Uninsured Coverage for COVID-19 Patients – Revenue Cycle Call to Action

Thoughtware Alert May 01, 2020
Healthcare workers were masks

Recently announced as part of the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the U.S. Department of Health & Human Services will provide reimbursement to providers for testing uninsured patients for the SARS-CoV-2 virus and incidence of COVID-19 and treating uninsured patients with a COVID-19 diagnosis.

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Providers that have conducted COVID-19 testing or provided treatments for COVID-19 uninsured patients on or after February 4, 2020, can submit electronic claims. In general, providers will be reimbursed at Medicare rates, subject to available funding. To participate, providers must attest to the following:

  • Verified no other payor will reimburse for COVID-19 testing and/or care for the patient
  • Accept defined program reimbursement as payment in full; agree not to balance bill the patient
  • Agree to program terms and conditions; may be subject to post-reimbursement audit review and Medicare timely filing limits

The option to submit uninsured COVID-19 claims is expected to be more heavily used for states that didn’t participate in Medicaid expansion.

Providers will need to think through the operational areas of their revenue cycle and consider process flow changes or modifications to identify the uninsured claims timely and submit accurately. Outlined below are a few suggestions organized by revenue cycle functional area.  

Finance & Accounting – Segmenting Population

Follow the guidance to enroll in the program, which includes submitting a provider roster and, starting May 6, 2020, a patient roster. After enrollment, BKD recommends creating two new payor codes to segment the potentially uninsured COVID-19 population, as suggested below:

  1. Self-Pay Pending COVID19: A patient presents with potential COVID-19 symptoms. A billing hold and/or claim edit could be created for each new payor code, allowing for review to confirm appropriate criteria are met before billing. 
  2. COVID19 HRSA Uninsured Testing and Treatment Fund: Per Health Resources and Services Administration (HRSA) guidance, uninsured patients tested for and confirmed as having COVID-19 with supporting diagnosis, i.e., direct admission, could be assigned to the payor. Payor ID 95964 should be used for claims submitted under this program. Billing hold and/or claim edit also should be created for this payor code, allowing encounters to be reviewed before billing. Finance should map payor to Medicare for billing and contract modeling purposes. See the HRSA Claims & Reimbursement page for more guidance. 

Registration & Financial Counseling – Identify the Uninsured

If a patient presents with potential COVID-19 symptoms, the registrar should follow existing registration guidelines: requesting insurance information, running eligibility and checking for additional coverage, such as presumptive eligibility for Medicaid. If the determined patient is uninsured, the registrar should add Self-Pay Pending COVID19 as primary insurance.

If a patient presents with confirmed COVID-19 and supporting diagnosis, registration should still follow existing registration guidelines: requesting insurance information, running eligibility and checking for additional coverage, such as presumptive eligibility for Medicaid. If the determined patient is uninsured, the registrar should add COVID19 HRSA (95964) as primary insurance.

Providers should review the HRSA Patient Details link to confirm that registrars are capturing the data needed to receive reimbursement through this program and that appropriate documentation is made if information is unavailable.

Noted below is a recommended registration workflow for COVID-19 uninsured:

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HIM – Coding the Testing & Care

To be reimbursed for COVID-19-related laboratory testing, claims must include one of the three following laboratory Current Procedural Terminology (CPT®) codes:

  • 86318 – Immunoassay for infectious agent antibody, qualitative or semiquantitative, single-step method, e.g., reagent strip
  • 86328 – Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method, e.g., reagent strip; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (corona disease [COVID-19])
  • 86769 – Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])

When billing for uninsured patients for testing and/or treatment, the COVID-19 diagnosis must be the primary/principal diagnosis.

  • For testing and related services, the following codes can be used:
    • Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19)
    • Z20.828 – Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)
    • Z11.59 – Encounter for screening for other viral diseases (asymptomatic)
  • For services related to the treatment of COVID-19, the following coding guidance is given:
    • For eligible encounters with dates of discharge prior to April 1, 2020, report B97.29 – Other coronavirus as the cause of diseases classified elsewhere 
    • COVID-19 diagnosis code for dates of service or dates of discharge on or after April 1, 2020, report U07.1 – 2019-nCoV acute respiratory disease

An exception to this rule is when the patient is pregnant, the ICD-10-CM code 098.5 – Other viral diseases complicating pregnancy, childbirth and the puerperium, should be reported as primary. Please visit the HRSA COVID-19 claims reimbursement page for more information. 

