Episode 093: Answers for Physicians During COVID-19

Speaker 1: You are listening to Your Practice Made Perfect: Support, Protection, and Advice for Practicing Medical Professionals. Brought to you by SVMIC.

J. Baugh: Hello everyone and welcome to another episode of Your Practice Made Perfect. This episode is a bit different than the others we have done in the past. We will have three SVMIC speakers here to help address the current coronavirus crisis facing our nation and directly impacting all of you, our listeners.

We understand that this is a time of great uncertainty and while we don't know what the final extent of the pandemic will be, we do know that SVMIC is here for you, and we want to provide as many resources as we possibly can. In this podcast, we will address some of the common questions we are receiving from our policyholders as well as some hot button issues that you may be facing. As we may not get to every single question we have received, I would also like to add that we have created a COVID-19 resource page that contains a wealth of resources and is updated regularly as changes continue to come through.

You can find this at SVMIC.com/resources/COVID-19 and we will link to that page in our show notes as well. And so, at this time I will have each of our speakers to introduce themselves.

Charmy: This is Charmy Shrode. I am Vice President of Underwriting and have been at SVMIC for 23 years.

Steve: This is Steve Dickens. I'm the Vice President of Medical Practice Services at SVMIC. I have been there for the last 12 years and spent 15 years before that working with physicians and medical practices.

Julie: And I'm Julie Loomis, Assistant Vice President of Risk Education. I've been with SVMIC for 14 years.

J. Baugh: And my name is J. Baugh. I'm the claims attorney at SVMIC. I've been at the company for 20 years and I'll be your host today. And so, Charmy, let's start with this first question for you. I'm being reassigned from a different specialty from a hospital's surge contingency plan. Will my malpractice insurance cover me for this work assuming that the work is within the scope of my state licensure?

Charmy: First, I want to clarify that my answer will be with respect to how SVMIC would respond and if for some reason you have coverage with another provider, you would want to reach out to that particular provider to find out how they would respond, as far as your coverage is going to respond to this. SVMIC is more than happy to work with you if a physician is willing and chooses to be reassigned to help out in this crisis situation. We would ask that you call us to discuss the details so we can make sure that you are fully equipped to have the policy respond as needed for that situation.

J. Baugh: So Julie, let me ask you a couple of questions about telemedicine services. First of all, am I covered to provide telemedicine services? And second of all, if I've never done telemedicine before, do you have any recommendations to teach me the basics?

Julie: Yes. To follow up with Charmy's comments earlier about coverage at SVMIC, we pretty swiftly recognize the need for our policyholders to start rendering medical professional services through telemedicine. We have also seen that has dramatically increased, and seems to be very well for many of our providers. So coverage is there, as Charmy mentioned, as much of our region is under the states of emergency for this COVID-19 pandemic. There are currently no changes necessary for adding telemedicine to your policy under the following circumstances, and again it would be appropriate to call underwriting to check.

Julie: So you want to be sure you're practicing within the scope of your licensure, you're following the telemedicine guidelines, if any, of your state medical board. And I'll make a note here that those are changing quite frequently. You may want to look at the Federation of State Medical Boards, which is FSMB.org to see. They are keeping a great update daily, practically of all of the states of emergency for the various states. You also want to ensure that you're providing care to an established patient and/or you can provide care to a new patient who resides within a state in which coverage has already been agreed upon by SVMIC.

So again, we recommended that you speak with the underwriting department before you go into the telemedicine arena, and particularly if you plan to practice on new patients or in other states. As far as the recommendations for teaching basics of telemedicine, there are a lot of great providers out there who are doing this. Let's start with if you have an electronic health record system, or an EHR, check with your vendor. They have functionally built it to facilitate telehealth visits where you can just use a component within your own system. That may help ensure more seamless integration.

We understand that during COVID-19, a lot of rules have been suspended and the application of telemedicine is much easier albeit temporary. What you want to do is reach out to organizations or practices similar to you or reach out to your state medical association for recommendations. You can also look at the American Medical Association. They have put a very nice physician innovation network together to connect companies who are providing telehealth services. They also have a quick guide to telemedicine and practice that's been developed to help physicians swiftly ramp up their telemedicine capability.

