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As a result of COVID-19, many healthcare organizations are facing unprecedented challenges with unclear guidance. Among these challenges is reimbursement, an already complicated component of healthcare further complicated by the pandemic. To maintain financial stability, healthcare organizations must become their own advocates when negotiating with payors. Below are actions all healthcare organizations should consider taking now to reduce administrative friction and protect their revenue.

Move to automatic, periodic interval payments.

• Work with payors to ensure consistent reimbursement while volume is in flux and estimate the normal monthly payment of fee-for-service claims.
• Confirm a guaranteed monthly payment with payors until volumes return to normal, or until both the payor and health system agree that problems stemming from COVID-19 are under control.
• Reconcile overpayment and underpayment of claims, and ensure balances are paid within five business days of reconciliation.

Suspend value-based care measures.

• Ask that payors suspend performance measures for 2020 in accordance with the Centers for Disease Control and Prevention’s (CDC) recommended cancellations.
• Do not include COVID-19 diagnoses for value-based care contracts, as the long-term effects of the diagnosis are currently unknown.
• Ease the pressure on the system by asking for reduced Medicare risk adjustments reporting. Confirm that Medicare risk adjustments for 2021 will account for the extenuating circumstances of 2020.

Remove administrative requirements.

• Suspend all authorizations, referrals, denials, medical record reviews, reporting, network requirements, primary care physician assignment and automatic offsets.
• Contact state Medicaid and the Centers for Medicare & Medicaid Services (CMS) to have the agency lift timely filing requirements.
• Review the programs that qualify for the latest policy exceptions and extensions for measure-reporting and data-submission deadlines from CMS.

Prohibit new policies.

• Obtain written documentation that there will be no new products, steerage, payment policies, site-of-service requirements or terminations put into effect that could impact reimbursement in any way until the end of June 2021, or until treatment and protocols for COVID-19 and its associated conditions have been established.
• Confirm COVID-19 testing and treatment drugs will be reimbursed in addition to standard payment and at a minimum of cost plus 5%.

Refine medical groups.

• Ask that new locations, offices and doctors — regardless of state licensing — be automatically considered in-network, unless there are sanctions or lawsuits against these entities.
• Eliminate requirement barriers within the same health systems (i.e., any accredited provider can treat a member within the same health system for any diagnosis).
• Ensure that telehealth visits are reimbursed at the same level as office visits.
• Streamline recredentialing unless there is medical malpractice, license suspension or a Drug Enforcement Administration (DEA) licensing issue, or other similar concerns have occurred.

For more information, contact us or visit our COVID-19 resources page.