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COVID-19 Modifications and Requirements for Provider Credentialing and Expanded Patient Care

May 26, 2020

There have been numerous Federal and State regulatory modifications and waivers enacted to ease the demands of provider credentialing during the COVID-19 pandemic and to allow for the care of greater numbers of patients. Telehealth services have been expanded by CMS to treat patients while minimizing the risk of exposure to the virus for both patient and provider. Despite these ongoing changes and allowances, it’s important to know that there are four credentialing requirements that are still mandatory for all providers treating patients during the pandemic.

During COVID-19 providers are still required to:

  • Be enrolled in the Medicare Program
  • Possess a valid license to practice in the state which relates to their Medicare enrollment
  • Furnish services in a state in which the emergency is occurring
  • Be free of any current federal or state sanctions, exclusions, or debarments

These four credentialing requirements cannot be overlooked or bypassed, even during the current global pandemic. Despite many modifications and allowances, these requirements remain mandatory. Federal and State modifications for COVID-19 does not allow an excluded provider to treat patients and receive reimbursement for services rendered. Health care organizations must continue to screen for exclusions, sanctions, and debarments during the pandemic.

Providers Must be Free of All Federal Exclusions

When bringing on additional providers, even during COVID-19, health care organizations must screen all providers for exclusions by OIG, SAM, and all 42 State Medicaid Exclusion lists. Additionally, all providers must adhere to individual State licensure requirements. A CMS 1135 waiver does not waive a State’s licensure requirements, which can vary by State. Each State and their Medical, Nursing, and Pharmacy boards have different temporary adjustments due to COVID-19 so it is important for all health care systems to stay up to date on these specific changes and allowances.

Centers for Medicare and Medicaid Services COVID-19 Modifications

CMS has expanded the telehealth services during the pandemic and has allowed for 1135 waivers to be granted in all 50 states, along with expanded services for Medicare programs, licensing board grace period extensions, certain screening requirements waived, and much more.

The following is a list of a few of the CMS actions taken to assist health care systems during COVID-19 (this is not an all-inclusive list):

  • 1135 Waivers
  • Expanded and accelerated an advanced payment program for Medicare providers
  • Extended quality reporting deadlines and applications for providers in value-based care programs will not be included for services rendered between January to June 30th and possibly beyond
  • Licensing boards allowing expiring licenses to remain active during the pandemic and have extended grace periods
  • Expanded the purposes for which telehealth services could be engaged
  • Temporarily waive requirements that out-of-state providers be licensed in the state where they are providing services
  • Toll-free hotline to enroll and receive temporary Medicare billing privileges
  • Allow licensed providers to render services outside of their state of enrollment
  • Postpone all revalidation actions
  • Expedite any pending or new applications
  • Waive the following screening requirements: application fee, criminal background checks, and site visits

What are CMS 1135 Waivers?

During a public health emergency under section 1135 of the Social Security Act, the HHS Secretary can temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in Social Security Act programs in the emergency area and time periods of the emergency and that providers who provide such services in good faith can be reimbursed.

Currently all 50 states have CMS 1135 waivers in place, but different states have different permissions granted them dependent upon the state’s needs during the pandemic. These permissions continue to change as each state deals with the varying levels of demand placed on their health care systems. You can find up to date information on each state’s 1135 waivers here.

CMS 1135 Waivers can modify the following (includes but not limited to):

  • Conditions of participation or other certification requirements
  • Program participation
  • Preapproval requirements
  • Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State
  • Emergency Medical Treatment and Labor Act (EMTALA) sanctions for redirection or transfer of an individual to receive a medical screening examination in an alternative location
  • Stark self-referral sanctions
  • Performance deadlines and timetables
  • Limitations on payment to permit Medicare enrollees to use out of network providers in an emergency situation

COVID-19 is Changing the Face of Telehealth

As part of the relief effort to treat patients remotely during the pandemic CMS is paying for 80 additional services via telehealth. Doctors can see new patients via telehealth, not just patients they already had an established relationship with. This is a huge change in telehealth services. COVID-19 will forever change the landscape of virtual treatment as both doctors and patients become more comfortable with the delivery and receipt of quality health care at a distance.

The benefits and conveniences of telehealth have proven to be invaluable during COVID-19 and will likely continue long after the national health emergency ends. Patients have access to providers and quality care from the comfort of their homes. Those who live in remote locations, lack transportation, or who are isolated for any number of reasons have access to a licensed practitioner who can diagnose and treat them virtually. Providers can treat more patients via telehealth and can do so from the comforts of their homes saving organizations time and money. With the shortage of PPE (personal protective equipment) that has been experienced during COVID-19, this type of virtual care preserves those limited resources for the most critical frontline workers.

Verisys Screens Providers Following All Current Federal and State COVID-19 Adjustments

Verisys screens providers and verifies licenses against 3,500 primary sources following all the current COVID-19 adjustments at the Federal and State levels. A FACIS search looks for results or potential matches from all federal data sources: OIG, SAM (including SDN), FDA, DEA, GSA, TRICARE, FBI, PHS, ORI, U.S. DOJ, U.S. Treasury Dept., U.S. State Dept., and all state-level Federal Healthcare Entitlement Program (FHEP) sources (State Medicaid Exclusions, State Contractor Disqualification/Debarment Lists, HEAT Task Force News, State Attorney General News, Federal District – Attorney General News, Medicare/Medicaid Opt-Out Lists). FACIS uses a matching logic algorithm to identity match individuals with 99.5% accuracy.

The compliance team at Verisys gathers information on COVID-19 modifications from a variety of sources and makes every effort to provide complete, accurate, and up to date information to assist your organization in remaining compliant to all Federal and State requirements during the pandemic. These modifications are fluid and continue to evolve as the demands of the pandemic change. Please visit our COVID-19 Resource Page for the most up to date information on the modifications and requirements for provider credentialing. You can also view a webinar that discusses these modifications and requirements in more detail here.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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