So, it talks about the recent actions taken by health and human services, centers for Medicare and Medicaid services, or CMS. This guide gives instructions on getting started, on policies, on coding and payment - which is very important - and changing also almost daily, practice implementation and other links to helpful resources. Every specialty society and every private insurance company also has guidelines out there. The AMA also has a really nice short video. It's 10 minutes long. It includes tips on connecting with patients, setting up a telemedicine workspace, conducting your exam, including things like checking a patient's throat or getting vital signs from the patient, getting informed consent recommendations on how to note and document the visit, and also recommendations for AMA current procedure terminology or CPT codes and modifiers, as those are very important right now so that you get paid at the highest level possible.

And if audiovisual is not an option for true telemedicine for your practice, currently there are opportunities for verbal or audio only, telephone visits, as well as virtual check-ins through maybe your patient portal or other messaging technologies.

J. Baugh: So Steve, let me ask you this question. Can I see new patients or should I only see established patients?

Steve: That sounds like it should be a simple yes or no question, but there are some complexities there, some of which Charmy and Julie have mentioned. Certainly, we are seeing many physician practices now that are seeing established patients via telemedicine, and there is no issue with that. In terms of seeing new patients, while the rules have been relaxed, there are some things physicians and practices really need to consider, and those are the issue of licensure, the scope of practice, as well as the individual payers. Most of the regulations that we've seen come out in the relaxation of rules have really centered around what CMS is doing with Medicare, and of course there are a lot of other payers out there and depending on your practice specialty you may not have many Medicare patients.

So, you want to figure out what the individual insurance companies are doing and then you also need to make sure that you have the appropriate liability coverage in place too. And even though we are seeing these guidelines and these changes come out from CMS, and we're looking at those on a federal level, as we have certainly seen in the news in terms of how states are responding to the pandemic, not every state has relaxed the rules or has extended the same courtesies to physicians and providers as perhaps a neighboring state.

So, you want to make sure that you have researched those rules. You may be required to have a license in a different state where the patient is residing, even if that is an established patient. If you're seeing new patients in a new state, you want to make sure that you contact SVMIC to ensure the appropriate coverage is there as well too. There're a number of really good FAQs on our website that address these changes and will walk you through this process. I would encourage you to review those before you do start doing telemedicine, or even as you're continuing to do telemedicine and see changes within your practice. And of course you're welcome to call us with specific questions.

J. Baugh: So Charmy, let me ask you this question. Let's say my patient's volume is down 50% from normal. Do I have to keep paying my full malpractice premium?

Charmy: SVMIC called an emergency board meeting to gather the physician board together to decide on a quick action for us to be responsive to this immediate need that you have, with a significant reduction of your patient volume due to the requirements and restrictions that have been placed on each of the practices. So no, you don't need to pay the full price during this. SVMIC has implemented a temporary discount to be applied for those that let us know that their practice has significant reduction in the patient volume.

And in addition to the discount that we're adding during this time, we are also more than willing to work with you on installments, and payments, as we understand that revenue has just immediately shut off for most practices during this time. And, we continue to hear the hardship that this is putting on our physician practices, and we are trying to be as responsive to those individual needs as well as being good stewards of the company at large. So, if you do have a significant reduction in your practice, please contact the underwriting department so we can help you walk through what your options are to help with your premium during this period of time.

J. Baugh: So Steve, my next question to you is similar to the one that I asked Charmy, but it has to do with looking at things from sort of a business perspective. My practice has come to a virtual standstill. And, many of the procedures are considered nonessential, and my patients are canceling, and so this is impacting my ability to pay my employees as well as myself. So, do you have any suggestions and what are my options in this situation?

