COVID-19 Policy Updates

The Alabama Rural Health Association has been working to develop policies and flexibility for providers in order to best protect themselves and meet the needs of their patients in a safe and effective manner.

We have provided an update, below, of all policy changes enacted by various state and national organizations related to COVID-19.  Please read carefully and call us at 334.697.8541 if you have any questions or need additional information.


Resources

COVID-19 Screening Tool

Telehealth Revenue Calculator (tool provided by Azalea Health)

COVID-19 and Telehealth Coding “Cheat Sheet” (supplied by the AMA)


Alabama Division of Medicaid (DOM)

The extension of telemedicine services through the Alabama Division of Medicaid is effective March 16, 2020. This extension allows clinicians to provide medically necessary services that can be appropriately delivered via telecommunication services including telephone consultations. The extension also allows some behavioral health services to be appropriately delivered via telecommunication services including telephone consultations. These actions will be effective for one month, expiring on dates of service April 16, 2020. It will be reevaluated for a continuance as needed. This is applicable for recipients who wish to receive their care remotely and limit their exposure to the virus. It can also serve as an initial screening for recipients who may need to be tested for COVID-19. For guidance on coronavirus testing, please refer to the Centers for Disease Control & Prevention, Alabama Department of Public Health, and Alabama Department of Mental Health websites.

 


Centers for Disease Control and Prevention (CDC)

CDC Infection Control Guidance: This updated guidance from the CDC provides updated PPE recommendations for the care of patients with known or suspected COVID-19.

  • Facemasks are an acceptable alternative to N95 respirators when respirators are unavailable in healthcare settings.
  • Respirators should be prioritized for procedures that are likely to generate respiratory aerosols.
  • When an adequate supply of respirators is available in a healthcare facility, facilities should return to use of respirators per their respiratory protection program.
  • Continue to use eye protection, gown, and gloves.
  • If there is a shortage of gowns, they should be prioritized for aerosol-generating procedures, high contact patient care activities, and activities where splashes and sprays may occur.

Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients undergoing aerosol-generating procedures.

Medicare will pay doctors and hospitals for a broad range of telehealth services on a temporary basis, effective March 6. The program will pay for office and hospital telehealth visits and include a wide range of providers including nurse practitioners, clinical psychologists and social workers. Telehealth visits will be reimbursed for the same amount as in-person visits.

CAH Swingbed Flexibility

CMS issued a Section 1135 waiver to allow CAHs and rural (non-CAH) swing-bed hospitals to move patients from their acute care beds to swing beds for extended care services without a 72-hour prior hospitalization. This clarification will help utilization review processes in rural hospitals to better maximize use of patient care beds.

Elimination of Geographic Restrictions

March 6, 2020, Medicare began temporarily paying clinicians to furnish beneficiary telehealth services residing across the entire country. In addition, the beneficiary generally could not get telehealth services in their home.

Services and Providers

Under this Section 1135 waiver expansion, a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, can offer a specific set of telehealth services. The specific set of services beneficiaries can get include evaluation and management visits (common office visits), mental health counseling, and preventive health screenings. Beneficiaries can get telehealth services in any health care facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.

Diagnostic Billing Code Tookit

CMS recently published a telehealth toolkit to assist providers in the new telehealth policies and diagnostic billing codes.

Co-Pay Requirements Waives

The Office of Inspector General stated that if a provider wishes to waive collection of the 20% coinsurance, they can and the OIG will not consider this a violation of the antikickback rules. This is voluntary.

To read the Fact Sheet on this announcement visit: https://www.cms.gov/newsroom/factsheets/

 


Centers for Medicare and Medicaid Services (CMS)

Medicare will pay doctors and hospitals for a broad range of telehealth services on a temporary basis, effective March 6. The program will pay for office and hospital telehealth visits and include a wide range of providers including nurse practitioners, clinical psychologists and social workers. Telehealth visits will be reimbursed for the same amount as in-person visits.

Elimination of Geographic Restrictions

March 6, 2020, Medicare began temporarily paying clinicians to furnish beneficiary telehealth services residing across the entire country. In addition, the beneficiary generally could not get telehealth services in their home.

