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Op-Ed: Alabama Medical Practices Hit Hard by COVID-19, Survey Finds

Op-Ed: Alabama Medical Practices Hit Hard by COVID-19, Survey Finds

By:          John S. Meigs, Jr., MD, President Medical Association of the State of Alabama

In a span of just a few months, the coronavirus pandemic has changed the way we function as a society and has fundamentally altered our healthcare delivery system. It has exacerbated weaknesses in the infrastructure of health care and exposed limitations in current policies at a time when costs are rising and access to care is dwindling.

In an effort to understand these changes and their effects, the Medical Association of the State of Alabama released a survey summary detailing the impact of the novel coronavirus (COVID-19) on medical practices and care delivery.  The survey identified several key findings:

  • Public Health Concerns: Survey data shows that patient volume is down considerably and there are concerns that Alabamians are not going to their physician for routine care, including childhood and adult vaccinations, which will have long term public health consequences.
  • Financial Impact: More than 70% of respondents said COVID-19 has had a severe impact on practice finances, causing layoffs and furloughs and limiting access to care
  • Patient Volume: Nearly 60% said patient volume reductions cut revenues by at least 50%, underscoring the extent to which patients are delaying or skipping necessary care
  • Telemedicine Increase: More than 71% said they’re likely to continue providing telemedicine so long as insurers continue covering the services for patients
  • Liability Concerns: More than 71% are concerned about the potential liability from lack of PPE and patients canceling or delaying procedures and other medical care

In addition, a similar study[1] found that Alabama is ranked sixth in the country in the number of patients that are delaying care. While COVID-19 may change how you receive care, it’s still important to look after yourself by getting the time-sensitive medical care you need to stay healthy.

In light of the findings of the survey, the Medical Association recommends several public policy proposals to combat COVID-19’s effects on physician practices and care delivery:

  1. Allocate state stimulus funds to reimburse practices for COVID-19 related expenses
  2. Expansion of testing, PPE, and cleaning supply availability
  3. Continued coverage of telemedicine by insurers at existing rates
  4. Enactment of “safe harbor” legislation to provide liability protections to health care providers

This pandemic has made telehealth more important than ever, enabling access to care to patients whose needs can be met remotely. Telemedicine has saved lives, helped reduce the spread of the virus, and enabled physicians to care for patients in a time when they might have otherwise been unable to. However, it is not a “silver bullet” and should not be viewed as a total replacement for in-person care.

Whether in a hospital, surgery center, or in a clinic, COVID-19 has drastically changed the care we as physicians provide for our patients. We cannot allow this virus to decimate our already strained healthcare system. Supporting those who care for us is needed now more than ever.

View the complete survey summary by clicking the button above or by using this link:

John S. Meigs, Jr., MD, President Medical Association of the State of Alabama

[1] Bean, M., 2020. States Ranked By Percentage Of Americans Delaying Care: Nationwide, 40 Percent Of Americans Are Still Delaying Care, According To A Survey From The U.S. Census Bureau.. [online] Available at: <> [Accessed 26 August 2020].

Posted in: Coronavirus, Members

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Underwood Minority Scholarship Awarded

Underwood Minority Scholarship Awarded

The Underwood Minority Scholarship Award is named for long-time Montgomery physician and the Medical Association’s 152nd President Jefferson Underwood III, M.D. Dr. Underwood became the first African-American male to serve as President of the Association in 2018-2019. The Underwood Minority Scholarship Award is for African-American individuals underrepresented in Alabama’s medical schools and the state’s physician workforce.

It is with great pride that we award the following candidate the 2020 Underwood Minority Scholarship Award, and we wish her all the best and hope this monetary award helps her accomplish her goals:

Alicia Williams, University of Alabama at Birmingham School of Medicine

A Fort Payne native, Alicia is headed for a career in general pediatrics where she will combine her leadership, clinical skills, knowledge of sports medicine and passion for providing care in rural underserved areas of Alabama. She has had the opportunity to work with teenage youth in Birmingham through Girlz Talk, an organization that teaches professionalism, safety and reproductive education. Alicia has also presented research to Governor Kay Ivey’s team and has collaborated with Secretary Jenna Ross and the Department of Early Childhood Education.

David Bramm, MD, Director of the Rural Medicine Program at UAB states, “Alicia is a breath of fresh air. She is strong without being overbearing, confident without being cocky, devoted to her patients and utterly reliable. I have been privileged to have been a preceptor for several medical schools since 1982 and fully believe Alicia is one of the best I have ever taught. I can recommend her without reservation for the Underwood scholarship.”