Reimbursement Rates – COVID-19 Uninsured

HRSA has a set of determined eligible services for this program. Unless clarified by HRSA elsewhere, reimbursement will be based on the current-year Medicare fee schedule and updated information related to CPT or ICD-10-CM/PCS codes will follow CMS guidance. CPT codes 86328 and 86769 were adopted by the American Medical Association (AMA) CPT Editorial Panel on April 10, 2020, and are effective for use immediately on or after that date. For these codes, where a CMS published rate doesn’t exist, claims will be held until CMS publishes corresponding reimbursement information. See the HRSA Frequently Asked Questions for additional guidance on reimbursement.

Professional Services Reimbursement

For professional services, water and air ambulance claims with the primary diagnosis of COVID-19, HRSA will reimburse at the current-year CMS pricing with geographical adjustments, if applicable. If geographical adjustments aren’t available, HRSA will use the CMS national pricing. The COVID-19 testing specimen collection procedures will be priced using the published rates in the CARES Act and the CMS interim final rule.

Facility Reimbursement

For facilities, claims will be priced by traditional Medicare reimbursement. HRSA gives examples of exceptions.

  • Inpatient cases won’t include the 20 percent increase to the DRG weight with the diagnosis code of U07.1 or B97.29
  • Reimbursement rates for facilities not paid on IPPS—critical access hospitals, rural health clinics, children’s hospitals and PPS-exempt cancer hospitals—won’t be updated after February 4, 2020
  • Ambulance claims with the primary diagnosis of COVID-19 will be:
    • Ground or water: $350 per claim
    • Air: $2,300 per claim
  • Home health services will follow a per-visit methodology, established by the program as follows:

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It’s important to note that the current guidance set by HRSA is subject to change. Please visit the HRSA Reimbursement Details page for more information.

Patient Financial Services – Billing

Providers should identify and review historical uninsured patients to determine if their accounts contain COVID-19 testing and/or treatment meeting criteria for this program. BKD recommends reviewing all uninsured accounts on or after February 4, 2020, that have an associated COVID-19 diagnosis and/or received a COVID-19 test (see guidance above). Providers should consider placing a hold on these accounts to prevent generating patient statements while reviewing.

Once identified, eligibility for uninsured patients should be reprocessed. Providers must confirm there’s no other insurance or Medicaid available for the account. If the account is confirmed as uninsured, a review of the COVID-19 testing results and diagnosis codes should be performed. If there’s a negative result, only the testing would qualify for reimbursement. If there’s a positive result, the entire account may qualify for reimbursement under FFCRA (see coding guidance to confirm criteria are met). At this point, we recommend adding COVID-19 HRSA as primary insurance.

For a claim to qualify for reimbursement under this program, it’s important for billing and coding to work together to review and confirm each claim individually against the HRSA coding and billing guidance. Providers can’t submit interim bills, corrected claims or late charges. Appeals for claim denials also won’t be allowed. The first claim is all that’s available, and the unique coding guidance must be adhered to for reimbursement.

Upon identifying the population of uninsured patients that qualify for reimbursement under this program, the organization will then need to complete patient attestation and upload the patient roster to the website. Temporary IDs will be provided for patients submitted within one to three days and remain valid for claim submissions for 30 days. BKD recommends preparing the list for all uninsured patients confirmed to qualify under this program and be ready to have the claim submitted. A batch upload feature is available beginning May 6, 2020. All claims must be submitted electronically. Please see HRSA Patient Detail for further information.

Moving forward, new patients presenting to the provider should be identified through registration with one of the two new payor codes on the account. Upon discharge, the accounts will then be identified by billers before claim submission through either a billing hold and/or claim edit. Billers should continue to follow guidance outlined above to determine if the claim can be submitted to the payor with HIM/Coding support. If criteria are met, billing and finance should work together to complete attestation for the patient and receive the temporary ID timely for claim submission.

Billing – Recommended Workflow for COVID-19 Uninsured

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Patient Financial Services – Follow-Up

Providers should track COVID-19 HRSA claims and reimbursement. Claims should be paid in approximately seven to 10 business days. It’s important to review the initial remittances received to confirm there’s no patient responsibility remaining. Per the program guidance, providers can’t bill the patient for any portion of the claim covered as part of the FFCRA. If patient responsibility exists, we recommend adjusting off the amount to a new adjustment code for tracking purposes.

In addition, it is important providers review denials received on COVID-19 HRSA claims to determine root cause and mitigate denials on future claims. Based on the guidance provided, this program doesn’t allow for appeals on claim denials received.

As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication. For more information, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.

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