PARAREV Weekly eJournal January 26, 2022

ej o u r n a l january 26, 2022

Detailed Billing OIG And Coding Guidance Auditing Out Of Network COVID Billing

Revenue Cycle Game Plan 1

Proven Strategies That Deliver Results

PARA Weekly eJournal: January 26, 2022

Up d at ed 1/ 12 / 2 2

2022 c o mp r eh en s i v e COV ID-19 Gu ide

Click an yw h er e on t h is page t o be t ak en t o t h e f u ll on lin e docu m en t .

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PARA Weekly eJournal: January 26, 2022

TUESDAY WEBINARS: COMPLYING WITH THE NO SURPRISES ACT

t ime is r unning out .

PARA exper t s ar e pr ovidin g a f r ee w ebin ar each Tu esday design ed t o h elp h ospit als u n der st an d an d com ply w it h t h e r equ ir em en t s u n der t h e No Su r pr ises Act .

Ever y Tu esday 11:30 am PST

Sign Up By Click in g HERE, Or Scan Th e QR Code

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PARA Weekly eJournal: January 26, 2022

DID YOU MISS IT? NO SURPRISES ACT WEBINARS? CATCH UP HERE! Did you miss t hev er y impor t ant "No Sur pr ises aCt " Webinar s and Q&A's? If you did you still have a chance to participate in the live versions (see previous page for links). And if you can't participate live, here are the links for the NSA Tool Demo Video , Webinars, Q&A sheets, and the Specific NSA Forms.

Our PARAREV team is always available to help.

Please reach out on our website.

DEM O -

NSA No Surprises Act Tool Demonstration Video

WEBINARS -

NSA No NSA No NSA No NSA No

Surprises Act Surprises Act Surprises Act Surprises Act

Update Webinar- 12/21/21 Update Webinar- 12/28/21 Update Webinar- 1/04/22 Update Webinar- 1/11/22

Q&A -

NSA No Surprises Act Update Q & A? 12/21/21 NSA No Surprises Act Update Q & A? 12/28/21 NSA No Surprises Act Update Q & A? 1/11/22

FORM S -

PARA - NSA Template for Convening Facility or Provider Good Faith Estimate - updated 12.28.21 PARA - NSA Template for Right to Receive a Good Faith Estimate of Expected Charges - updated 12.28.21 PARA - NSA Template for Disclosure Notice - updated 12.28.21

LOGINS - If you already have a PDE login ? you have access to the NSA Tool by logging into the PDE and clicking on the PTT/NSA Tab and NSA Link Tab - The Generic Log-Ins are available ? Please reach out to your Account Executive for more details.

- The Generic log-in providedexpir es on Jan u ar y 31, 2022, due to CPT® license agreement with the AMA. - You will need to create an individual account for those who will be creating Estimates.

- Please have your Administrator fill out this FORM to designate your facilities Primary Contact(s) for the NSA Project so we can create a user ID for them.

- Please make sure we have an updated email address for you ? Fill out this FORM to confirm your email and to be added/updated onto the Distribution List.

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PARA Weekly eJournal: January 26, 2022

STATE-LEVEL ENFORCEMENT OF NO SURPRISES ACT

The No Surprises Act (NSA) is a set of laws within the Consolidated Appropriations Act of 2021, which offers certain protections for patients against ?surprise? medical bills. The law prohibits facilities and other providers from ?balance billing? patients in certain situations, and the regulations require facilities to offer uninsured (or self-pay) patients a ?Good Faith Estimate? of charges in advance of services.In addition, facilities and certain providers are required to provide patients with a standard Disclosure notice which informs the patient about these protections under state and federal law.

State agencies are partially responsible for enforcement of provider compliance with the NSA rules.Since the regulations became effective on 1/1/2022, CMS surveyed states to determine the state?s authority and intention to enforce new provisions of the NSA. CMS has published state-specific letters which provide details on NSA enforcement at the state level and how the federal dispute resolution processes compare with existing state processes.The state-specific letter can be found on the CMS website at the link below: Consolidated Appropriations Act, 2021 (CAA) | CMS

Information in the state letters may be useful in preparing the NSA Disclosure notice, particularly as it pertains to state enforcement authorities.Providers are encouraged to check back frequently if your state is not yet listed ? state letters will continue to be added as the information is gathered

by CMS.