Services and Providers

Under this Section 1135 waiver expansion, a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, can offer a specific set of telehealth services. The specific set of services beneficiaries can get include evaluation and management visits (common office visits), mental health counseling, and preventive health screenings. Beneficiaries can get telehealth services in any health care facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.

Diagnostic Billing Code Tookit

CMS recently published a telehealth toolkit to assist providers in the new telehealth policies and diagnostic billing codes.

RHC Code Updates

Distance site telehealth visits for RHCs must be billed with HCPCS code G2025. For distant site services rendered between January 27th, 2020, and June 30th, 2020, RHCs must bill G2025 with modifier CG. After July 1, RHCs will no longer need modifier CG. Furthermore, modifier 95 is completely optional for all G2025 claims.

Audio-only services such as the audio E/M services 99441, 99442, and 99443, may now be billed as G2025 services.

View More Details

RHC Telehealth Reimbursement Prior to June 30, 2020

All CMS G2025 claims prior to June 30, 2020 must be billed with modifier CG and will reimburse at the RHC’s all-inclusive rate. Beginning July 1, 2020 all these claims will be reprocessed to $92.03. After July 1st, the CG modifier is no longer needed, and these claims will pay $92.03 from the onset.  Guidance has been provided that CMS may recoup the difference between the all-inclusive rate paid prior to July 1, and the $92.03 fee schedule.

Co-Pay Requirements Waives

The Office of Inspector General stated that if a provider wishes to waive collection of the 20% coinsurance, they can and the OIG will not consider this a violation of the antikickback rules. This is voluntary.

To read the recently released RHC billing practice form: visit www.cms.gov/files/document/se20016.pdf 

To read the Fact Sheet on this announcement visit: https://www.cms.gov/newsroom/factsheets/


CARES Act

As part of the CARES Act, Congress has authorized Rural Health Clinics to be the “distant site” for telehealth visits. Until now, RHCs could only be the originating site for these visits. CMS is working on the guidance necessary to allow you to begin submitting claims for these visits but you can begin doing these visits as of March 27th Providers may need to hold these claims until billing guidance is issued.

The CARES Act establishes a $100 billion grant fund exclusively for health care providers who are enrolled in the Medicare and Medicaid program. The purpose of this fund is to provide grants to healthcare providers who have experienced a reduction in revenue due to the COVID19 pandemic.

The CARES Act creates the Paycheck Protection Loan Assistance program which expands and modifies an existing Small Business Administration (SBA) Loan program. What makes this “loan” program unique is that the government will be able to FORGIVE all or most of this loan if the business does not terminate employees during the pandemic. If the small business uses the loan to cover monthly expenses such as: payroll, continuation of health benefits for employees, rent, mortgage, utilities and interest on other loans you may have, then that portion of the loan will be forgiven.


Department of Health and Human Services (HHS)

During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies.  Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.

OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  This notification is effective immediately.

This may include:

  • Facetime
  • Skype
  • Unencrypted Zoom / GoToMeeting, etc

This should not include:

  • Facebook live
  • YouTube
  • Other publicly facing streaming services

Blue Cross and Blue Shield of Alabama

As we continue to monitor the outbreak of the new coronavirus (COVID-19) in Alabama, we are expanding telehealth to ease access to appropriate medical services for your patients who are Blue Cross and Blue Shield of Alabama members.

What does the expansion include?

The expansion of telehealth services is effective March 16, 2020, and allows clinicians to provide medically necessary services that can be appropriately delivered via telephone consultation. These actions will be effective for one month, expiring on April 16, 2020. It will be reevaluated for a continuance as needed.

This is applicable for patients who wish to receive their care remotely and limit their exposure. It can also serve as an initial screening for patients who may need to be tested for the coronavirus. For guidance on coronavirus testing, please refer to the Centers for Disease Control & Prevention and the Alabama Department of Public Health websites.

Member cost-sharing (copayments, deductibles, etc.) will apply according to the member’s contract benefits. This applies to all Blue Cross and Blue Shield of Alabama members including Blue Advantage®.