Steve: Yes. This has really devastated many practices and particularly some of the specialties that were performing different types of surgical procedures, as governments have issued orders limiting nonessential services so that they can divert personal protective equipment. There're a number of things here, as we've talked about for some time now. A lot of practices have gone to telemedicine, which is one option to attempt to keep up some amount of revenue, some amount of patient volume, but the government has also put in place several programs that can assist practices.

There are a number of loans that are available through the Small Business Administration. Any practice that bills Medicare or has a history with Medicare, is eligible to request accelerated payments against their future billings. Also, last Friday CMS began issuing emergency funds to groups that bill Medicare to assist with the cost associated with the pandemic. Each of these programs has different guidelines and requirements, so you want to make sure that you understand the potential payback obligations as you consider what is best for your personal situation.

And while this is unfortunate, we have also seen a number of practices that have had to reduce hours of staff, or furlough, or lay off employees, and while that does sound horrible, the opportunity there for an employee who has been laid off is to collect unemployment. One of the other changes brought on by this crisis is that independent contractors and self-employed individuals which may be some of our physicians can now qualify for unemployment as well too.

While unemployment is administered on a state level, it is being supplemented by the Federal Government, so the benefits are much larger during this crisis than they traditionally were. Each individual state administers its own unemployment program, so the individual state payment varies but the Federal Government again is adding a supplement to this. And if you think you qualify or if you have employees who are in this position, you should go to your state department of employment to see what the qualifications and process are there to apply.

J. Baugh: So Charmy, let me ask you this question about volunteer policies. I'm a retired physician, but I want to come back to volunteer during the public health emergency. What happens to my tail insurance and how do I get a volunteer policy? And what if I already have a volunteer policy am I covered to help during the surge?

Charmy: It has been so rewarding to talk to the physicians that are willing to jump in and help wherever is needed, and we really appreciate that heart to serve. We want to respond favorably to those kinds of requests. It is my understanding there is some immunity that is being granted for physicians that are volunteering in the crisis situation. So to answer the question, it sounds like it should be very straightforward, but it depends on where you plan to volunteer, how long you've been out of the practice of medicine, what your current volunteer policy is.

If you have a current volunteer policy with us, and you want to volunteer in an area that is within the same state in which you had the volunteer policy issued for, then we would accommodate that certainly for you to go in and help volunteer in that situation. If you plan to volunteer in a different state, for example going to New York to volunteer there, there would be like I said immunity for those that are volunteering for specific COVID situations, but you would want to check with us, or any provider, whoever that is, to see if you need an additional policy to carry you through that action.

J. Baugh: So Steve, I'm seeing a lot on the news about loans that are available from the government for small businesses, so how do I get in on the government loans that are available for small businesses?

Steve: These loans are being managed through the Small Business Administration. So, the links to apply for them are there on their website, and so that's where you'll want to go and get started with that, and very likely your local banker can assist you as well too, because local banks are involved with this if they are approved by the SBA to do so. And we've had a lot of feedback from different practices and varied experiences among the groups, depending upon when they applied for it. As time has gone on, there have been some requests for additional information or the process has changed.

So, connecting with your local banker is really probably the best thing for you to do to help you get started on that, because it is ultimately going to flow through them. Beyond that I would advise you to do this as quickly as possible. There is at the moment a finite amount of money that has been allocated to these loans, and our understanding is that they will be distributed on a first-come first-serve basis, and given the volume of people and the need out there I cannot imagine that there will be enough to go around.

J. Baugh: So Julie, we talked a little bit earlier about telemedicine and we have another question about that. How do I bill for telemedicine, to get the highest possible reimbursement from either Medicare or a commercial payer and where do I go to find this information?

Julie: Actually, one of the best resources is the SVMIC website, the COVID-19 page specifically. There's a tab for telehealth, HIPAA, and billing. And, we have an excellent summary of coding and reimbursement during the COVID-19 pandemic. You can click right on that and you will have a table with many, many links based on the topic primarily for the Federal Government, but a lot of these topics also will be similar with the commercial payers. A couple things we'd like to talk about though specifically is for Medicare. There are now approximately 200 services that can be rendered by telemedicine. They are all payable at the in-person rate.