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PARA Weekly eJournal: January 26, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Most Part A and B Medicare Administrative Contractors offer ?Ask the Contractor ? (ATC) teleconferences to provide hospitals and other providers an opportunity to ask questions about Medicare policies and procedures.

Some MACs permit providers to submit questions to their Medicare Administrative Contractor in advance.

Each MAC may hold separate ATC teleconferences for Part A, Part B, and DME suppliers; furthermore, each MAC mayfocus on certain topics during each ATC webinar.Not all MACs follow the same format.

Her e ar e dat es an d lin k s f or u pcom in g ATC con f er en ces f or Par t A M ACs: WPS Ju r isdict ion 5 - Iowa, Kansas, Missouri, and Nebraska - Next ATC 1/25/2022 - Topic:Outpatient Rehabilitation Updates http://wpsghalearningcenter.com/confirm-course?courseid=AM2awu6Lzvg1 NGS Ju r isdict ion 6 an d K - J6: Illinois, Minnesota, and Wisconsin; - JK: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont - Last meeting held 12/16/2021 https://www.ngsmedicare.com/web/ngs/-/ af_ask-the-contractor-teleconference_091421?lob=93617&state=97206&region=93624 - 2022 ATC conferences have not yet been announced WPS - Ju r isdict ion 8 - Indiana and Michigan - Past ATC conference recordings are available, but 2022 session schedule not yet announced WPS J8 Part A Training Guides and Resources Nor idian Ju r isdict ion E - M edicar e Par t A - California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jea/education/act 6

PARA Weekly eJournal: January 26, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Nor idian Ju r isdict ion F - Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jfa/education/act Novit as Ju r isdict ion H - Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Indian Health & Veteran Affairs - Next ATC scheduled for February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion J - Alabama, Georgia, and Tennessee - January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jja.nsf/DID/AU9QTU8307 Novit as Ju r isdicat ion L - Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania - Next ATC February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion M - North Carolina, South Carolina, Virginia, and West Virginia - Next ATC January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jma.nsf/DID/89BJAR3017 Fir st Coast Ser vice Opt ion s - Ju r isdict ion N - Search for ?Ask the Contractor ? found no results https://medicare.fcso.com/FAQs/0453634.asp

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PARA Weekly eJournal: January 26, 2022

OIG WILL AUDIT COVID-19 OUT OF NETWORK BILLING

Heal t h and Human Ser v ices (HHS) Of f iceof t heInspect or Gener al (OIG) announced t hey wil l conduct a nat ionwideaudit t o r ev iew how pr ov ider s cal cul at ed out - of - net wor k bil l s f or pat ient s admit t ed f or Cov id- 19 t r eat ment .

The Provider Relief Fund (PRF), distributed through HHS and the Health Resources and Services Administration (HRSA) provides funding to health care providers for expenses and lost reimbursement because of COVID-19. As a condition for receiving the payments, a provider cannot collect more from an out-of-network patient treated for COVID-19 than the patient would have owed if the care was provided in-network.In their audit, the OIG will review the documentation on presumptive or actual COVID-19 positive patients to ensure providers who received PRF funds complied with the requirements of the program and did not incorrectly balance bill the patient.

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000647.asp

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

For hospit al s and heal t h syst ems, ext er nal f or ces ar e conv er ging t o make it incr easingly dif f icul t t o consist ent ly opt imize r ev enue cycl e management and sust ain pr edict abl e cash f l ow.

On the front-end, transparency regulations and consumer-driven healthcare are imposing new realities on traditional hospital business models, making accurate, market-appropriate, and publicly available pricing essential.

Separately, the COVID-19 pandemic has transformed the labor landscape? perhaps permanently? by accelerating both the need and desire of employees to work from home.

Employee burnout, vaccine mandates and an historic shift in employment priorities are further complicating the task of finding top-quality revenue cycle personnel.

Kaufman Hall?s 2021 Healthcare Performance Improvement Report found that 92% of responding healthcare organizations said they were struggling to recruit staff, and all reported they were facing issues with staff burnout, vacancies, wage inflation and high turnover.1 The growing challenges of recruiting and retaining experienced claims analysts can have a major impact on claims and denial management, given the exponential growth in the complexity and volume of payer rules and policies.

