Financial Implications of Provider Enrollment During the COVID-19 National Emergency

Financial Implications of Provider Enrollment During the COVID-19 National Emergency

May 19, 2020

Author: Joe Morris, Writer, HealthStream


This blog post is based on an Industry Insight Webinar: COVID-19 Enrollment and Financial Implications, Facts and Resources


Hospitals have been operating in a national emergency for a few weeks now, which has dramatically altered credentialing and privileging processes. Providing care to patients and responding to this pandemic is the focus of your staff and the entire healthcare system right now. But to keep your business healthy and serving patients, you will have to get reimbursed for services rendered.


Here’s what you should know about Medicare/Medicaid’s response to the disaster and how it impacts credentialing and enrollment.

Medicare/Medicaid Response: 1135 Waiver


What is it:


In certain circumstances, the Secretary of the Department of Health and Human Services (HHS) using section 1135 of the Social Security Act (SSA) can temporarily modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements, called 1135 waivers. There are different kinds of 1135 waivers, including Medicare blanket waivers. When there's an emergency, sections 1135 or 1812(f) of the SSA allow the issue of blanket waivers to help beneficiaries access care. When a blanket waiver is issued, providers don't have to apply for an individual 1135 waiver.

How it impacts credentialing and enrollment:

Emergency requirements were met on: 3/12/20

  • President declares disaster or emergency (under the Stafford Act or National Emergencies)
  • HHS Secretary declares public health emergency (under Section 319 of the Public Health Service)

The declaration allows for:

  • Reimbursement during emergency/disaster for providers that do not meet certain requirements for Medicare, Medicaid or CHIP payment and is retroactive effective as of March 1, 2020.

The declaration does not allow for:

  • Reimbursement for services otherwise not covered.
  • Individuals to be eligible for Medicare who would not otherwise be eligible.

Medicare Blanket Waiver


CMS implements specific waivers or modifications on a “blanket” basis when a determination has been made that all similarly situated providers in the emergency area need such a waiver or modification. Once approved, these waivers apply automatically to all applicable providers and suppliers. Providers and suppliers do not need to apply for an individual waiver if a blanket waiver is issued by CMS.


There is a 26-page document listing all Medicare Blanket Waivers available here. But the following are a few key waivers that pertain to credentialing and enrollment:


#1 Medicare Blanket Waiver Practitioner Location


This waives requirement for an out of state practitioner to be licensed in the state they are providing services in when licensed in another state. To be eligible, practitioners:


  • Must be enrolled in the Medicare program
  • Must have a valid license in the state related to Medicare enrollment
  • Perform telehealth or in person services in a state which the emergency is occurring
  • Not be excluded from practice in state or any other state that is part of the 1135 emergency area

#2 Medicare Blanket Waiver-Provider Enrollment


This pertains to several enrollment requirements.


  • Non-Waiver CMS Action: CMS has a toll-free hotline for physicians and non-physician practitioners and Part A certified providers and suppliers establishing isolation facilities to enroll and receive temporary Medicare billing privileges. Hotline information is available here.
  • Waive Screening Requirements:
    • Application Fee (to the extent applicable)
    • Criminal background checks associated with fingerprint-based criminal background checks (FCBC) (to the extent applicable) - 42 CFR §424.518
    • Site visits (to the extent applicable) - 42 CFR §424.517
  • Postpone all revalidation actions
  • Allow licensed providers to render services outside of their state of enrollment
  • Expedite any pending or new applications from providers
  • Allow physicians and other practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location
  • Allow opted-out physicians and non-physician practitioners to terminate their opt-out status early and enroll in Medicare to provide care to more patients

States and Provider/Supplier Waivers


Individual waivers can also be issued for states and provider/suppliers. These only need to be applied for if something is needed beyond what is provided under an existing Medicare blanket waiver.


Two new areas in this emergency are:

  • COVID-19 facility setup, such as transfer from SNF, HH, etc. to another location (e.g. a hotel used as a temporary treatment facility)
  • Medical evaluation at drive-thru testing location

Flexibilities at the state-level for Medicaid program requirements could include:

  • Prior authorization in fee-for-service programs
  • Allowing providers located out of state/territory to provide care to another state’s Medicaid enrollees impacted by the emergency
  • Temporarily suspending certain provider enrollment and revalidation requirements to increase access to care

As of April 14, 2020, CMS has approved 50 emergency waivers, 28 state amendments, 9 COVID-19 related Medicaid disaster amendments & one CHIP COVID-related disaster amendment.


CMS Telehealth Facts


CMS has been focusing since 2019 on expanding the use of tele-health services and allowing for payments for those, but the focus has greatly increased during the COVID-19 National Emergency. Eligible services have been expanded to include 80+ services including mental health counseling, preventive health screenings, emergency department visits and more. The requirement to have face-to-face contact with ta patient, has also been lifted. Making use of proper codes when billing will be critical for reimbursement of these services. More information can be found here.


CMS Accelerated Advance Payments


CMS is also authorized to provide Accelerated Advance Payments) during this public health emergency to any provider and/or supplier who submits a request and meets requirements. They have delivered over $50 billion through expansion of Accelerated Advance Payments. These advance payments are loans providers must pay back. This funding is separate from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The CARES Act appropriation is a payment that does not need to be repaid. More information on submitting requests for APPs can be found here.


You are not alone


Much is being done to address both the needs of patients and the needs of economy during the COVID-19 pandemic. CMS is making it easier to get more providers on the frontline and expanding the scope of services covered to meet emerging health needs. On March 27, 2020 the President signed a $2.2 Trillion stimulus plan, which allocated $130 billion in relief funds for the medical and hospital industries. Commercial payers are doing their part with expedited credentialing and accelerated payments. And, organizations like the CAQH are also focused on bridging the gap between payers and providers to be sure patients continue to receive critical care during these turbulent times.


If you have credentialing, enrollment or reimbursement questions – you are not alone. VerityStream and our partners are here to help.

COVID-19 Enrollment and Financial Implications, Facts and Resources

Want to learn more about this topic? Watch the recording of our webinar: COVID-19 Enrollment and Financial Implications, Facts and Resources, a VerityStream Industry Insight webinar.

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