What types of providers can perform telehealth?

This applies to physicians and their extenders who currently receive Blue Cross reimbursement on the Preferred Medical Doctor (PMD), Physician Extender, Select and Select Extender fee schedules. Urgent care is also included; however, at this time, we are not including other provider types.

How does this affect behavioral health?

Behavioral health providers are included in this policy expansion. Some of these providers already perform telemedicine services. Under this policy, all behavioral health providers will be able to perform services telephonically. This policy expansion will expire on April 16, 2020, but be reevaluated for continuance as needed.

For more information about behavioral health phone consultations, see our telemedicine operational policy. For behavioral health billing and coding guidelines specific to this telehealth expansion, refer to the New Directions Behavioral Health telehealth expansion memo (link will be posted here when available).

New Directions will communicate additional telehealth services information to providers. To support providers who may have patients experiencing distress or anxiety, New Directions is offering a crisis hotline for the public at 1-833-848-1764.

What services can be performed?

Telehealth is appropriate for consultations and visits for either low complexity, routine or ongoing evaluation and management. This would include acute illnesses or chronic disease management that, based on the provider’s medical judgment, can be managed over the phone.

What codes apply?

Providers should bill established-patient evaluation and management codes up to a level 3 (CPT codes 99211, 99212 and 99213). Standard documentation applies and additional billing guidelines will be posted on ProviderAccess. Claims should be filed with place of service 02 (telehealth). A modifier is not required.

Providers should only bill for telephonic consultations when the provider speaks directly with the patient. Providers should not bill Blue Cross for services when, for example, a nurse speaks to the patient, even if the provider was consulted.


Department of Health and Human Services (HHS)

During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies.  Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.

OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  This notification is effective immediately.

A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients.  OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency.  This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.

Read More


Substance Use Disorder Services Via Telehealth

CMS released guidance for rural health care and Medicaid agencies on telehealth flexibilities provided by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act.

Read More

Status Report of the Alabama Primary Care Physician Workforce, 2019

Summary

Access to care is identified as Alabama’s number one health issue in the 2015 State of Alabama Community Health Improvement Plan, with the most significant and universal barrier being access to a Primary Care Physician (PCP).

In 2019 Alabama needs an additional 126 primary care physicians working 8 hours per day, 5 days per week located in 40 specific population centers to eliminate Alabama’s shortage of PCPs.

Alabama has one Full Time Equivalent (FTE) PCP for every 2,410.6 residents. This ratio globally suggests that Alabama has adequate numbers of PCPs available for its 4,850,771 residents, but in Alabama the PCP shortage is the result of the current distribution of PCPs and the lack of PCP access it creates.

Purpose

This report identifies Alabama’s licensed primary care physicians (PCPs), their spatial distribution and their availability to Alabama residents. This model addresses access to primary care physicians at the community level while at the same time giving direction and allowing coordination at a state level.

The Office for Family Health Education & Research, UAB Huntsville Regional Medical Campus

  • William H. Coleman, MD PhD
  • Kyle Seigrist, PhD
  • Caleb Lenox, Research Associate
  • Alex Kearns, MS III

98% of Alabama’s PCP practices are located in 79 Alabama population centers.

These population centers are towns and cities where most Alabamians currently could or do obtain direct patient access to a PCP(s). These population centers are spatially located such that 96% of Alabama’s 4,850,771 residents are within a 30 minute or less travel time from one of these 79 population centers. The Alabama county map (Figure 1) shows the location of these 79 cities and towns and the practice locations of Alabama’s PCPs (green icons). Counties are geopolitical units, but they are not appropriate boundaries for defining population units (catchment areas) that can be linked to the 79 locations that house Alabama’s current PCP workforce.

Figure1

Figure 2 shows Alabama’s 79 PCP population centers as points of access for residents in their catchment areas (Primary Care Service Areas or PCSAs). The boundaries of these PCSAs place each population center equidistant from all other population centers as measured by Alabama’s road network. PCSAs link PCPs in the network’s 79 towns and cities to their accessible populations in a manner that allows accurate calculation of PCP shortages based on local population demand. Towns and cities with shortages of PCPs in 2019 are denoted in red while centers in blue are population centers with an adequate number or a surplus of PCPs.