By some estimates, a claims analyst must access or address upward of 1,200 separate pieces of information daily. Unfortunately, many analysts simply aren?t equipped with either the skills or tools required to manage this data and complete their work effectively. It?s no wonder that even though 90% of denials are preventable, 65% are never corrected and resubmitted for reimbursement.2

75% of r espon den t s said labor pr oblem s h ave im pact ed

In the Kauffman Hall survey, 75% of respondents said labor problems have resulted in poor revenue cycle impacts, with the most common r even u e being ?an increased percentage of Medicaid patients, followed closely by an increased rate of denials, a lower percentage of commercially insured patients, and an increase in bad debt and uncompensated care.?3 9

cycle .

PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

HARNESSINGTHEPOWEROFAUTOMATION In today?s environment, hospital and health system leaders can no longer expect traditional revenue cycle processes to produce the desired outcomes. To maximize cash flow, hospitals must instead harness automation and advanced analytics to augment their existing approaches at each step of the revenue cycle.

That means developing an end-to-end action plan? from pricing through closed-claims audits? that can transform revenue cycle operations and help personnel quickly and consistently make the right decisions.

PRICEOPTIMIZATIONANDTRANSPARENCY That plan begins with pricing. In the face of rising consumer expectations surrounding healthcare price transparency, hospitals that make their prices easily available online will have a competitive edge over those that do not. Equally important, they?ll mitigate the potentially severe financial consequences of non-compliance with Centers for Medicare and Medicaid Services?

(CMS) transparency regulations.

Before prices can be posted, however, organizations must be certain that the numbers they?re releasing make economic sense and are justifiable and competitive when compared to peer pricing. To accomplish this, hospitals should work with pricing experts equipped with advanced analytics to create consistent, rational pricing models assembled around cost, reimbursement, and peer pricing data.

This process begins with a joint review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies. Detailed comparisons should then be made to peer prices using ubiquitous, publicly available data sources.

Price-setting should also take into account contractual reimbursement rates to ensure all new rates are consistent with payer policies.

Finally, timelines should be established for the implementation of any price adjustments designed to align with market conditions. Refined pricing models? carefully calculated by experts equipped with analytic applications and developed in close partnership with hospital finance personnel? can help organizations improve revenue capture and strengthen margins while remaining competitive in local markets and compliant with the CMS rules.

Additional intelligent automation processes capable of providing programmed revenue integrity audits can help mitigate revenue leakage to increase collections and improve margins

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

AUTOMATEDDENIALMANAGEMENTANDPROCESSFLOW Once pricing has been refined, the next step in optimizing the revenue cycle is strengthening denial management. Most hospital leaders understand the financial damage denied claims can produce. Yet organizations continue to fight a losing battle when it comes to eliminating new denials and resolving existing ones.

The complexity of revenue cycle management, coupled with frequent changes in payer policies and rules, can make it extremely difficult for providers to consistently identify and mitigate denial root causes. As a result, the problem of denials is becoming substantially worse, with the average denial rate jumping by 23% in 2020 compared to four years earlier.4 A recent American Hospital Association report found that nearly 90% of hospitals and health systems had experienced an increase in denials over the past three years, and more than half said the increase was significant.5 And even with the administrative costs of resolving denials estimated at nearly $9 billion a year, only about one-third of denials are actually reworked.6 As a result, operating cash flow margins for not-for-profit hospitals fell to a median of 7% in 2020, down from 8.3% in the three prior years, according to Moody?s.7

Aver age den ial r at e ju m ped 23% in 2020 vs f ou r year s ear lier .

Effective denial management requires an entirely new approach that utilizes intelligent automation-driven decision trees to help staffers quickly make good decisions when working a denied claim. New guidance platforms accessible to analysts via the web provide a systematic and consistent approach for working claims, regardless of where the employee is located.

With these platforms, denial inventory can be organized by department, carrier, complexity, or dollar size. Once categorized, coded data indicating why a specific claim was denied is extracted from the payer electronic remittance advice (ERA) 835 files and assigned to the claim interface. When the claims analyst opens the denial, they?re presented with a click-through decision tree that includes brief descriptions of the steps required and presents progressive, ?if-then-else? questions to isolate details about the issue.