So, that is if you were paid $75 say for a 99213, that's what you'll expect to receive via telemedicine. For other digital services, CMS refers to these collectively as communication based technology services, or CBTS, that reimbursement will vary. From a Medicare perspective, payments range from $15 for those virtual check-ins that we mentioned earlier for portals, some telephonic visits, et cetera, to $65 for a 30 day remote physiologic monitoring. That may be someone talking to you about a glucose meter or a blood pressure monitor. Ultimately, the most favorable reimbursement is that which is provided by the telemedicine encounters.

On April 11th, the Federal Government instructed all payers to provide COVID-19 services without any patient cost sharing. That is for free. Although each payer can determine its own starting date, CMS is offering 100% reimbursement - no copayment, no coinsurance, or deductible - for Medicare patients retroactive to March 18th. So, in order to get paid at 100% of the allowable, physicians must submit these claims with a CS modifier.

Interestingly, the digital services that CMS refers to collectively is CBTS aren't technically telemedicine. These again are E-visits, remote patient monitoring, and virtual visits. The key factor in payments and reimbursements revolves around how the service is delivered. So, if you start with a patient over the portal - for example - you can look at codes for E-visits or virtual visits. The other core factor is what is delivered, and a closer look at codes will help you determine which one is most appropriate to use.

Again, go to the SVMIC website, but also the American Medical Association has excellent material that walks through each of these remote non face-to-face services and provides scenarios about how and when to use each of them. Be sure to document when your visit begins and ends, to meet the length requirements for payer and/or states. Based on the requirements of coding and billing also keep a checklist for how you have to document in order to meet those particular regulations.

J. Baugh: So Steve, another question that we have dealing with reimbursement is whether or not Medicare is doing any advanced payments?

Steve: Yes, they are. That is one of the relief options that is available to groups. It is not an automatic event though. It is something that a physician must request, and in general assuming that the physician/ the practice meets the qualifications, you can request 100% of the three previous months Medicare payments. Now, this is an advance. It's somewhat of a short-term loan. It's not a freebie and repayments start 120 days after the advance is issued.

In terms of those qualifications, the physician must have billed Medicare within 180 days immediately prior to the date of the signature on the request form for the advance. So, at some point in the previous six months to whatever the date is that the physician requests this, he or she must have billed Medicare. He or she cannot be in bankruptcy. They cannot be under some type of active medical review or any type of integrity program investigation from Medicare. And also, you cannot have any delinquent Medicare overpayments.

So you want to make sure that your practice, that your physician, is in good standing when these funds are requested, again, keeping in mind that they will have to be paid back in approximately four months after the request is made.

J. Baugh: So Steve, we have another question for you and it's in a different area than reimbursement. The question is what changes with HIPAA in a public health emergency?

Steve: It is somewhat confusing. I don't really understand why. Everyone seems to think that in a crisis HIPAA goes away and despite all of those rumors, HIPAA is not waived during a crisis. The rule has actually always had contingencies built into it for certain emergencies. Where I believe this confusion stems from, is the relaxation of the rules as they relate only to telemedicine for the duration of this public health emergency.

And in regard to telemedicine/ telehealth, the Office of Civil Rights has recently provided notice that they will waive penalties for any potential HIPAA violations by healthcare providers who use everyday communications for telehealth. Some of the specific ones that they're mentioned are FaceTime, Skype, Facebook Messenger video chat, Google Hangouts video chats, and other similar private facing platforms that can be utilized for these telehealth services.

The OCR has also specifically pointed out programs that they believe are inappropriate, such as Facebook Live, Twitch, and TikTok. Those are considered to be public facing and should absolutely not be used for telehealth services.

J. Baugh: So Steve, another question that we have related to HIPAA has to do with PHI, and that is can I, or can I not, share PHI about a COVID-19 positive patient, and if so with whom can I share that information?