Alicia graduated from Mercer University with a 4.0 GPA and a Bachelor’s degree in biology. Currently, she attends UAB School of Medicine and is expected to graduate in 2021. Alicia’s personal interests including writing music, singing and playing basketball.

“I am very grateful to be the first recipient of a scholarship that honors such a respected and esteemed physician as Dr. Underwood,” Alicia states. “This scholarship serves great purpose towards my goals as a future physician, and Dr. Underwood’s leadership and service is a great example for me and other aspiring physicians like me.”

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The Effect Differing Medical Opinions Have On Falsity and Scienter in False Claims Act Lawsuits

The Effect Differing Medical Opinions Have On Falsity and Scienter in False Claims Act Lawsuits

By: Jim Hoover with Burr Forman, LLP

There is currently a circuit split among the Federal Circuit Courts of Appeals regarding the effect differing medical opinions have on the elements of falsity and scienter in False Claims Act lawsuits.  

Earlier this year the Third Circuit Court of Appeals ruled that conflicting medical opinions can create a genuine dispute of material fact on “falsity” in a False Claims Act action. The case is United States v. Care Alternatives. This holding directly conflicts with the Eleventh Circuit’s September 2019 decision in United States v. AseraCare, which held that a mere difference in medical opinion between physicians regarding a patient’s prognosis was not enough to establish falsity under the FCA. In Care Alternatives, the Third Circuit rejected AseraCare and found that conflicting physician testimony about the validity of physician’s certifications was sufficient to raise a dispute of material fact regarding the element of “falsity.” The Third Circuit sought to make clear that in its Circuit, findings of falsity and scienter must be independent from one another for purposes of FCA liability. According to the Third Circuit, the scienter element helps limit the possibility that providers will be exposed to liability under the FCA any time the Government or relator can find an expert who disagreed with the certifying physician’s medical prognosis.

Former employees of Care Alternatives filed a qui tam action against the hospice provider, alleging the hospice had improperly admitted patients who were not eligible for Medicare’s hospice benefit and directed employees to falsify Medicare certifications in order to meet the eligibility requirements. The relators’ physician opined that in 35% of the sample cases he reviewed a reasonable physician would not have certified the patient as terminally ill with a prognosis of six months or less based on the accompanying documentation. Reviewing the same sample set, Care Alternatives’ physician disagreed, finding that a reasonable physician could reasonably certify each case. Thus, there was a disagreement among the parties’ experts. The United States District Court for the District of New Jersey agreed with AseraCare by adopting and applying AseraCare’s holding that an “objective falsehood,” something more than a retrospective difference of opinion, was required to create a genuine dispute of fact.

On appeal, the Third Circuit Court of Appeals disagreed and reversed and remand the case for consideration of the other elements of FCA liability, particularly the element of scienter. The Third Circuit noted it is well-established that subjective opinions can be false, and applied this reasoning to the FCA’s falsity element. The Third Circuit opined that AseraCare’s “objective falsity” standard improperly conflated falsity with scienter, i.e., that the whistleblower prove a certifying physician was making a knowingly false certification. The Third Circuit held that these elements must be considered separately, and the purpose of the scienter requirement is to limit the possibility that a provider could be found to violate the FCA any time the Government or a relator could find an expert who may establish falsity simply by disagreeing with a physician’s prognosis.

Thus, in the Third Circuit a determination that a claim was false does not immediately trigger FCA liability. Relators must still establish that the provider knew the claim was false when the claims was submitted. Unfortunately, however, one of the big problems for False Claims Act defendants is credibility determinations are typically reserved for the jury thus almost forcing the False Claims Act case to trial.  

Because of the circuit court split, a United States Supreme Court opinion is needed to resolve the differing circuits’ approaches. In the meantime, the key takeaway for health care providers across the country is these differing standards will be fought in FCA cases where defendants have made reasonable subjective judgments.  The arguments should focus on both the falsity element and the scienter element.  

Jim Hoover is a partner at Burr & Forman LLP and works exclusively within the firm’s Health Care Practice Group and predominantly handles healthcare litigation.

Posted in: Legal Watch, Members, MVP

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Advocacy Efforts During COVID-19

Advocacy Efforts During COVID-19

The spread of COVID-19 has affected nearly all aspects of our daily lives. For the Medical Association’s efforts in protecting physicians and patients, this was also true. Nonetheless, between March 13 (when Gov. Ivey issued the COVID-19 state of emergency) and mid-May, our advocacy work continued in full-force.

