Payor Policy and Payment Changes Targeting COVID-19

Over the past several days, both federal and state government agencies have implemented numerous policy changes and laws designed to increase coverage for COVID-19-related services and supplies, and reduce administrative burdens for providers and insurance plans. Many of these new payment rules apply to both commercial insurers and government payment programs.

Families First Coronavirus Response Act Testing Coverage

The Families First Coronavirus Response Act (the Act), signed into law by the president on March 18 (and which implements many new requirements outside the scope of this alert), requires most commercial and government health plans and programs to cover COVID-19 testing without any cost-sharing by patients. Specifically, the Act requires most commercial insurance, Medicare Advantage and managed Medicaid plans, as well as the Medicare and Medicaid Fee-For-Service programs, to provide coverage for any FDA-approved COVID-19 diagnostic products, and any items or services related to COVID-19 testing that are provided to an individual when an individual comes to a provider for testing for COVID-19. These requirements apply, regardless of the site of service where the test is administered, i.e., whether in a doctor’s office, emergency room, urgent care clinic or telehealth visit. These plans and programs must also waive any patient cost-sharing amounts that might otherwise apply to the testing, i.e. copays, deductibles and co-insurance amounts. Lastly, the Act prohibits commercial and government payment programs from applying any prior authorization requirements for coverage of COVID-19 tests or related services.

Congressional Letter to Insurers

On March 20, a group of seven Democratic senators sent a letter to a number of commercial health insurers urging them to enhance their coverage for treatment of patients who are either diagnosed with or presumed to have COVID-19, since currently there is no comprehensive coverage for all methods of diagnosis and treatment for COVID-19.

The senators noted that temporary coverage, without any patient cost-sharing, for diagnosis and treatment of COVID-19 is just as important as coverage of authorized COVID-19 tests. Because testing for COVID-19 is frequently unavailable for clinicians to provide to patients, clinicians must resort to various other testing modalities. Thus, the senators also want insurers to cover testing of any type, not just authorized COVID-19 testing, at no cost to the patient, at least until widespread authorized testing is available. In addition, they ask for the insurers to cover therapeutic care, without any cost-sharing, for those instances when a provider cannot access authorized COVID-19 testing, but believes a patient would test positive based on their clinical assessment. The senators requested a response to these questions no later than March 23.

State-Level Changes

Some state insurance agencies, particularly those in states that have declared a State of Emergency, are recommending that insurance plans modify their utilization review and admission notification requirements to help reduce administrative burdens and speed the flow of suspected and diagnosed COVID-19 patients through the continuum of care. For instance, on March 20, the New York Department of Financial Services (the Department) issued a Circular Letter encouraging insurance companies and third-party administrators to suspend and/or modify many utilization review and admission notification practices for a period of at least 90 days. The Department strongly advised health plans and third-party administrators to:

1. Suspend preauthorization review for scheduled surgeries or admissions at hospitals.
2. Suspend concurrent review for inpatient hospital services.
3. Suspend retrospective review for inpatient hospital services and emergency services provided at in-network hospitals.
4. Suspend preauthorization requirements for home health care services following an inpatient hospital admission.
5. Suspend preauthorization to the extent it is required for inpatient rehabilitation services for mental health or substance use disorder treatment following a hospital admission.
6. Not require submission of medical records from hospitals when hospitals notify insurers of an emergency admission, and not impose a financial penalty if a hospital fails to provide notification to an insurer of an emergency admission due to staffing issues related to COVID-19.
7. Toll the timeframe for a hospital to submit an internal or external appeal.
8. Suspend nonessential audits of hospital payments.

The Department also notes that it is aware that the current circumstances may hinder the timely submission and payment of claims, and may provide future guidance on that issue.

Conclusion

It is clear there is still much change to come which will affect provider reimbursement for COVID-19-related services. We will continue to monitor the changes and alert clients to the implications and effects of these changes.

As the number of cases around the world grows, Faegre Drinker’s Coronavirus Resource Center is available to help you understand and assess the legal, regulatory and commercial implications of COVID-19.