Steve: That is one of the contingencies that was built into the rule, what exactly can be shared during a situation like this, and there is a decision tool which will walk you through the appropriateness of the disclosure. And to just go over those very quickly the reasons are, first of all, for treatment you may share information with a patient's other treating providers and those to whom you might be referring the patient for treatment. You may also share the information as it relates to public health activities.

There are various organizations out there, the Health Department, CDC, other entities that are authorized by law to collect or receive such information, and of course the purpose there is to prevent or control the further contamination, the disease, or the injury. Family friends or others who are involved in the patient's care limited information may be disclosed with them if they are involved in the care. I recommend here that you continue to get verbal permission from the patient and that you document that, unless it is so obvious that authorization can be inferred from the patient that he or she would not object, or the guidelines also say that the physician, the provider, may use his or her professional judgment if they determine that it is in the patient's best interest to disclose those to those family, friends, or others involved in the care.

Information may also be disclosed to prevent a serious or imminent threat and by that we mean that the relevant information may be shared with anyone necessary to prevent or lessen a serious or imminent threat to the health or safety of that individual or to the public. The guideline here again is that the physician or the practitioner uses his or her professional judgment in making that determination as to the nature and severity of the threat. And then, finally information may also be disclosed to first responders who are at risk for infection.

The relevant information may be shared with those individuals, so that they can take the appropriate steps to protect themselves or utilize personal protective equipment. And given that we do have this decision tool, I think it's always appropriate when talking about HIPAA to remind everyone that while there may be circumstances where it's appropriate to reveal information, you always want to reveal only the minimum amount necessary to convey whatever the message is, or whatever it is that is needed to let others know what they need to know.

J. Baugh: So Julie, our next question's for you, and it's in a completely different direction than the last couple of questions that we have had. Since the live risk education courses in my area were canceled, do you have any options for me to get my prescribing CME credits this year, and do I even still need CME this year? I heard the requirements were relaxed.

Julie: Yes. SVMIC has an option of prescribing CME credits this year for all policyholders in our insured states, and yes with a few exceptions healthcare practitioners are still required to meet their continuing education obligations for licensure renewal. Some states have suspended certain requirements for applications to reinstate licensure, such as in the case of retirees reentering medicine during this COVID pandemic.

So there was a little confusion there. Certain rules and policies are suspended in order to grant a license, certificate, or registration to a healthcare professional without requiring that individual to demonstrate continued competency, or even submit to an interview before a licensing board, provided that the individual satisfies all other requirements for licensure certification or registration.

So generally, the CME requirements will remain in place for current licensees. SVMIC is putting up an online version of the live risk education seminar titled Prescribe and Control Drugs, Minimizing the Risks for All of its PolicyHolders and Other Prescribers. For policyholders looking for specialty specific and other general CME options, we also offer 11 courses on various topics including telemedicine, documentation, burnout, as well as risks pertaining to specialties including anesthesia, surgery, and radiology.

As an added benefit now through the remainder of the year, SVMIC has made all online education courses free of charge. So this is really a great benefit to policyholders and I hope that everyone is able to take advantage.

J. Baugh: So Steve, there are a lot of mayors and governors who have issued executive orders, and if I am under an executive order to not have more than 10 people gathered, I'm wondering if that applies to physicians offices?

Steve: Those executive orders typically relate to public gatherings for nonessential purposes. I am not aware of any restrictions placed on gatherings in physician offices. Typically, what we've seen in terms of the executive orders as they relate to physicians, have been about the provision of essential versus nonessential services. Again, the goal there is to eliminate nonessential services, thinking that we can save personal protective equipment or we can transfer it to facilities where it is more desperately needed.

Now, as you pointed out J, we are seeing both local municipalities and state governments issue these orders, so you do want to check those local websites and review those executive orders to see what it is they say to make sure that you are following those. Some of them have done a more thorough job of defining what a nonessential service is, and if you have any questions about those types of things your local medical board, your state medical board, should be a good resource to provide you further guidance about that.

