Best Practice to Maximize Patient Collections Now that the HRSA COVID-19 Uninsured Program has Ended

On March 15, 2022, the Health Resources and Services Administration (HRSA) announced that the Uninsured Program would stop accepting claims as it had exhausted its federal pandemic funding. 

In the COVID-19 Uninsured Program Shutdown FAQs, HRSA stated:

Claims submitted after March 22 for COVID-19 testing and treatment, and after April 5 for vaccination will not be adjudicated for payment. 

Confirmation of receipt (from HRSA) of your claim submission does not guarantee payment.

Claims submitted before the deadline will be adjudicated and paid subject to their eligibility and the availability of funds.

Claims submitted by the deadline may take longer to process than the typical 30 business day timeframe.

For two years, (February 2020-March 2022) the Uninsured Program allowed providers to submit claims for COVID-19 testing and treatment for reimbursement at the Medicare rate.

This program was profitable for providers because they did not have to bill or attempt to collect payments from uninsured patients, and were able to receive reimbursement at the 2020 Medicare rate ($100.00).     

With the program ending, providers are left to determine what to do about claims billed to HRSA that have been left unpaid due to insufficient funds, and how to manage uninsured COVID-19 claims moving forward.

What to Do About Outstanding Claims Left Unpaid by HRSA

In May and June, XIFIN clients received reimbursement from HRSA for some final claims submitted in March. However, there are other clients with existing claims that still have not been paid. Most of these claims were submitted on March 21st and 22nd.

For uninsured claims submitted but not paid by the program, providers can choose to:

  1. Bill the patient directly for the service
  2. Bill the provider who ordered the test
  3. Write off the claims as uncollected bad debt

Consider utilizing the strategies below to determine the best solution for your practice, which may differ based on the referring client.

Determine the total financial impact. The first step is to determine the number of claims submitted to HRSA that were not paid due to lack of funding and the potential revenue impact of those claims.    

Analyze unpaid claims billed by provider. Once the total financial impact has been identified, analyze unpaid claims further by referring facility or provider to determine the financial implications per referring entity and what percentage of total unpaid claims are coming from which provider.

Evaluate your Laboratory Service Agreement (LSA). Evaluate your LSA with ordering clients to determine if there is any existing language that provides direction on how to handle unpaid HRSA claims. For example, some providers have language written into their LSAs requiring the client to reimburse the laboratory for a certain percentage of COVID-19 test claims when the patient is uninsured, and the lab is unable to obtain reimbursement through HRSA. 

Work with referring clients and facilities. Contact the referring provider, starting with your largest client, to discuss the issue. Some clients may consider working with you to pay a portion of the bill versus billing the patient directly.

Consider billing the patient. If you decide to bill patients for the services, consider putting language in the statement explaining the elimination of the HRSA and why they are now receiving a bill for services that were previously provided at no cost.

Adjust claims off as uncollectable bad debt. Unpaid claims submitted in March now fall within accounts receivables greater than 180 days. Depending on the financial impact of the claims, another option is to write the claims off as uncollectable bad debt.

Review the information below for additional considerations when billing the uninsured patient.

How to Manage COVID-19 Testing Self-Pay Claims Moving Forward

On average, 90% of all self-pay claims are uncollected from patients. Therefore, it is essential to have a process in place to ensure patient collections are maximized. Listed below are key considerations when implementing a strategy to bill uninsured patients for COVID testing:

Verify insurance eligibility. Thirty-five percent (35%) of all laboratory claims submitted have incorrect or missing information.  Providers should have processes in place to follow up on missing or inaccurate insurance information provided. Obtaining accurate insurance information before billing the patient is a critical step to ensuring diagnostic claims are fully reimbursed and reimbursed in a timely manner.

Invoice the patient. Once the patient has been identified as truly self-pay, the next step is to bill the patient for services. Establish a reasonable self-pay rate for COVID-19 testing services. For your area, determine the Medicare payment rate for the test and establish your practice’s self-pay fee schedule for COVID-19 testing and treatment. Most of the large national labs have taken this approach.

Educate the patient. When invoicing the patient, consider adding language to the patient statement, stating why they are now receiving a bill for services they have not had to pay for the past two years.  

Prepare the call center. Educate your employees on the situation so that they are prepared to respond to patient inquiries. Consider providing your call center representatives with a script to follow, to ensure a clear and consistent message is communicated.