Executive Actions & Proposals

  • Worked with various stakeholders and Governor Ivey to secure liability protections via an Executive Order for physicians, their staff and their practices against frivolous COVID-19 lawsuits (summary available here);
  • Successfully advocated against multiple dangerous scope of practice expansions proposed by both state and national organizations. Among other things, these proposals would have (1) eliminated physician supervision and destroyed the team-based care model; (2) granted CRNAs the ability to prescribe controlled substances; and (3) allowed pharmacists to switch a patient’s drugs without prescriber authorization and without any requirement to notify to the prescriber or the patient; and
  • Successfully advocated against a proposal to give out-of-state telehealth corporations special treatment that physicians currently living, working, and paying taxes in Alabama do not enjoy.

Telehealth Payment Parity

  • As one of our longstanding priorities (payment parity between in-person visits and telehealth services), we were proud to see reimbursement rates addressed and the policy of parity come to fruition.

Miss our 2020 Legislative Recap, What if No One was on Call? Click here for the annual rundown.

Posted in: Advocacy, Coronavirus, Liability, Members

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Honoring Dr. Jefferson Underwood

Honoring Dr. Jefferson Underwood

Long-time Montgomery physician and Medical Association member Jefferson Underwood III, M.D., was recently honored with two distinct awards.

The Alabama Chapter American College of Physicians recognized Jefferson Underwood III, MD, FACP, as the 2020 Laureate Award recipient and the Medical Association of the State of Alabama presented Dr. Underwood with the 2020 Samuel Buford Word Award. These presentations are typically made in person at the annual meetings, but due to the cancellation of this year’s events because of COVID-19, Dr. Underwood was honored in his home with a small group of family and colleagues present.

In 2018, Dr. Underwood became the first African-American male to serve as President of the Medical Association. He previously served the Association as President-Elect, Vice President and Secretary-Treasurer.

He is a Summa Cum Laude graduate of Alabama State University in Montgomery and Meharry Medical College in Nashville, Tenn. He completed his internship and residency at D.C. General Hospital/Georgetown University in Washington, D.C.

He previously received the Douglas L. Cannon Award from the Medical Association for Outstanding Medical Journalism for Community Service, the Alabama Young Democrats Achievement Award for Community Service in Health, 2005 Physician of the Year and 2015 Montgomery’s Top Doctor by the International Association of Internal Medicine.

“It was an honor for me to present the 2020 Samuel Buford Word Award, the Medical Association’s highest honor, to Jefferson Underwood.  The Word Award is presented to a physician for outstanding service to humanity that goes above and beyond the usual call of duty.  That certainly describes Jefferson Underwood,“ said John S. Meigs, Jr., MD, current President of the Medical Association. “Whether in his service to the Association, his service to the community or his service to his profession, Jefferson has always exemplified grace, dignity and compassion with a quiet strength and conviction that characterized his own sense of fairness and respect for others that resulted in true service to humanity.”

Giving back to his community is one of Dr. Underwood’s passions. As an adjunct professor at Alabama State University, he taught biology. He also served on the board of directors for the Montgomery Area United Way, the Alliance for Responsible Individual Choices for AIDS/HIV, Montgomery County Health Department Hunt Diabetic Clinic, Central Alabama Home Health, Oxford Home Health, Father Walter’s Center for Gifted Children, Habitat for Humanity, and was the health editor for The Montgomery Advertiser.

During the presentation of the awards, Dr. Underwood was also presented with a clock from the Alabama Board of Medical Examiners as a memento of his service to the Board.  “Why do we present you with a clock?  Because, the clock represents time, and, time represents eternity.  As a member of our Board staff has said, ‘Once a member of the Board, always a member of the Board,’” Dr. Mark LeQuire, MD FACR, explains. “In preparation for this presentation, I walked about the halls of the Board building, admiring the composites of previous Board members, and was invigorated to remember the giants in medicine in the State of Alabama whom have served.  Jefferson you are one of those giants, and now, you will always be one of those giants.  The fraternity of your fellow Board members thanks you for your service, for the exemplary manner in which you modeled the perfect physician priest, for your calming demeanor and influence in times of both need and stress, and for just simply being our brother and our friend.  Remember, we will always cherish you, you will never be forgotten, and we are always at your service.  May our God bless you and yours every so richly and deeply.”