Now, having said that, we realize that many practices are still up and running and are still having patients in their offices, so I do think there are some steps you can take that will help you better comply with the social distancing guidelines. Again, to begin with, think about what is essential versus nonessential and that is really a clinical decision. That is a decision the physician has to make. As you consider people coming into your building what does that look like?

This is the only time, probably in my career, you will ever hear me say this but distance at the front desk is appropriate in these circumstances if you do have a window, if you do have some type of barrier, this is the only opportunity that I can see that those are functional in keeping that distance between you and the patient. As you think about patients who may be in your waiting room is there a way to distance them there? Think about the size there. Letting your patients know that they are welcome to wear masks into the office.

While we know that the masks are different and that they don't necessarily provide all the protections of true personal protective equipment, there are some reasons that people might want to do that. Instead of passing paperwork with your patients, is this something that you could just ask, then they can give you their card number instead of handing it to you? Using baskets if you need to get insurance cards instead of touching one another and handing those back and forth.

One of my rare outings recently, we were out and in paying for something the person at the desk just asked us to insert our card and said "Is it okay if you don't sign the receipt?" And so, we never really touched one another back and forth there. To the extent that you have hand sanitizer that you can use that at the desk. Keeping your building/ your facilities clean, disinfecting all of those types of things. We know that there are practices now that are asking patients to sit in the parking lot and they'll call them on their cellphones to let them know when it's safe for them to come to the building. They're using that to maintain social distancing. So just consider those different types of ways you might do things to help protect everyone, not only your patients but your staff as well too.

J. Baugh: So Julie, we have a couple of more questions about telemedicine and the first question is how do I prescribe controlled substances via telehealth or telemedicine?

Julie: That has changed so much during this COVID-19 pandemic. According to the Drug Enforcement Administration, or the DEA, while a prescription for a controlled substance issued by means of telemedicine generally must be predicated on an in-person medical evaluation - that had been the DEA's position - they have decided to suspend that particular provision and allow for controlled substances to be provided via telemedicine. The Controlled Substances Act contains certain exceptions to this requirement.

So as of March 16th, 2020 and continuing for as long as the secretary's designation of a public health emergency remains in effect, DEA registered practitioners in the United States may issue prescriptions for all scheduled two through five controlled substances, to patients for whom they have not conducted an in-person medical evaluation provided all the following conditions are met.

Three simple conditions. One, the prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his or her professional practice, so legitimate medical purpose is very important here as well as this should be in the usual course of your professional practice. This is not the time to get into chronic pain management if you will.

Second, the telemedicine communication is conducted using an audiovisual real time two way interactive communication system, so according to this DEA rule, it appears that a one-way audio only telephone call would not be sufficient for the prescribing of controlled substances via just a straight telephone call. And finally, the practitioner's acting in accordance with applicable federal and state laws, so that tells us you do still need to go back to your state board and check to ensure that there isn't a superseding state law that would prohibit or limit you prescribing controlled substances via telemedicine in some way.

And I do know that some state boards have not amended their rules involving telemedicine at all, and that would include the writing of controlled substances using telemedicine. So provided that you follow these rules and you check the dots the practitioner may issue a prescription, either electronically if you have a prescription available for schedules two through five, or by calling in an emergency schedule two prescription to the pharmacy, or by calling in a schedule three to five prescription to the pharmacy. As we all know, a reminder, generally schedule two prescriptions cannot be phoned into a pharmacy, so they would have to be picked up by the patient, a handwritten script, or electronically prescribed.

J. Baugh: And how about in regard to informed consent for telemedicine? Julie, can you speak on that a bit?

Julie: Yes. Informed consent is very important with telemedicine, and each state may have an additional requirement that we're not going to go over here, so again, check with your state board to ensure that they don't have additional elements in their informed consent that you should be required to obtain. For instance, in Tennessee there's a requirement to disclose the name, current and primary practice location, medical degree, and recognized specialty area if there is one. It's a good practice if you don't have written consent but it's also maybe required by your board.