Figure2

Using PCSAs instead of counties maintains Alabama’s usual designation of rural and urban areas and results in a more appropriate allocation of residents to rural or urban population centers, and PCPs, based on geographic accessibility. Figure 3 is an Alabama PCSA map color coded to identify rural and urban PCSAs, with 18 PCSAs designated as urban, and 61 designated as rural.

Figure3

The results of Alabama’s PCP workforce analysis is presented in Figure 4. This table quantifies and details the results of Alabama PCP shortages in a concise, easily identifiable format. In summary, 40 population centers have a shortage of PCPs and 37 of these are rural. These population centers need a total of 126.3 additional FTE PCPs to eliminate the PCP shortage for the state as a whole. The other 39 population centers have adequate or surplus PCPs and 24 of these are rural. The PCSAs with a surplus have 493.2 more FTE PCPs than needed. In this table PCP shortages, adequate balance and surpluses are quantified at specific locations to identify not only how many PCPs are needed but also where they are needed.

Figure4

98% of Alabama’s PCP practices are located in 79 Alabama population centers.

These population centers are towns and cities where most Alabamians currently could or do obtain direct patient access to a PCP(s). These population centers are spatially located such that 96% of Alabama’s 4,850,771 residents have 30 minute or less travel time access to PCPs. This map (Figure 5) shows the spatial distribution of Alabama’s towns and cities where Alabama residents have access to 98% of Alabama’s PCPs.

Figure5

Conclusions

Alabama has 79 population centers identified as primary care service points based on PCP availability and population accessibility. The results table (Figure 4) serves as a template for focused needs evaluations, resource determinations and barrier assessment. It allows unique individualized community approaches, regional approaches where common issues among population centers exist, and realistic identification and consideration of issues that can to be addressed a state level.

Alabama population centers with shortages of PCPs are documented. The number of PCPs needed to resolve the shortages at these 40 population centers are documented. In addition Alabama’s FTE PCP statewide workforce is accounted for.

This analysis establishes that Alabama has a data-driven model with the capacity to accurately identify and quantify primary care workforce data, and produce annual updates. It serves as a tool to monitor outcomes and is able to project future needs based on PCP and population demographics. This model matches patient demand, based on average visits per year and average time per visit, with PCP availability, based on a standard physician workweek. Other models lack this specificity, which could result in different need computations, but most of these would identify the same service areas in need.

Recommendation

While this information is basic to understanding, accessing and addressing population center based shortage issues, the fact is, this information is not generally known. Thus the first step is broad-based dissemination of this information.

ARHA Concludes Statewide Listening Sessions | Develops 2020 Policy Agenda

The Alabama Rural Health Association recently concluded its four-part statewide Policy Road Show with a board retreat to develop its 2020 Policy Agenda.

The Policy Road Shows opened opportunities for constituents across Alabama to voice their opinions on major healthcare issues in their communities.  More than 250 attendees were able to provide feedback.  The Road Show events took place in Rainsville, Wetumpka, Livingston, and Enterprise.

ARHA directors and advisory board members gathered after the final Road Show to study results and determine policies and legislation that would best help to accomplish the desires of constituents.  After robust discussion, the following was proposed:

  • Medicaid expansion / increased Medicaid funding
    • Pursue approaches to Medicaid improvements, including considerations of Medicaid expansion and/or increased reimbursement for current Medicaid covered services.
  • Physician and dental rural tax credit bill
    • Pursue a physician tax credit bill to help recruit physicians to rural areas.
  • Behavioral health and oral health improvement
    • Support behavioral health and oral health in Alabama for structural, access, and reimbursement improvements.
  • Health promotion (including health literacy) and focus on social determinants
    • Support health promotion efforts statewide (including health education, health literacy, and health system advocacy and navigation) and policies and legislation that would support or assist with health promotion.
  • Telehealth
    • Support expansion and reimbursability of telehealth statewide. This may include support of a parity law.
  • Public/private insurance reform
    • Support various public/private insurance reform issues.
  • Tax credit bill for physicians who serve in preceptor roles for student physicians.
    • Support for a tax credit bill for physicians / providers who teach students as a preceptor to help with recruitment of physicians in rural areas.
  • Transportation
    • Support for emergency and non-emergency medical transportation support.
  • Vaccinations
    • Support for continued use of immunizations and vaccinations of patients.
  • Advance physician extenders
    • Support for nurse practitioners, physician assistants, and other healthcare providers that extend care into underserved areas and to provide needed care as appropriate.
  • Access to healthy food
    • Support for rural grocery stores, farmers markets, and subsequent nutrition education in rural communities.
  • Social determinants
    • Support for recognition and support of social determinants of health in order to improve patient compliance and outcomes.
  • Broadband support
    • Support for the advancement of broadband in rural Alabama for increased internet speed for electronic medical record systems and telehealth.
  • Chronic disease prevention and compliance
    • Support preventive services related to chronic health conditions as well as treatment services.
  • Encourage additional health system collaboration
    • Encouragement of new partnerships, whether direct or indirect, to increase resources and decrease cost for value-based care and access to care.

The Alabama Rural Health Association would like to thank each member and constituent who participated in the Road Shows, and each board member and advisory board member who participated in the planning and execution of the events as well as worked to develop the 2020 Alabama Rural Health Policy Agenda.

For more information, contact the Alabama Rural Health Association at 334.697.8541 or arha@arhaonline.org.

Jackson County physician selected as ‘Community Star’ for National Rural Health Day

National Rural Health Day is an annual observance that emphasizes the importance of rural America and promotes the need for accessible, high quality health care. National Rural Health Day falls on the third Thursday in November each year and recognizes the efforts of those serving the health needs of over 60 million people across the nation. This year’s observance will be on November 21.

The Alabama Department of Public Health’s Office of Primary Care and Rural Health (OPCRH), the Alabama Family Practice Rural Health Board, the Alabama Hospital Association, the Alabama Primary Health Care Association, the Alabama Rural Health Association, and the University of Alabama at Birmingham Rural Hospital Resource Center are proud to recognize the innovation, quality of care, and dedication of health professionals and volunteers in the state during National Rural Health Day 2019.

This year, Dr. Muhammad Ata of Pisgah, Ala., a true champion of rural health care, has been selected as a “Community Star” for his many contributions in rural communities. The annual “Community Stars” eBook publication honors and gives a personal voice to rural people, providers, advocates and communities across the country. His story will appear in the 2019 eBook that will be available on the PowerofRural.org website, the official hub for National Rural Health Day and the Power of Rural movement, beginning November 21.

Rural health care professionals, hospitals, county health departments, and clinics are dedicated to providing health care in Alabama’s 54 rural counties, which are home to almost 2 million people. These rural communities have unique health care needs and challenges, including the distance to nearest health care facility. In addition, these counties have a population that is generally older, and with health conditions that require a greater need for health care.

Rural hospitals are the economic foundation of many rural communities, but they are being threatened with declining reimbursement rates and disproportionate funding levels that make it more difficult to serve their residents. The OPCRH is dedicated to addressing these issues through a number of programs, such as the following:

·        Loan repayments for physicians, dentists and other health care professionals through the National Health Service Corps
·        No-cost recruitment of physicians using a national recruitment and retention database
·        Adoption of telehealth services to bring distant health care to the local community
·        Designation of physician and dental shortage areas for federal assistance programs
·        Assisting rural clinics in becoming certified to receive enhanced medical payments

In addition, OPCRH works closely with rural hospitals and safety net providers to identify problems and provide needed technical assistance and resources. More than 170 health care providers are presently working throughout the state under programs administered by the office, dispersed among the state’s 154 community health center service delivery sites, 109 rural health clinics, and other providers. The OPCRH’s services are available to any rural health care organization that is dedicated to providing accessible, high quality health care to its community.

Gov. Kay Ivey has issued a proclamation encouraging citizens to recognize the valuable services of rural health practitioners on this day.
To learn more, visit https://nosorh.org/calendar-events/nrhd/