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Alabama Department of Public Health Advises Health Care Providers in Use of COVID-19 Tests not Approved by the United States Food and Drug Administration

Alabama Department of Public Health Advises Health Care Providers in Use of COVID-19 Tests not Approved by the United States Food and Drug Administration

The Alabama Department of Public Health (ADPH) supports health care workers’ efforts to care for Alabama citizens during this COVID-19 health crisis. As this public health emergency evolves, there is need for increased availability of SARS CoV-2 diagnostic testing. In response to this demand, the United States Food and Drug Administration (FDA) released policies to authorize emergency use of in vitro diagnostics to increase testing capacity and development to promote widespread testing for COVID-19. As a result, the availability of commercial testing devices proliferated, many with false claims by distributors. ADPH therefore advises health care providers to choose COVID-19 testing systems that are FDA approved when making decisions regarding their patients.

Tests not approved by the FDA can produce false results and lead to unintended consequences for the patient and broader community. A false negative result from a non-approved kit may lead someone who has COVID-19 to think they are not infected and cannot spread the illness. Patients need accurate information about their health, and health care providers and officials need accurate information to provide appropriate medical care and make public health decisions.

Currently, the most accurate FDA-approved testing available is polymerase chain reaction (PCR) assays. PCR tests can detect small amounts of the virus collected in samples from the patient’s nose or throat. Public health, commercial, and some clinical laboratories use PCR technology to diagnose COVID-19 infections. Many of these tests have FDA approval through emergency use authorization (EUA).

Serology testing is gaining momentum in the marketplace as collection of blood samples is easy and many platforms are point of care with results in minutes.  Serological tests detect if an individual’s body is developing antibodies against COVID-19. While these tests can be used to track disease, they are not reliable as or recommended for diagnostics and is even stated on most package inserts. At this time, there are only three serological tests that are EUA approved (

If your facility is considering a serology-based test that is not EUA approved by FDA, understand that:

  • Currently no Centers for Disease Control and Prevention guidance exists as to how to interpret or take public health action in response to a positive or negative COVID-19 serology result.
  • These tests have not had performance reviews by FDA.
  • Negative serology results do not rule out COVID-19 in a patient.
  • Serological testing should not be the sole basis to diagnose or exclude infection, or to inform infection status. 
  • The immune response to SARS-CoV-2 infection is poorly understood at this time.
  • Cross reactivity is likely. Positive results could reflect past or present infection with non-SARS-CoV-2 strains.
  • False negative results could occur when the immune response is too low to be detected.
  • If serology-based test results are submitted to ADPH, they will not be included in the COVID-19 counts at this time due to lack of guidance regarding interpretation.

ADPH fully supports health care providers on the front lines of this pandemic and trust they will use this advisory to make informed decisions regarding their patient’s health. It is important to be aware of distributors’ false claims. Thank you for your commitment and dedication in service for the citizens of Alabama. If you have questions regarding this information, contact Burnestine Taylor, M.D., at

Posted in: Coronavirus, Members

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Chronic Care Management in the Coronavirus Pandemic

Chronic Care Management in the Coronavirus Pandemic

Article contributed by: Tammie Lunceford, CMPE CPC with Warren Averett

Chronic Care Management Expands Care

Several years ago, the Center for Medicare and Medicaid Services released Chronic Care Management to assist in improving patient outcomes, extend care, and improve quality in chronic illness.  The initial chronic care code, 99490 allowed for 20 minutes of non-face to face phone communication with clinical staff per month which reimbursed forty-two dollars per month.  The patient had to agree to be enrolled in the program and agree to an $8 co-pay.  Only one physician can enroll a patient and the patient must have at least two complex chronic conditions lasting more than twelve months.  Most physicians did not adopt chronic care management due to the low reimbursement, the physician had to treat all chronic conditions which excluded most specialists from participating.

Some large practices outsource chronic care management and share the reimbursement.  Whether the practice uses internal staff or outsourced staff, CCM services provide additional care and coordination to the most chronically ill.  The patients receiving this service feel more connected to their provider and a change in their status is identified quickly.  If the practice also has telemedicine, a non-face to face service can quickly become a face to face visit to address concerns. Due to the recent COVID-19 pandemic, these interactions could provide the care needed to protect the chronically ill from being exposed to the deadly virus. 

The 2020 Final Medicare Physician Fee Schedule added some provisions to Chronic Care Management services.  The addition of Principle Chronic Management allows a patient with a single high-risk chronic condition lasting more than 12 months to qualify for the program. PCM should increase the use of chronic care management with specialists, such as cardiologist and pulmonologists.  Also approved for 2020, is G2058 which is an add-on code to allow an additional 20 minutes of time spent in continuous communication with the patient.  The add-on code reimburses $37.89 and can be billed concurrently to 99490, two times monthly, per beneficiary.  The total possible reimbursement for 60 minutes of non-complex CCM is $118.01. 