The decision tree can lead the analyst through the correct protocol to mitigate the problem and resubmit the claim, regardless of whether the core issue involves coding and billing, coverage, utilization, contractual issues, submission/re-billing, cash posting, or process delays. This level of automated decision support is a game-changer when it comes to denial management, both in terms of reducing the burden on staff and in enforcing quality control.

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

Instead of searching manually through multiple documents to find specific payer guidance? likely located in a three-ring binder or computer folder? the analyst is presented with all payer-specific information within the application and simply clicks through to the appropriate next step.

Importantly, these solutions also automatically generate detailed, clearly constructed notes that immediately populate an adjacent note field as the analyst works through the steps to resolve a claim. This concurrent documentation not only ensures an accurate record of the actions taken, it also saves an enormous amount of time. It?s estimated that each denial management note can take from one-to-11 minutes to complete.

root causeanalysis As critical as it is to address denials quickly and accurately, it is arguably even more important to consistently identify where, when, and why they?re occurring. Root causes ranging from flawed internal processes and technology errors to insurance and clearinghouse mistakes must be uncovered and resolved.

Scrutiny therefore must be brought to bear in a wide array of areas, including front-end processes and payer issues. In addition, system edits and automation opportunities should be explored to ensure denial triggers are permanently eliminated. From this process, hospital revenue management staff can develop a comprehensive knowledge base around the issues that trigger payment delays, either independently or in partnership with an AR follow-up vendor.

Going forward, the hospital will then be positioned to systematically address the full spectrum of shortcomings that contribute to payment delays and write-offs.

For truly effective denial remediation and prevention, it is important for hospitals to align with a qualified AR follow-up management vendor; one that utilizes intelligent automation to automatically categorize and prioritize claims by root cause and identify relevant deadlines associated with each claim.

Combining this level of intelligent automation with staff specialization will help streamline and accelerate the resolution process. However, an effective process also requires ongoing collaboration and communication between the parties. That means essentially treating the vendor as an extension of the hospital?s internal business office.

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

DIVISIONOFLABOR Best practice AR management strategies likewise should incorporate a division of labor between billing teams, with separate groups focused on different tasks before and after the claim has dropped.

Pre-submission team responsibilities can include: - Analyzing the chargemaster to identify and correct chargemaster errors, compliance issues and missing charges. Conducted by Health Information Management (HIM) coding staff, this is essentially an audit designed to map as many claim data points as possible back to their originating source before claims submission - Analyzing current pricing methodology and comparing it locally and with similar-sized facilities to identify opportunities to be more competitive - Assessing the efficiency of current clearinghouse and coding edits in place prior to claims submission.

Post-submission teams should take responsibility for claims from the point of submission out to 30-60 days. At 60-180 days, another team can pick up the claim to free the initial billing staff to focus on younger claims.

At 180-210 days, it is useful for a secondary team to step in to target remaining aging claims.

Finally, once any account is at zero, deploying another secondary team to handle zero-balance and bad debt forensic analysis is an effective strategy.

Creating dedicated teams for each phase of AR management helps establish a competitive yet cooperative environment, with each team striving to perform at the highest level when they?re ?up to bat.? The approach also helps create checks and balances at various stages of the revenue cycle. That said, staffing challenges may compel organizations to incorporate external partners for assistance with some or all these AR-related tasks.

ARSTRATEGIESFORAGEDACCOUNTS: EXTERNALPARTNERS A growing number of hospitals are partnering with third parties to implement end-to-end AR management strategies that can help ensure facilities collect every dollar they?re entitled to on every denial. These hybrid approaches typically see hospital billing staff focusing exclusively on the newest claims, then turning over unpaid balances to specialists at specific aging intervals.

Relying on external experts to pursue low-dollar, high-volume claims is often the most cost-effective way to optimize collections and minimize write-offs, since it frees up staff to concentrate on fresher, higher-dollar claims.

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

Pre-write-off insurance collection experts well-versed in health plan policies can provide an additional safeguard to help prevent legitimate claims, regardless of age or size, from going uncollected. A comprehensive approach will help organizations obtain hard collectible dollars from the full spectrum of aged accounts, including pre-write-off claims and even closed balance accounts.