Evaluate client profitability. Examine the payor mix and test mix for each client to determine what percentage of referrals are self-pay, governmental payors, or commercial payors, and what percentage of tests are COVID-related. This will help you examine the profitability of each client. In addition, keep referring clients educated on the issue and ensure they understand the percentage of self-pay versus insured work they are referring to.  

Collect patient pre-payments. Utilize web services and portals, which can be integrated with your billing system, to allow referring providers or the laboratory to collect pre-payments at the time of the service. Integrating these services will enable payments to transfer automatically to the billing system.    

Provide multiple payment options. When billing the patients, provide user-friendly payment options so patients can make payments when convenient for them, set up payment plans, view bills, make payments, or update insurance information online. 

Stay up-to-date on payor policies, legislation, and issues, including

COVID-19 Testing Price Gouging – When trying to ensure that patients would not have to pay for testing, legislation was enacted that required insurers to pay laboratories an amount equal to the lab’s “cash price” as listed online for the tests. No limit was put in place as to what the prices should be, and many laboratories took advantage of that--setting COVID cash prices three- to five times higher them Medicare reimbursement. Several commercial payors have sued for over-inflated COVID-19 test pricing charges.

Good Faith Estimate – Under the No Surprise Act, providers must provide patients with a good-faith estimate of charges before services are rendered. Providers billing uninsured patients for COVID-19 testing must comply with the good-faith estimate requirement. For more information on providing a good-faith estimate to patients, visit the XIFIN No Surprises Act Resource Center.

Audits and Payment Recoupments – When implementing a process to bill patients for COVID-19 testing, providers must remain up-to-date on payor-specific COVID-related policies to ensure compliance and avoid audits or payment recoupment.

Expanded COVID-19 Test Audits

During the first two years of the pandemic, the Medicare program and commercial payors focused on ensuring that labs had the resources to meet the demand for massive COVID-19 testing. This included generous reimbursement rates and a waiver of physician-authorization requirements for COVID-19 testing. The Medicare Part B program spent $1.5 billion on COVID-19 testing in 2020 alone. Laboratory Economics estimates that total Medicare Part B spending on COVID-19 testing is more than $5 billion.

In the Health Care Fraud and Abuse Control Program FY 2021 report released in July 2022, the Centers for Medicare and Medicaid Services (CMS) acknowledged the waivers and flexibilities offered at the start of the COVID-19 public health emergency (PHE) may have created new fraud risks. In May 2022, the Office of Inspector General (OIG) announced it would expand its COVID-19 testing audits to include labs that billed Medicare for the $25 add-on payment for timely COVID-19 testing.  

Currently, the OIG audits are concentrated on several key areas:

Were COVID-19 tests eligible for Medicare payment? 

Medicare covers tests for beneficiaries who either have signs or symptoms of COVID-19 or have a known or suspected exposure to COVID-19. Medicare does not cover non-diagnostic tests, such as employee screening programs or public health surveillance.

Was it appropriate to bill for specimen collection/travel? 

If a lab travels to and collects COVID-19 test samples for homebound or nursing home patients, Medicare may be billed for travel and specimen collection. Tests performed in the exact location where the test sample is collected are not eligible for Medicare reimbursement of any travel expenses. Labs billing Medicare for specimen collection related to travel are required to have logs supporting the mileage traveled.

Were add-on tests medically necessary? 

Under revised rules finalized in September 2020, a beneficiary may receive Medicare coverage for one COVID-19 (and related) test without the order of a physician or other health practitioner. Additional testing requires a physician’s order. OIG has concerns that these relaxed rules led to potentially fraudulent billing for add-on tests for respiratory panels, allergy tests, and genetic tests

Was the $25 add-on fee used appropriately? 

Effective January 2021, CMS instituted a rule to incentivize labs to process COVID-19 test results faster. CMS established a new code (CPT U0005) that would pay labs $25 if the COVID-19 test was completed within two calendar days and if the majority of all their COVID-19 high-throughput tests (from all payers) were completed in two days in the prior month. OIG plans to review supporting lab documentation to determine if the criteria for billing the add-on payment were met.

Based on the OIG expanded focus, providers could see increased audits and recoupments from commercial and governmental payors. For example, we may see HRSA audits focusing on the process of identifying the uninsured and the insurance discovery process. What approach did you take to ensure the patient was uninsured?

Additional Resources:

Interested in learning how XIFIN customers are managing the end of the HRSA Uninsured Program? Watch this 10-minute video from a recent XiConnect customer webinar.

Published by XiFin
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