospitals, in particular, CMS has issued waivers for virtually every segment of the healthcare industry, but I focus this series on those that were issued for hospitals in particular.
Now keep in mind as I’ve said through the other podcast, this is for Medicare only. So, when you hear about these waivers if there’s a comparable state provision for Medicaid, or if there’s something similar that your commercial payers may require, or something distinctly different than your commercial payers may require. You’re going to have to look to those entities to figure out how these waivers tie into what they’re requiring and the obligations you have to comply with the regulations associated with Medicaid and your obligations under your commercial payer contracts. And again, as a reminder, this is not addressing any of the stark or the anti-kickback waivers that have been issued or the enforcement discretion that CMS has indicated it might exercise.
So, for today, I want to start talking about verbal orders as a general premise Medicare doesn’t like verbal orders and they actually have said that they should only be used in very rare instances but recognizing that providers are going to need to free up as much time as possible to care for the influx of patients. They might have as a result of the Coronavirus. They have indicated that at least during the public health emergency, they will waive the requirement to authenticate the verbal order and you can take more than 30 hours to authenticate the order. As a normal requirement again, verbal orders have to be dated inside and there’s a read-back requirement that the order gets read back to the clinician that’s providing the verbal order and that is still a requirement. But the authentication, IE the person that has to co-sign the order, no longer has to occur within 48 hours.
Now, this is again Medicare so you may need to look to your state law because some states may require the verbal orders be signed within a shorter time period and so you want to make sure that the state has either waive that requirement or you’re still meeting it if you’re using verbal orders, and they’ve also indicated that verbal orders can be used for drugs and biologicals.
So again, that’s some of the compliance considerations are making sure that verbal orders does get authenticated. So, although you don’t have to authenticate it within the standard 48 Hours. It is saying that it’s going to have to be authenticated at some point. So just making sure that if verbal orders are issued they getting an authenticated and their get us getting us indicated was in the appropriate time frame that means looking at that state law provision and ensuring that your meeting it as well as the Medicare guideline and you might consider auditing this after the public health emergency is lifted to make sure again that those orders have been authenticated and that they have been dated and signed and there’s some documentation that the read-back did occur.
Now one of the other waivers that CMS issued is around restraints. Under the Medicare regulations if a patient is in soft restraints in an (ICU) Intensive Care Unit. Then the organization has to report the death of that patient or the fact that they have they were in soft restraints at the time of their death by the close of business on the next business day after death. And that’s true whether there is an indication that the soft restraints might have or contributed to the patient’s death or if the soft restraints had nothing to do with the death.
So under this waiver, if the soft restraints aren’t thought to have anything to do with the patient’s death, then that waiver lifts the requirement to report that death within, I’m Sorry, by close of business the next business day after the death. The requirement remains that if the restraints might have contributed to the patient’s death, then it still has to be reported within that standard time frame that is by close of business on the next business day.
So again, some compliance considerations are ensuring that those deaths were the soft restraints were used are properly reported and it’s not saying you don’t have to report them. It’s just saying that you don’t have to report them by close of business on the next business day if the soft restraints did contribute at all to the patient’s death, but they desired I’d rather of their disease process.
And again, making sure that you return to your normal process and reporting requirements once the public health emergency has been lifted. This might be an area that you consider auditing and reviewing, particularly if your organization tends to you soft restraints. And it’s not that uncommon when you have patients in an ICU where there’s lots of lines lots of IVs and things of that nature that are at risk of being pulled out of the patients moving around a lot.
So again, just consider what you want to audit after the public health emergency is lifted. CMS is also ease the requirements for provider enrollment. They’ve said they’re going to waive criminal background checks associated with fingerprint-based checks, and they’re going to wave site visits. They will postpone all revalidation actions as it relates to provider enrollment. They will expedite new and pending applications if the application is clean and has no errors. They have said they will process it within 7 days, and they will grant billing privileges on a provisional basis.
And once the public health emergency is lifted, the provider will be asked to submit a complete CMS 855 application in order for those temporary privileges to become permanent. If they don’t respond within the 30 days, then their temporary privileges will be deactivated, and they won’t be eligible to bill for Medicare services.
So again, the compliance consideration here is to just help ensure that providers who have been granted. Those temporary privileges are submitting that full 855 application in a timely fashion after the public health emergency is lifted so that they can continue to work for you.
Another area that CMS has issued waivers around is discharge planning for post-acute care settings. There’s no need to provide patients with quality and research resource use measurements for home health agencies, skilled nursing facilities, inpatient rehab facilities, and long-term care hospitals.