ZERO-BALANCEREVIEWSOFCLOSEDBALANCEACCOUNTS The final, critical element in a comprehensive AR management strategy is a zero-balance claims review. Zero-balance reviews are essentially forensic audits of written-off claims that also serve to validate claims integrity and maximize contractual revenue from all payers. They are designed to assess whether the factors that initially caused a payer ?s denial can be mitigated to secure retroactive reimbursement.

While some may assume that pursuing old write-offs isn?t likely to be productive, experts skilled at identifying common mistakes that frequently result in denials can recover up to one percent of a hospital total net patient revenue. For large hospitals and health systems that may generate hundreds of millions of dollars annually, this can translate into a significant amount of found revenue. Issues that can cause claims to be written off include underpaid commercial and government insurance dollars, complex reimbursement methodologies, ambiguous contract language causing underpayments, and lack of time to reprocess claims.

Another area of vulnerability that can cost hospitals millions in revenue is when Medicare and Medicare Advantage patients?discharge status codes don?t reflect the post-acute care received.

While these services are outside the hospital?s control, the use of customized intelligent automation can greatly improve the reconciliation of post-acute care discharge status codes.

OPTIMIZEREVENUEANDREDUCELEAKAGEWITHPARAREVSERVICESANDSOFTWARE Hospitals are projected to lose $54 billion in net income through 2021, according to recent analysis by the American Hospital Association.8 The reduced income reflects the ongoing effects of the COVID-19 pandemic, including fewer outpatient visits, greater patient acuity, and higher costs for supplies, labor, and medications. Hospitals and health systems consequently must evolve rapidly to ensure long-term financial health and sustainability.

For many, that means adopting new approaches to administrative staffing, revenue cycle management, reimbursement, and pricing to control labor costs and replace lost revenue.

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PARA Weekly eJournal: January 26, 2022

REVENUE CYCLE EXECUTIVE GAME PLAN

Many understand that integrating intelligent automation into the revenue cycle can help optimize the process. However, taking these steps can be challenging due to lack of IT resources and funding.

Par aRev offers a full spectrum of healthcare revenue cycle management services, from front-end charge master analysis and contract management to end-of-cycle zero-balance denial recovery. The Par a prefix, which means alongside or parallel, reflects the company?s commitment to working seamlessly with hospital financial and billing staff to minimize denials and bad debt, improve collections and boost revenues.

Par aRev has three operational divisions focusing on the core pillars of the healthcare revenue cycle. RevCap, the revenue capture services division, supports primary and secondary AR recovery resolution, targeted denial resolution and zero-balance underpayment recovery.

RevTeg, revenue integrity services division, provides contract analysis, coding and compliance services and market-based pricing analysis.

RevTek , the revenue technology services group, offers Par aPat h, our revolutionary denial decision software, and Par aRev Dat a Edit or , a robust web-based single source solution for pricing, coding, reimbursement, and compliance, along with price transparency, contract management and payer scorecard tools. Par aRev ?s comprehensive capabilities, when aligned with hospital internal teams, can help hospitals improve operating margins and collect additional revenue.

1

2021 State of Healthcare Performance Improvement Report: COVID Creates a Challenging Environment, KaufmanHall, October 18, 2021 2

Glen Reiner, ?Success in Proactive Denials Management and Prevention,? HFMA, May 18, 2021

3

2021 State of Healthcare Performance Improvement Report: COVID Creates a Challenging Environment, KaufmanHall, October 18, 2021 4

Jacqueline LaPointe, Hospital Claim Denials Steadily Rising, Increasing 23% in 2020, RevCycle Intelligence. Feb. 4, 2021.

5

Jacqueline LaPointe, Hospital Claim Denials Up for Most, Driven by Prior Authorizations, RevCycle Intelligence, Dec. 8, 2020

6

Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA Resource Library, July 7, 2015

7 Susan Moore, Moody?s: Rising costs will slow hospitals rebuilding margins to pre-COVID-19 levels, Healthcare Finance, Oct. 26,

2021 8

Report projects U.S. hospitals will lose at least $54B in net income this year, American Hospital Association, Sept. 21, 2021

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PARA Weekly eJournal: January 26, 2022

AUDIO-ONLY TELEHEALTH CODING FOR 2022

Ef f ect iv eJanuar y 1, 2022, physicians and qualified health care providers who render telehealth services through audio-only real-time telecommunications may append m odif ier 93 to the CPT® on the professional fee claim. The instruction was provided by the American Medical Association: https://www.ama-assn.org/system/files/ cpt-appendix-a-modifier-93.pdf

CMS updated the telehealth services list on November 1, 2021. It is available as a download from the link below. Column D, ?Can Audio-only Interaction Meet the Requirements?? identifies those services with a ?Yes.?At the time of publication, Medicare has not indicated modifier 93 is required.

https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes

Further instruction from Medicare is expected in the coming weeks.When it is available, Par aRev will publish an update to this paper.

