In an effort to ease the cash flow challenges associated with the COVID-19 emergency, many home health providers took on advance and accelerated payment loans from the U.S. Centers for Medicare & Medicaid Services (CMS).
Now, the time has come for the recoupment process to begin. But CMS has been quiet on the matter, creating a cloud of confusion among home health agencies and other Medicare providers.
CMS originally expanded its advance and accelerated payment programs for Medicare providers in March as a response to the emerging public health emergency. In April, CMS then suspended the program for Medicare Part B providers and said it would reevaluate pending applications from Part A providers, largely in response to the availability of the CARES Act provider relief grants.
As of May, CMS had disbursed $100 billion in accelerated payments, with 2% of funds — or about $1.7 billion — going to home health providers, according to federal data. In comparison, short-stay hospitals had received more than $78 billion.
For the providers that were approved for loans, the repayment period was set to begin 120 days after the funds were received. That time has come, but CMS hasn’t started the recoupment process — and many providers are wondering why.
“In August, we started seeing some chatter on [email lists] and things, where providers were saying, ‘Hey, we got one of these advance payments and haven’t seen the recoupment begin yet,’” Aaron Little, managing director at BKD, told Home Health Care News. “Along with monitoring that chatter, we looked back at our client base, and this is consistent with what we’re hearing from clients and what we are seeing from clients.”
BKD is a Springfield, Missouri-based accounting services firm that provides billing and revenue cycle outsourcing services. As part of its services, BKD has been monitoring clients who have received accelerated loan payments, according to Little.
Most providers expected to begin hearing from CMS a few weeks ago, according to Beth Prince, vice president of revenue management services at Corridor.
“Our company handles billing and collections for a lot of agencies across the country — and none of our agencies have seen any recoups at all,” she told HHCN. “CMS has remained silent on the status of this.”
Corridor is an Overland Park, Kansas-based health care consulting firm that specializes in home health, hospice and home care.
While the exact reasons for a delay in the recoupment process remain unknown, many suspect that Congressional activity surrounding repayment extensions and loan forgiveness might be playing a role.
“Hospitals and professional organizations have really pushed to have that repayment period modified. One bill requested that all loans just be 100% forgiven,” Prince said. “I think that has caused CMS to maybe pause what they were looking at doing. I think part of it is because not everyone has returned to normal patient volumes. I think the resurgence — or the initial surge of COVID-19 in some areas — has impacted referrals that would have come from elective surgeries.”
In March, CMS recommended reducing “non-essential” or elective medical and surgical procedures in order to preserve personal protective equipment (PPE), beds and ventilators. Since then, CMS has released guidelines on how to resume these procedures, but this only applied to states or regions that are seeing a relatively low number of coronavirus cases.
Little believes that amid the public health emergency, there has been a lot for CMS to keep tabs on.
“So much has happened during the [COVID-19 emergency], in terms of waivers, and new money being made available through the CARES Act and PPP loans,” he said. “There’s just been such a flood of information — and, quite frankly, a lot of money. CMS, of course, didn’t know that we’d still be in a public health emergency after Day 120. Nobody had a crystal ball.”
PPP, or the Paycheck Protection Program, is a Small Business Administration (SBA) loan program launched in response to the economic disruption caused by the coronavirus. Home-based care organizations have received hundreds of millions of dollars in PPP loans, with some individual loans in the $5 million-to-$10 million range.
Like Prince, Little says CMS may be in reevaluation mode at this time.
“It could very well be that CMS is … trying to determine what they can and can’t do in terms of initiating these recoupments. Do they have the flexibility to extend that out beyond what was initially laid out in the plan? But that’s purely speculation.”
While Little stresses that he has no additional insight into CMS’s plans, he cites the changes made in the Review Choice Demonstration (RCD) as a possible parallel.
“I think that advocacy works,” he said. “It didn’t completely make RCD go away, but it definitely made it a little more palatable in terms of how it’s being turned back on. Just looking at what happened there; it certainly wouldn’t be unreasonable to say maybe … they’re going to extend out that timeline a bit and just haven’t landed on exact logistics of how to do it.”
Though an extension would certainly give many providers room to breathe, some of them are ready to start paying back the loans, according to Prince.
“[Some providers] want to get that started and in the face of not having the money recouped automatically through the claims process, they’re now considering cutting a manual check for that,” she said. “The other thing we have to consider is that, at certain point in time, if [CMS hasn’t] received their entire amount that they loaned to an agency back, then a demand letter is supposed to be generated. After that point, essentially, it starts to accrue interest.”
Providers could potentially start to lose revenue they’ve earned because of the interest amount.
Providers haven’t received any communications from CMS on how to proceed. But while they wait, it’s crucial to set up a reconciliation program, according to Prince.
“Best practice is always to be able to reconcile to the penny on every single remittance, so that you understand what was taken out, what you were paid for and that you’re looking at any variances,” she said. “We always recommend that you set up a system within your agency, whether it’s in your EMR or through your accounting software.”
At the end of the day, providers should be prepared. The recoupment process could begin any day from now.
“We passed 120 days and recoupment hasn’t started yet, but that doesn’t mean that it won’t start on Tuesday after the holiday,” Little said. “Who knows?”