On January 31, 2020, the Secretary of Health and Human Services (HHS) declared a public health emergency under section 319 of the Public Health Service Act (42 U.S.C. 247d) in response to a novel coronavirus known as SARS-CoV-2 (COVID-19). Then, on March 13, 2020, the President of the United States issued a declaration of a national emergency based on the spread of COVID-19. In this environment, much has seemed out of our control.
The American managed care system was on its way toward developing and implementing models that incorporated flexibility in telehealth visits, innovative approaches to care, and other mechanisms. Given current circumstances, the time is now to utilize the unprecedented flexibility given by the Federal and State governments to transform your delivery system into a virtual patient-centered environment.
- Telehealth and Telemedicine – Plans should take full advantage of the flexibility offered by Federal and State governments to increase the use of telehealth. The Centers for Medicare and Medicaid Services (CMS) had already opened this door with new regulations that were effective January 1, 2020, that gave Medicare Advantage plans the ability to include such benefits in their basic packages. CMS used its 1135 waiver authority and has provided further guidance for Medicare effective March 6, 2020, which allowed for telehealth visits for new and existing patients, and virtual check-ins and e-visits for existing patients, to be reimbursed in a broader set of situations. These instances include a wider range of providers and technologies including patients conducting the telemedicine visit from their homes. CMS will allow relaxed copays and, in some instances, such as virtual check-ins and e-visits, a recognition of a “good faith” effort to serve patients pursuant to HIPAA requirements. This means that many providers without prior technology in place to offer telemedicine visits can now do so using methods like FaceTime or Skype. It also means that the oversight body for health technology, the Office of Civil Rights, will not penalize providers for using this technology during the public health emergency.
Large Managed Care states like California have directed health plans to utilize telehealth and waive copays as well as to ensure parity of provider reimbursement so that providers offering telehealth services are paid at the same rate as they would be for an in-person visit.
- Modernize Utilization Management (UM) and Claims – Mechanisms such as e-prescribing, automatic prior authorizations, and others have been slowly entering into the Managed Care system, but now the need to “socially distance” thousands of UM workers at health plans makes a strong case for remote workers, relaxation where mandated of certain prior authorization requirements, and increases the need for strong decision support software backed up by up-to-date policies, procedures, and job aids for the staff.
Related to claims processing, many mandates from Federal and State governments call for waiver of copays, prior hospital stay requirements (i.e., skilled nursing), parity of provider reimbursement for telehealth, and other benefit limitations and system edits. Health plans and their business partners need flexible benefit system configurations that can be programmed to make these changes while emergency declarations are in place.
- Be Proactive with Care Management – Update and use algorithms to identify patients that are at high risk for COVID-19 and develop an aggressive delivery plan for targeted member education. Seek and use any available government flexibility that allows for a decrease in in-person case management touchpoints. For example, on March 20, 2020, in California, CMS has worked with the Department of Health Care Services (DHCS) to suspend face-to-face care coordination activities for Medicare and Medicaid Plans (MMPs) and replace them with telehealth or other mechanisms.
- Work Closely with Delegated Entities – Work with Pharmacy Benefit Managers (PBMs), pharmacies, Medical Services Organizations, and care management vendors to make sure that they are limiting unnecessary face-to-face contact and implementing all required mandates. On March 20, 2020, CMS issued guidance that pharmacy signature requirements including those for controlled substances, will not be subjected to audit during the public health emergency. CMS also released guidance to Part D plans that they can relax refill-too-soon, prior authorization, and maximum fill edits and requirements. However, this level of flexibility means that proper oversight and system testing is needed.
- Broadly Assess Risk – Ensure that the latest COVID-19 guidance is being followed and that Business Continuity plans are in place for your health plan and all of your delegated entities. Be sure to include additional cybersecurity considerations that are an unfortunate stressor on an already vulnerable healthcare system.
Remember that once this public health crisis is over, organizations will be judged on how they mobilized and handled the situation. Regulators such as CMS have been known to select cases during these types of situations in order to gauge how well health plans ensured that members received necessary care, supplies, and medications.
Remaining flexible and converting your workforce and processes to more virtual means can go a long way towards preventing further issues related to COVID-19 and readying your organization for future issues.
 See CMS Telemedicine, Healthcare Providers Fact Sheet, March 17, 2020. CMS Telemedicine Fact Sheet
 See Department of Managed Health Care, All Plan Letter APL 20-009, March 18, 2020, APL. DMHC APL 20-009
 See CMS Emergency Declaration, Healthcare Providers Fact Sheet CMS Emergency Declaration Fact Sheet
 See CMS Memorandum, California Medicare-Medicaid Plan Flexibilities Related to Coronavirus Disease 2019 – COVID-19, March 20, 2020.
 See CMS Memorandum, Minimizing Face-to-Face Contact for Medication Delivery or Dispensing, March 20, 2020.
 See CMS Memorandum, Information Related to Coronavirus Disease 2019 – COVID-19, March 10, 2002.
 Id at pg. 4.
© Copyright 2020. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.