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PARA Weekly eJournal: January 26, 2022

NEW CMS PUBLICATION ON RURAL HEALTH CLINICS

CM S h as pu blish ed a n ew book let det ailin g n ew ch an ges f or 2022 f or Ru r al Healt h Clin ics.

You can dow n load t h e book let h er e by click in g an yw h er e on t h e gr aph ic.

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PARA Weekly eJournal: January 26, 2022

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

Sect ion 125 of t heConsol idat ed Appr opr iat ions Act of 2021(CAA) cr eat ed t he Rur al Emer gency Hospit al (REH) model as a new Medicar epr ov ider t y pe.

This new provider type will be eligible for enhanced Medicare fee-for-service rates at 5% above OPPS rates, plus an ?Additional Facility Payment? (AFP) designed to bolster the financial viability of providing emergency care in rural areas.The designation is effective as of January 1, 2023.

Current Critical Access Hospitals (CAHs) and rural Prospective Payment System (PPS) hospitals with fewer than 50 beds may convert to REH status to furnish certain outpatient hospital services in rural areas, including emergency department and observation services, but an REH may not offer acute care inpatient services. An REH may offer non-emergency outpatient services and subacute skilled nursing care, however.

New requirements for ?Rural Emergency Hospitals? are among the priorities discussed in the Department of Health and Human Services (HHS) Regulatory Plan for Fiscal Year 2022.A link and an excerpt are provided below: https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf The Department also plans to issue a proposed rule on Requirements for Rural Emergency Hospitals. This rule would establish health and safety requirements as Conditions of Participation (CoPs) for Rural Emergency Hospitals (REHs) participating in Medicare or Medicaid, in accordance with Section 125 of the Consolidated Appropriations Act, 2021, and will establish payment policies and payment rates for REHs. This rule will aim to address barriers to health care, unmet social needs, and other health challenges and risks faced by rural communities.

Excerpts from the Consolidated Appropriations Act are provided below: https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf? Beginning on page 1779 ?(2) RURAL EMERGENCY HOSPITAL.? The term ?rural emergency hospital?means a facility described in paragraph (3) that?

(A) is enrolled under section 1866(j), submits the additional information described in paragraph (4)(A) for purposes of such enrollment, and makes the detailed transition plan described in clause (i) of such paragraph available to the public, in a form and manner determined appropriate by the Secretary;(B) does not provide any acute care inpatient services, other than those described in paragraph (6)(A); 18

PARA Weekly eJournal: January 26, 2022

MEDICARE TO PRIORITIZE RURAL EMERGENCY HOSPITAL RULES

?

(6) DISCRETIONARY AUTHORITY.? A rural emergency hospital may?

(A) include a unit of the facility that is a distinct part licensed as a skilled nursing facility to furnish post-hospital extended care services; and (B) be considered a hospital with less than 50 beds for purposes of the exception to the payment limit for rural health clinics under section 1833(f).

Interested readers may wish to review a summary of the new provider type prepared by the National Rural Health Association at the following link: https://www.ruralhealth.us/NRHA/media/Emerge_NRHA/Advocacy/ Government%20affairs/2021/04-15-21-NRHA-Rural-Emergency-Hospital-overview.pdf

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PARA Weekly eJournal: January 26, 2022

FDA ISSUES EUAS FOR ANTIVIRAL PILLS TO TREAT COVID-19 AT HOME

On December 23, 2021, t heFood and Dr ug Administ r at ion appr ov ed emer gency useaut hor izat ion (EUA) f or Mer ck Mol nupir av ir pil l for the treatment of COVID-19.The drug is cleared for patients 18 and older who test positive for COVID-19 and are at high risk of hospitalization or death.The treatment course includes four capsules every 12 hours for 5 days beginning as soon as the patient tests positive for COVID-19 and within five days of exhibiting symptoms.