If you're a provider treating new patients via telemedicine, then remember that the consent should also include a consent for treatment in general, not specific to a telemedicine consent. In a nutshell, the provider should tell the patient that this visit via telemedicine has benefits, such as improved access to medical care by allowing you, the patient, to remain at your home to access care. There're also some unique risks to receiving care via telemedicine. Let your patient know you may not be able to completely assess their condition given the diagnostic limitations namely inability to touch, or to smell, or to potentially even accurately visualize the condition.

There may be limitations in the equipment, security, or connection, which may render the visit inadequate for treatment or may result in a breach of privacy. So just simply state if I'm unable to adequately assess you, then I'll refer to for in-person treatment. Also, acknowledge that sometimes this is not in the best interest to pursue care by remote or virtual visit. Clearly, during this pandemic, the goal is to provide as much remote care as possible. We certainly don't want patients traveling to medical offices if it's not indicated, but just be sure that you are aware of the standard of care and that there may be times that you just can't perform this virtual visit.

And then, maybe wrap up with "Do you understand the benefits and risks of telemedicine?" Ask your patient to affirm that. And "Do you have questions before we proceed?" And ask the patient "Do you wish to continue with this telemedicine visit?" You need to get that consent that they understand what a telemedicine visit is and that they're allowing that to proceed. Another thing to consider is that since most states require the location to be known, and some even require the type of virtual platform that you're using, ask the patient where they're located, to affirmatively say where they're located, and how they are participating in this telemedicine visit with you.

J. Baugh: So Steve, the next few questions we have are for you. Once practices and physicians are able to start seeing patients full-time again, it may take some time for reimbursements to catch up. Is there any advice for those who may deal with this?

Steve: Yes. Physicians and offices should expect a lag in payments. As we all know, there is generally some type of payment floor that is enforced by the payer in terms of the time between the claim is submitted, and when the claim is actually paid. So right now, practicing physicians, practitioners need to go ahead and get in the mindset that's what's going to happen. So in terms of advice, the first thing I would suggest is that physicians in groups look at those government programs that are currently available to see what you are eligible for to help minimize the impact to your cash flow.

There are links on our site on the COVID page that go to the Small Business Administration. We've got some FAQs there that talk about the different programs that are available. Again, as I said earlier, you want to apply for these as soon as possible because they are being administered on a first come, first serve basis. Beyond that, what you can really be doing now is looking at your operations. Do you have any opportunities to minimize existing office expenses? Now is the time to talk to your business partners, to talk to your vendors, about possibly extending the payment terms on products that you are purchasing.

Keep a close eye on revenue. We're all a little bit stressed right now. Many of us are working from home. I suspect many practices have their billing personnel working from home as well too. Make sure that they are continuing to keep billing current. That they are monitoring how they're managing accounts, that they're following up on denials, requests for information, those types of things that are going on. You don't want to cut off cash flow on services that have already occurred and have already been billed.

If you don't have a line of credit now is the time to talk to your banker. A great opportunity when you're talking to them about these Small Business Administration Loans is to go ahead and open up a line of conversation with them about a line of credit. At some point, we will return to some version of normal, and physicians will begin seeing practices again. Indeed, I think many practices probably will be overwhelmed with the appointments that they've had to cancel or reschedule.

So, it's not unreasonable to consider a line of credit to get you through this short-term. If you have business interruption insurance, that is an essential component of any good disaster preparation plan, and business continuity plan. So talk to your broker and see if there are resources available there as well too. Again, I really encourage practices to take the initiative now, to think about where they're going to be a few months from now, and get ahead of the curve, because there will be people who won't stop to think about these things and you don't want to get caught up in the logjam of them trying to manage their operations at this point.

So go ahead, take the time while you have it to sit down and think about who can I call on? Who are the business partners I can work with? What are the resources available to me to plan for the future?

J. Baugh: So Steve, another question for you would be do I still have to report my QPP data on time?

Steve: CMS has actually extended the deadline to April 30th at 8:00 PM Eastern. Again, the deadline to report the QPP data has been extended to April 30th at 8:00 PM Eastern. For groups for physicians that want to submit the data, you need to go ahead and assume that deadline is going to stick. We've not seen any indication that it's going to be extended, so don't wait until April 30th thinking they're going to extend it and then being caught in a situation where you have to do it.

