Recommendation For CMS To Protect VBP Progress

To protect the progress of the value-based payment reform, the American College of Physicians (ACP) recently reached out to the Centers for Medicare & Medicaid Services (CMS) recommending to extend flexibilities in the Quality Payment Program (QPP) to protect clinicians against long-term effects of the COVID-19 crisis.

For visibility to the proposed flexibilities ACP outlined please see the below.

Medicare Advantage Penetration Continues To Grow – Opportunity For Facilities

Senior living facilities currently show that around 30% of their residents are enrolled in a Medicare Advantage (MA) plan.
We’ve been tracking this for years, noting that MA continues to grow across Ohio’s 88 counties.
Our most recent MA enrollment report shows that Ohio now exceeds 50% MA penetration in some urban counties and 40% in many rural counties.

For more on the ‘Tremendous Opportunity’ that facilities can find by educating themselves on their market see the article below.

We also provide custom reports on payer and penetration information upon request! Contact us today at

CMS Rule Encourages MA Plans To Increase Telehealth Access

The Centers for Medicare and Medicaid Services (CMS) has finalized rule changes that encourage Medicare Advantage (MA) plans to increase their telehealth benefits. Now, MA plans will be able to cover a wider range of telehealth specialty providers.

CMS is also looking to ease policies for rural healthcare to make MA offerings available to rural residents. For more on this please see the article below.

2021 CMS Proposed Payment and Policy Changes For SNFs

Recently, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule for skilled nursing facility (SNF) payments for the coming year.

If finalized, the rule would see nursing homes receive a 2.3% Medicare pay bump, update the SNF prospective payment system (PPS) wage index and update the way IDC-10 codes map under the new Patient-Driven Payment Model (PDPM). 

For visibility to the CMS fact sheet see below.

COVID-19 Payer Updates 4/21/20 – Access Advantage

Payer COVID-19 policies continue to come in, with anticipated additions over the days and weeks ahead. Payers are relaxing their policies and implementing emergency actions to accommodate the influx of healthcare services needed at this time. Please see below for the latest update(s) since our last alert.

Ohio Department of Medicaid (ODM) – In response to COVID-19, ODM has partnered with Managed Care Plans (MCPs) and MyCare Ohio Plans (MCOPs) to implement an Executive Order which affects telehealth services, recently updated to include home health providers and authorization requirements. Some of the changes include extended timely filing limits to 365 days for all provider types and deferring medical necessity determinations to providers. Some providers have provided payer-specific information which can be found below. For ODM details (Click Here).

Buckeye Health Plan – Has expanded all prior authorizations requirements for telehealth services through June 30, 2020. For details (Click Here).

CareSource – CareSource has temporarily suspended prior authorizations for new nursing facility admissions. Note, level of care determinations will continue in accordance with OAC rule 5160-3-08. CareSource reserves the right to perform concurrent nursing facility reviews to determine if nursing facility services are still necessary. For details (Click Here).

Primetime – Primetime continues to update its telemedicine guidelines in accordance with CMS and asks that providers bill accordingly. For details (Click Here).

UnitedHealthcare (UHC) – UHC has extended its prior authorization provisions for all individual and Group Market health plans, Medicaid and Medicare Advantage plans. UHC has implemented a 90-day extension based on the original authorization date. For more details (Click Here).

We will continue to partner with our managed care payers throughout the situation and provide updates accordingly. See below for a few things to remember:

  • As always, remember to verify benefits and eligibility for each patient prior to providing non-emergent services to ensure coverage, as benefits are plan specific and all enrollees may not be eligible.
  • Per Payer communications:
    • CMS is asking providers not to use place of service 02 unless that was for telehealth services covered prior to the pandemic. CMS is now asking providers to use the place of service code that they would have normally billed within the absence of the telemedicine and use modifier 95.
    • CMS has removed the three-day waiver for transfers to nursing facilities.
    • CMS is suspending the current 2% sequestration on Medicare payments effective 5/1/2020 through December 31,2020.
  • Telehealth visits should be billed with a place of service 02 with the appropriate modifiers.
  • For a list of CMS-approved codes as of 3/17/2020 (Click Here).

We will keep you abreast of the latest information regarding suggestions, policies, and changes surrounding the pandemic.

For more information please contact the Access Advantage Service Box at

All payer information sourced via payer website communications.

CMS Temporarily Postpones Facility Inspections

In light of the COVID-19 emergency, the Centers for Medicare and Medicaid Services (CMS) has temporarily postponed facility inspections. Focus has instead shifted to infection control and Immediate Jeopardy situations. 

For more on this as well as a look at the three-pronged approach to identify which providers, hospitals and labs across the country are prepared for COVID-19 see below.