The FDA cautions that the capsules are not approved for patients under 18 nor pregnant women due to potential birth defects and the effects on bone and cartilage growth. An FDA fact sheet for molnupiravir is available through the following link: https://www.fda.gov/media/155054/download

The Molnupiravir EUA follows just behind the December 22, 2021, announcement that the FDA authorized an EUA for Pfizer drug, Paxlovid? for high-risk patients age 12 and older who test positive for COVID-19. The 5-day Paxlovid? treatment course includes two drugs, two n ir m at r elvir tablets and one r it on avir tablet twice a day. Similar to the requirements for the molnupiravir treatment, paxlovid should be taken as soon as the patient has tested positive for COVID-19 and within five days of exhibiting symptoms.

The FDA published a fact sheet for Paxlovid? at the following link: https://www.fda.gov/media/155050/download

These prescription drugs are for at-home use, so they will not typically be charged on a hospital or professional fee claim form. There are no HCPCS codes assigned to describe these medications at this time.

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PARA Weekly eJournal: January 26, 2022

COVID VACCINE AND MONOCLONAL ANTIBODY BILLING TO MA PLANS

Or iginal Medicar e t r ansf er r ed r esponsibil it y f or Cov id- 19 vaccines and Cov id- 19 monocl onal ant ibody t her apy r eimbur sement t o Medicar e Advant age pl ans beginning Januar y 1, 2022.

Previously, Medicare required providers to report these services for Medicare Advantage patients to original Medicare for payment. https://www.cms.gov/medicare/ covid-19/medicare-billingcovid-19-vaccine-shot-administration

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PARA Weekly eJournal: January 26, 2022

COVID VACCINE AND MONOCLONAL ANTIBODY BILLING TO MA PLANS

Medicare instructs providers on the Monoclonal Antibody therapy through the following link: https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion

PARAREV offers a full list of the Covid-19 monoclonals and administration codes through the following link: https://apps.para-hcfs.com/para/Documents/New%20COVID-19%20Monoclonal %20Administration%20Codes.pdf

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PARA Weekly eJournal: January 26, 2022

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

The United States Congress passed a bill on December 9, 2021 which enables the Senate to use special expedited procedures to increase the debt limit.

Additional provisions of the bill make changes to several important issues for Medicare providers.

The text of the bill is available at the link below: https://www.congress.gov/bill/117th-congress/senate-bill/610/actions

The new law enacts the following changes for Medicare providers: - Ext en ds t h e m or at or iu m of t h e u su al 2% sequ est r at ion discou n t applied to Medicare payments until March 31, 2022, and reduces the discount on Medicare payments from 2% to 1% for three months, until June 30, 2022 - Ext en ds a M edicar e Ph ysician Fee Sch edu le paym en t in cr ease through calendar 2022; 23

PARA Weekly eJournal: January 26, 2022

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

- St ops f u r t h er r edu ct ion s t o t h e Clin ical Lab Fee Sch edu le in 2022 through 2025; - Avoids a 15% Cu t t o CLFS paym en t r at es f or m an y com m on lab t est s which was to become effective 1/1/2022, as part of the phase-in of rates developed from data collected in 2016 - Delays t h e Pr ivat e Payer lab r at e r epor t in g deadlin e for the January-June 2019 period another year to be due the first quarter of 2023; - Delays t h e im plem en t at ion of M edicar e?s Radiat ion On cology M odel until 2023 Salient excerpts of the changes to Medicare laws and regulations pertaining are provided on the following pages.New language is provided in highlighted italics.

Sequ est r at ion?changes to 2 USC 901a Enforcement of budget goal: (6) Implementing direct spending reductions ?

(B) On the dates OMB issues its sequestration preview reports for each of fiscal years 2022 through 2030, pursuant to section 904(c) of this title, the President shall order a sequestration, effective upon issuance such that(C) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2022 shall be applied to such payments so that with respect to the period beginning on April 1, 2022, and ending on June 30, 2022, the payment reduction shall be 1.0 percent. ?(D) Notwithstanding the 2 percent limit specified in subparagraph (A) for payments for the Medicare programs specified in section 256(d), the sequestration order of the President under such subparagraph for fiscal year 2030 shall be applied to such payments so that? ?(i) with respect to the first 6 months in which such order is effective for such fiscal year, the payment reduction shall be 2.25 percent; and?(ii) with respect to the second 6 months in which such order is so effective for such fiscal year, the payment reduction shall be 3 percent.