Beyond that, however, CMS is also allowing the use of an extreme and uncontrollable circumstance clause to grant exceptions to physicians, to practitioners in groups, who have submitted their data or who have not submitted their data. So if you are an eligible clinician - and that is the term CMS uses - if you are an eligible clinician who has not submitted any MIB's data prior to the April 30th 8:00 PM Eastern deadline, you will automatically be identified and you will receive a mutual payment adjustment for 2021.

So again, if you have not submitted any data, and do not submit it by April 30th, there is nothing you need to do. The government will automatically take care of that and you will receive no adjustment in 2021. For those groups who have started the submission of the data, but are for whatever reason unable to complete their data, you must submit an application citing the extreme and uncontrollable circumstances of the COVID-19 crisis, and you have to submit that application between April 3rd and April 30th to override any previous data submission.

So again, if you have not reported and are not going to report you're fine. If you want to report you have until 8:00 PM Eastern on April 30th. If you have made only a partial report and want to stop that, then you need to request the exemption to do so or you need to complete it. And as I've been talking about groups who say there are so many groups who aren't going to do it, or who are just going to take the exemption, I want to make sure I get mine in, remember the entire idea behind the mirrored incentive payment system, is that groups who get a payment increase are taking money from groups that get a decrease.

We very likely will see few decreases in the coming years, so the likelihood of getting a significant increase for reporting your data is pretty slim, but it is an individual group decision whether you want to go ahead and do so.

J. Baugh: So Steve, our last question is for you. How should we direct our patients on how we are handling the coronavirus situation?

Steve: That's a really important issue. I know a lot of patients are very concerned about what their physicians, about what practices are doing, so the first thing is to look at what are your normal modes of communication. You want to make sure that your website is updated. If you are a practice that is utilizing a patient portal, that information is there absolutely to your patients. If you have phone triage systems of any type, these automated answering systems, re-record those messages to let your patients know what's going on.

If you are using reminder systems for appointments, whether they are automated or individual phone calls, that's a great time to let your patients know what it is that they need to know about your office hours, about scheduling appointments, about what to do if they think they do have the virus, about how you're going to manage these types of things. We have seen several groups depending upon how they're managing the situation that have made the determination they want to mail letters to their patients.

We have two sample letters on our website that you are welcome to download. Both require modification to your specific circumstances. They should be printed on your office letterhead, so if you do want to take a look at those examples, they might be a good starting point for you. It is very important that you let your patients know what you're doing, so look at all of those different modes of communication you have, and make sure that they are updated to reflect the current situation.

I just want to make one other point too. Charmy, Julie, and I have discussed a lot of things today, and as we've tried to address these questions we've been getting from physicians and practice executives in their groups, I want to make sure that everyone understands that the information we've given out today is in the context of the public health emergency. Many of the things that we're dealing with are the result of exemptions, of a relaxation of rules, of executive orders. These are all intended to be temporary.

Now, at some point we will return to some version of normal, although none of us probably know what that looks like. But, as you consider the changes around how you're operating your practice, these government programs, telehealth, all of these things understand that there will very likely be significant changes, or in some cases a total reversion back to the way that the rules were once the emergency is declared over, so please keep that in mind. This is not the way we will do business forever.

J. Baugh: As we bring this episode to a close I'd like to thank Charmy, and Steve, and Julie for joining us today and providing all of this very important information through a very difficult time that we're going through, and I would also like to thank all of our listeners for everything that you're doing during this COVID-19 pandemic. We know that your practice can be very demanding, especially during these trying times, and if there's any way that we at SVMIC can be of any help please feel free to give us a call.

As a reminder we want to let you know that we have a COVID-19 resource page that's available for you, and it can be found at SVMIC.com/resources/COVID-19 and we will link to that page in our show notes as well. Thank you for listening.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast.

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.