AMGA CFO Council: Receiving Federal Funds and Telehealth Issues

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Discussion Summary
April 22, 2020

This summary is based on discussion during a conference call held by AMGA’s Chief Financial Officer/Finance Director Council on April 22, 2020, following a federal policy update given by Chet Speed, J.D., LL.M., chief policy officer, AMGA, and comments on telemedicine by Ted Matthews, CFO of the Austin Regional Clinic. For more information about the CFO Council, please click here.

Questions Following Federal Policy Update from Chet Speed, J.D., LL.M., Chief Policy Officer, AMGA

Question: Is there any discussion of including Medicare Advantage receipts in the next round of funding?

Speed: The Department of Health and Human Services (HHS) indicated payments have already been paid, so they are trying to figure out how to get money from the plan to the providers. It has to go through HMOs which is perceived to slow the process. AMGA joined with insurance companies to ensure money gets to MA providers.

Question: Can you clarify the funding breakdown of the Coronavirus Aid, Relief, and Economic Security (CARES) Act?

Speed: A total of $70 billion was passed in the CARES Act and remaining in relief fund, and another $75 billion will be added to a relief fund Thursday, April 23, or Friday, April 24. Out of the $70 billion:

  • $10.7 billion is going to providers with extreme revenue loss through provider certification form (will be provided by HHS)
  • How are they measuring hot spots, and how are they going treat hospitals vs provider groups within those hotspots?
    • $10 billion allotted for hospitals and distribution based on hospital beds and COVID admissions (NYC, NJ)
  • $9.3 billion is allotted to Medicaid, children’s hospitals, OBGYNs, etc.
  • $20 billion is part of remaining $67 billion
    • AMGA is asking for $320 billion on top of that

Question: What might be required of commercial plans?

Speed: Payers are basically making $3.5 billion per day on claims not being paid out and are already making claims for additional money. Payers are expecting people to not pay premiums. AMGA opted not to pursue payers [in their request for additional money], but rather focus on [AMGA members] and not take on big stakeholders.

Question: Have you heard anything about guidance for loan repayments under the Paycheck Protection Program (PPP)?

Group member said the three caveats are:

  • Figuring out the number of full-time employees that were reduced
  • Amount of salary reduction (main question is: How will this be calculated?)
  • Overall exemption of forgiveness if by June 30 all employees are rehired at same wages received prior to COVID

Group member stated federal loans not yet available due to banks not knowing how to administer them.

Question: Is there any summary guidance on how to use the funds?

Speed: Not sure at this time; AMGA will research requirements and provide advice based on findings.

Healthcare Financial Management Association (HFMA) letter focused on compensation limitation to executive two level, which wouldn’t cover physicians’ salaries. Consider following PPP program format; focus on employee-related functions, primarily keeping furloughed staff’s health insurance premiums paid.

Question: What has been the operational impact?

  • One group experienced voluntary furlough initiated by 25% of entire staff; some were also eligible for unemployment
    • Larger number of idle staff on primary care side; shifting employees clinic to clinic
    • Management and directors managing billing and patients
    • Many telemedicine visits can be doctor-only, which reduces the need for nursing and front-desk support
  • Another group furloughed 385 out of 730 staff
    • Couldn’t thread needle re: groups greater than 500 receiving aid
    • Will be hard to get all 385 staff back
    • 277 out of 385 still burning hours; 108 sitting on sidelines fighting for unemployment checks
  • One group with 800 employees received PPP funds; alternative size provision interpreted into the law does work
    • No more than $15 million in net assets owned by organization and no more than $5 million a year of income to qualify

Question: Are you worried about staff not returning when things get back to normal?

  • One group is expecting most employees will return, but anticipating a real surge of people will want to continue telework they have already experienced.

Comments and Questions Following Telehealth Discussion with Ted Matthews, M.B.A., CPA, CGMA, Chief Financial Officer, Austin Regional Clinic

  • Epic virtual visit platform works best; Epic agreed to waive license cost for each new MyChart that is required.
  • Visits are mostly initiated by patients calling in, but clinic is also conducting outgoing calls, for instance for routine appointments.
  • Pros: Physicians are working from home and can turn calls around more quickly than moving a patient through the clinic.
  • Physicians also using IQHealth app to enter information directly into EMR through their phones, and some physicians have secured an additional phone for this purpose.
  • Limiting factor is that the patient has to have capability to do a video visit in order for provider to not bill an audio-only visit; doctor has to quiz the patient to find out if they can switch from audio to virtual visits.
  • Majority of patients have FaceTime, etc. MA populations have more flip phones, so providers are getting paid less for audio-only visits. Blue Cross has been pretty good at paying at normal rate.
  • Federal Communications Commission COVID-19 telehealth program was talked about to provide funding for telehealth. Funding did not apply due to the group being for-profit and not a community health center, etc.
  • One-third to two-thirds of visits are now virtual, averaging almost half overall.

Question: What is your percentage of visits now versus pre-COVID?

Matthews: Close to 60% overall, primarily from family medicine and internal medicine.

  • Internal medicine: 85%
  • Family medicine: 90%
  • Specialists: 20% - 60%

The decreased number of procedures like elective surgeries has had the biggest impact.

Question: Have you done any telephonic visits, and how are people instructing physicians to code?

Matthews: We are using E/M codes with telephonic visit modifier and following relaxed rules around telemedicine visits.

  • We visited with major payers in advance to confirm their understanding of honoring relaxed rules.
  • One negative was that it was going to take payers some time to get their systems reconfigured to process claims correctly.
  • Everyone except Aetna was able to get it straightened out, so that our group is getting paid at the regular E/M visit rate.
  • Expecting to see coding level drop because our group couldn’t do system-level checks; have experienced some of that, but more than that, have seen a loss of add-ons during visits.

Question: How did you ramp up to two-thirds of your patients being virtual?

Matthews: It’s easier to hit two-thirds with a low number of patients.

  • Conducted one-on-ones with doctors to show them how to use the system and explained that without this, there was no revenue for physicians.
  • Also implemented physician champions, who assisted other physicians with getting familiar with the new system.
  • Varied case by case, ranging from the doctors’ realization of being able to conduct visits from home, to physicians realizing conversion to the system would be the difference between the life and death of their own income.

Question: Are you doing annual wellness visits virtually? Will you do virtual visits after COVID?

Matthews: Yes and yes

  • Wellness visits depends on patients’ ability to go to a virtual visit if required.
    • Have lobbied to have reduction of criteria on quality measures for this year or at least for a quarter of this year.
    • Not able to do the quantity of visits, but can do the visits; they are just more challenging and take more time to ensure everything is covered throughout the visit.
  • We already assumed we will continue virtual visits post-COVID.
  • Have moved to special clinic times. Examples include some pediatric wellness visits being offered during weekends. Special clinic times are expected to continue post-COVID.
  • Specialty physicians have really embraced virtual visits.
  • Not sure of the exact percentage of how many virtual visits will be conducted post-COVID, but anticipate there will be demand from both patients and doctors to continue virtual visits.
  • Another group is thinking of extending hours and adding more telehealth visits, and also considering the impact of potential loss to ancillary businesses.
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