Th e M edicar e Ph ysician Fee Sch edu le- (Changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395w-4) (t) Supporting physicians and other professionals in adjusting to Medicare payment changes during 2021 2021 or 2022

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PARA Weekly eJournal: January 26, 2022

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

(1) In general In order to support physicians and other professionals in adjusting to changes in payment for physicians' services during 2021 during 2021 and 2022, the Secretary shall increase fee schedules under subsection (b) that establish payment amounts for such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent for (A) such services furnished on or after January 1, 2021, and before January 1, 2022, by 3.75 percent; and (B) such services furnished on or after January 1, 2022, and before January 1, 2023, by 3.0 percent.

Clin ical Lab Fee Sch edu le? changes to TITLE 42 / CHAPTER 7 / SUBCHAPTER XVIII / Part B / § 1395m-1 revising the phase-in of reductions that would have reduced CLFS rates on many codes by as much as 15% in 2022: - (b) Payment rates for clinical diagnostic laboratory tests - ?

(3) Phase-in of reductions from private payer rate implementation (A) In general Payment amounts determined under this subsection for a clinical diagnostic laboratory test for each of 2017 through 2024 through 2025 shall not result in a reduction in payments for a clinical diagnostic laboratory test for the year of greater than the applicable percent (as defined in subparagraph (B)) of the amount of payment for the test for the preceding year.

(B) Applicable percent defined In this paragraph, the term "applicable percent" means(i) for each of 2017 through 2020, 10 percent; (ii) for2021 for each of 2021 and 2022, 0 percent; and (iii) for each of 2022 through 2024 2023 through 2025, 15 percent.

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PARA Weekly eJournal: January 26, 2022

DEBT LIMIT BILL BRINGS RELIEF FOR MEDICARE PROVIDERS

Lab PAM A r epor t in g-(Changes to 42USC 1395m-1(a)(1)(B) Improving policies for clinical diagnostic laboratory tests) (B) Revised r epor t in g per iod ·In the case of reporting with respect to clinical diagnostic laboratory tests that are not advanced diagnostic laboratory tests, the Secretary shall revise the reporting period under subparagraph (A) such that(i) no reporting is required during the period beginning January 1, 2020, and ending December 31, 2021 December 31, 2022; (ii) reporting is required during the period beginning January 1, 2022 January 31, 2023, and ending March 31, 2022 March 31, 2023; and (iii) reporting is required every three years after the period described in clause (ii).

Th e Radiat ion On cology pr ogr am -(Changes to the December 27, 2020 Consolidated Appropriations Act, Public Law 116-26): SEC. 133. DELAY TO THE IM PLEM ENTATION OF THE RADIATION ONCOLOGY M ODEL UNDER THE M EDICARE PROGRAM . Notwithstanding any provision of section 1115A of the Social Security Act

(42 U.S.C. 1315a), the Secretary of Health and Human Services may not implement the radiation oncology model described in the rule entitled ??Medicare Program; Specialty Care Models To Improve Quality of Care and Reduce Expenditures??(85 Fed. Reg. 61114 et seq.), or any substantially similar model, pursuant to such section before January 1, 2022 January 1, 2023.

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PARA Weekly eJournal: January 26, 2022

MLN CONNECTS

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Th u r sday, Jan u ar y 20, 2022

New s -

COVID-19: Vaccine Access in Long-term Care Settings There?s Still Time: Recommend the Flu Shot Chiropractic Treatment of the Spine: Comparative Billing Report in January

M LN M at t er s® Ar t icles -

Calendar Year (CY) 2022 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment ? Revised New & Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE ? Revised

Pu blicat ion s -

Rural Health Clinic ? Revised

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PARA Weekly eJournal: January 26, 2022

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PARA Weekly eJournal: January 26, 2022

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PARA Weekly eJournal: January 26, 2022

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PARA Weekly eJournal: January 26, 2022

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