Physicians Find Perks in COVID-19 Relief Bill

Ken Terry

December 22, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The mammoth COVID-19 relief bill passed by Congress Monday night includes several provisions that will have a major impact on physicians going forward. The bill now moves to President Donald Trump's desk for his approval.

Foremost among these components is a measure that bans most surprise medical billing, starting in 2022. In addition, the 5593-page legislation softens the impact of a provision in the 2021 Medicare Physician Fee Schedule that was expected to lower some physicians' Medicare payments next year.

The legislation also includes a second round of funding for the Paycheck Protection Program, which will again make forgivable loans available to small businesses that have lost a certain percentage of revenue because of the pandemic. However, the new legislation does not include anything like the Provider Relief Fund that was used to assist practices during the earlier phase of the pandemic.

Surprise Medical Billing

The agreement on surprise medical billing follows a 2-year lobbying battle that involved hospitals, physicians, insurers, patient advocacy groups, air ambulance companies, and private equity firms, which own a growing number of medical practices. Physicians got some relief in the compromise, but insurers and other payers also benefited.

Under the compromise struck in the COVID relief bill, patients will be required to pay only the in-network cost-sharing amount for out-of-network emergency care, certain ancillary services, and out-of-network care at in-network facilities without the patients' consent, according to a statement from the American College of Cardiology. Patients who receive bills for out-of-network care provided without their consent to the charges have to pay only in-network cost-sharing amounts, the Pacific Business Group on Health (PBGH) writes in a blog post about the legislation.

What this consent means, an NPR story said, is that out-of-network physicians who intend to balance-bill patients have to give them a cost estimate and seek their consent at least 72 hours before providing nonemergency treatment. Some physicians are excluded from this provision and cannot get around the ban on out-of-network charges by asking for patient consent, including anesthesiologists, radiologists, pathologists, neonatologists, and assistant surgeons. Laboratories are also excluded.

According to the PGBH, most healthcare settings are covered by the surprise billing protections, including hospital inpatient and emergency department care, outpatient clinics, surgical centers, and clinician offices. They also apply to air ambulance transport, but not to ground ambulance services.

A major point of contention in the surprise billing fight was the question of how out-of-network payment rates would be negotiated between providers and payers. Under the COVID relief bill, the two sides have 30 days to negotiate out-of-network claims. If they're unable to reach an agreement, either of the parties can request independent dispute resolution (IDR).

In this binding arbitration process, both parties submit their "best final offer" to the arbitrator, the PGBH reported. Both sides may submit additional information supporting their offer, but the arbitrator is not allowed to consider either providers' billed charges or Medicare or Medicaid payments, which are usually far below the rates negotiated with private payers. Using "baseball style" IDR, the arbitrator must choose one of the two offers rather than split the difference.

The American Medical Association (AMA) told Medscape Medical News that it was still sifting through the legislation and was not ready to make an overall comment. "However, further improvements were made in surprise medical billing, in particular the elimination of public program rates from the independent dispute resolution process, which was particularly welcome," the AMA said.

Pushing Back Medicare Cuts

The COVID relief measure also mitigated the impact of the recent overhaul of evaluation and management (E/M) payments by the Centers for Medicare and Medicaid Services (CMS). While primary care and some medical specialists will still get a boost in their payments, as CMS specified, the legislation restores a portion of the cuts that emergency physicians and procedural specialists were expecting.

According to a statement from the American College of Physicians (ACP), the bill "allows for increases in relative value and payments for long-undervalued E/M services to be implemented on January 1.

"It provides an additional $3 billion to raise reimbursements for all physician services by 3.75%, which will help to mitigate a substantial portion of the cuts that were expected from budget neutrality while further increasing payments to frontline primary and comprehensive care physicians."

The American College of Cardiology (ACC) also said it was pleased by this aspect of the legislation. "It addresses concerns by specialists practicing in the Medicare program to blunt the impact of budget neutrality in the 2021 Medicare Physician Fee Schedule," an ACC article said. The society estimated that this mitigation would avert about a third of the scheduled cuts to some physicians.

The ACP lauded this provision and many others in the new COVID bill. "ACP is particularly pleased that the legislation provides across-the-board increases in Medicare payments to physicians in all specialties, substantially offsets budget neutrality cuts, and supports CMS's decision to finalize higher payments for office visits and other related evaluation and management (E/M) services," said ACP President Jacqueline Fincher, MD, in the statement.

PPP Rides Again

The resurrection of the Paycheck Protection Program (PPP) should also help many practices. Under the COVID-19 relief bill, $284 billion is set aside for forgivable PPP loans. To be eligible for a PPP loan, the ACC noted, a business must have 300 or fewer employees and must be able to show a 25% loss of revenue for any quarter of 2020. PPP loans don't have to be paid back if they're used to retain employees.

The vast majority of practices should qualify for these loans. In June, according to the Medical Group Management Association (MGMA), average revenues for MGMA member practices were only 76% of what they were in 2019. Moreover, the bill's language would allow practices that saw crushing drops in volume last spring to apply for the PPP loans. Ninety percent of respondents to a MGMA survey said they'd obtained these loans the first time around.

On the other hand, the COVID relief bill does not replicate the earlier grants made available to healthcare providers through the Provider Relief Fund. And the Small Business Administration stopped offering grants under the Economic Injury Disaster Loan program last summer.

Two other facets of the new legislation will have an economic impact on providers. The bill delays by 3 months the 2% Medicare sequester cuts that were slated to resume on January 1, 2021. The ACP would like to postpone the sequestration cuts until at least the end of the public health emergency.

The ACP praised other parts of the bill, including its funding for vaccine distribution and COVID-19 testing, new funding for community health centers, and the establishment of 1000 additional Medicare-supported graduate medical education positions.

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