Prior to the public health emergency this is something that acute care facilities were expected to do. You also must still ensure that the care setting that you’re discharging the patient to is still appropriate for the patient’s goals and the care that is needed and you still must provide the necessary medical information for that post-acute care provider to properly take care of that patient.
It also waves the requirements to provide the patient and their family with a specified list of those type of home health agencies, skilled nursing facilities, inpatient rehab facilities, and longtime term care hospitals. You have to inform, are not don’t have to inform rather, the patient or their family that they’re free to choose among any Medicare-participating provider.
And again, you don’t have to ID in the discharge plan the disclosable financial interest of any home health agency to which the patient is referred or any skilled nursing facility and the home health agency or skilled nursing facility doesn’t have to disclose that financial interest in a hospital under Medicare. So again, compliance considerations monitoring to help ensure there’s not an improper referral that’s being made there have been a number of OIG cases, Office of Inspector General Cases for false claims, where hospitals were appearing to steer patients to entities to which they had a financial interest or that might have been providing a kickback to the discharge planner to help get patients into their facilities. And again, this is an area where you probably want to consider auditing once the public health emergency is lifted.
Other waivers that Medicare is done in a more general fashion, the medical records provisions for organization of the medical records office to staffing in the completion of the record. Entities can take more than 30 days to complete the medical record now and not any surprise you to hear me say this is probably something you want to audit after the public health emergency is lifted. A lot of health information management departments have had difficulty getting providers to complete records before the public health emergency and now that might even be more difficult. So, you want to get those records completed as quickly as possible. But again, that’s not going to be the primary focus during the public health emergency.
Once it’s lifted, that’s where the focus needs to be an organization’s need to be very clear that providers still have that expectation and if their policy calls for suspending the provider for not completing the record in a timely fashion. Then they’ll probably need to define what that period is once they put the provider on notice that gets them back into compliance with their policies and procedures that were in place pre-public health emergency.
There’s also a waiver for the requirement to provide information on advanced directives. There are waivers around some of the reporting requirements on the inpatient prospective payment wage index occupational mix survey submissions. Their waivers around the requirements for utilization review processes. There is a waiver for the obligation to have a current therapeutic diet manual approved by a dietitian and medical staff available to all medical nursing and food service personnel.
This is specifically it’s not something that’s required to be maintained in a surge capacity site and again for surge capacity sites only there’s a waiver of requirement to have a policy and procedure in place for the appraisal of an emergency on an off-campus site and for emergency preparedness.
Again, we talked in earlier podcast about the fact that CMS is permitting hospitals to have temporary expansion sites and this ties back to that requirement to ensure that people aren’t focusing on trying to draft policies and procedures but to help free up time so that all care providers can focus on providing care to patients. And there’s no requirement now for a signature and proof of delivery of Part B be drugs or durable medical equipment. But under the waiver, CMS has indicated the medical record should still reflect the date of the delivery, and that signature was not obtained because of the COVID-19 crisis. There have also been some cost reporting extension times. For any cost report that was due at fiscal year and October 31st of 19 or November 30th of 19, that cost report would have normally been due March 31st of 2020 and April 30th of 2020 respectively.
CMS has extended that deadline to June 30th of 2024 both cost reports that were due at fiscal year-end of October 31st and November 30th of 2019. For cost reports that were doing fiscal year and for December 31st to 2019, those cost reports have been extended to June 31st of 2020. And they have indicated that if you still need additional time to file your cost reports, then you may appeal or submit something to Medicare to indicate that you still need additional time. But as of now, you have those three additional months for the cost reports do November and December, sorry, October and November of last year, and you have the additional time for your cost report. That would have been due at the end of December of last year. I’m sorry, that was due for fiscal year and at the end of December last year.
There are also some flexibility for Max and Q ICS to extend the time for appeals and to waive the timeliness request for any additional information. So, with all of these again, these are things that you want to consider looking at and auditing and making sure you’re meeting any extended times that might be appropriate. The anticipation for the waiver policies and procedures would be that you no longer have the surge capacity site in place once the public health emergency is lifted.
So, you won’t have to be concerned about those policies and procedures, but this goes back to anything we do in compliance is just making sure that we’re supporting the organization to meet its regulatory obligations, but also trying to provide the highest quality care to patients.
So, this concludes the three-part series of waivers under COVID-19 for hospitals, but I again remind you, this is only for Medicare. You need to look to your State Medicaid Agency and to your commercial payer for anything that they might be doing, and I hope you stay well, and stay healthy, and stay safe.
Thank you, Marti, for the continued guidance on CMS waivers for hospitals during the COVID-19 pandemic a note to our listeners this three-part series on CMS waivers for hospitals, makeup podcast episodes 15, 16, and 17. Please visit www.cynergistekcom/podcasts to listen to them all.
Thanks for listening!