The new opportunities to provide chronic care management and principle care management will allow specialists managing hundreds of patients with chronic conditions, such as, COPD or diabetes to improve the overall health of the patient, improve patient engagement, improve quality and receive reimbursement worthy of the effort.

Practices are currently working to provide many modes of communication to serve patients without seeing them in the office.  Patient portals have failed in the past because many portals were not user friendly or practices failed to make them valuable by offering valid information through the portal.  In times of crisis, such as COVID-19, it is quite possible for the phone lines to be full but utilizing the patient portal and offering CCM and PCM allows a practice to fulfill many patient’s needs without a physician or mid-level providing the interaction.

We are in crisis as COVID-19 cases increase across the nation, but we have seen monumental change through the emergency expansion of telemedicine.  As administrators and physician leaders review the options to expand communication through technology and ongoing medical management, we will be better prepared for crisis situations in the future.

Posted in: Coronavirus, Management, Members

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Charting & Documentation During the Coronavirus COVID-19 Pandemic

Charting & Documentation During the Coronavirus COVID-19 Pandemic

The world’s memory of this virus will be different when lawsuits are filed two years from now and juries try the cases two to three years after that. The acuteness of the issues, the confusion, the limited resources and the changing daily directives will not be remembered in any meaningful detail. Accordingly, the Risk Management dogma that has always emphasized charting is more important now than usual. If the standard of care is judged as care “under the same or similar circumstances”, and those circumstances are “delivering care in a COVID-19 pandemic”, how will we show those circumstances in a 2025 jury trial?  We recommend vigilant documentation.

In consideration of Alabama’s sample ventilator allocation guidance, and exemplary language from other states, Starnes, Davis, Florie, LLP. recommends the below language be charted in circumstances where a resource may be diverted away from a patient who could be in need.  The sample language specifically applies to decisions in triaging a patient and any initial treatment decisions regarding a specific (limited) resource.

Sample Language:

In making a clinical judgment regarding the allocation of [resource] during the [COVID-19 pandemic / public health emergency], I have assessed the patient’s history, symptoms, and condition and considered the limited availability of resources and clinical factors associated with the allocation of limited resources.  My clinical judgment, under the totality of the circumstances, is that [clinical decision] is appropriate for this patient as an alternative medical intervention.

We also recommend against language or specific explanations to patients as follows:

·        Language / an explanation to a patient or a patient’s family explicitly referencing financial issues or considerations.

·        Language / an explanation to a patient or patient’s family focusing the considerations on the resource itself as opposed to the specific patient.

·        Language / an explanation to a patient or patient’s family specifically documenting the condition of other patients or the specific condition of other patients receiving resources.

·        Language / an explanation to a patient or a patient’s family specifically quantifying any patient’s likelihood of successful treatment – that being the patient receiving the resource and the patient not receiving the resource.

·        Language / an explanation to a patient or a patient’s family specifically comparing patients or outcomes.

·        Language / an explanation to a patient or a patient’s family specifically referencing medical ethics.  Medical ethics underpins all clinical decisions and does not need to be specifically included in the chart.

This information is not intended to provide legal advice, and no legal or business decision should be based on its content. No representation is made that the quality of legal services to be performed is greater than the quality of legal services performed by other lawyers.  Read full disclaimer.

Posted in: Legal Watch, Members

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Families First Coronavirus Response Act (HR6201) Summary

Families First Coronavirus Response Act (HR6201) Summary

Last night President Trump signed what is being called the second coronavirus stimulus bill. It provides for free coronavirus screening, $1 billion in additional unemployment insurance funding to all states, a bump in Medicaid FMAP, $1 billion in food aid, and two provisions to provide paid sick leave to employees. 

 Emergency Paid Sick Leave

This provision gives 80 hours or 2 weeks of paid sick leave to individuals who work for employers with fewer than 500 employees. This applies to all employees, both full time and part-time with part-time receiving leave equal to the average number of hours worked. There is also no tenure of employment requirement. This leave is available to workers who are:

  1. In self-isolation because of a coronavirus diagnosis
  2. Obtaining a diagnosis or care due to coronavirus symptoms
  3. Complying with an order to self-isolate because of exposure to someone with coronavirus
  4. Caring for a family member with a diagnosis or symptoms
  5. Caring for a child without access to daycare or school because of closure.

If the employee falls under the first 3 categories, they are entitled to full pay, but if work is missed to care for a family member or a child without access to school or daycare only two-thirds of pay is due. An employer cannot force an employee to use existing, traditional sick leave first.

Emergency Family and Medical Leave Act (EFMLA)

If after the first 2 weeks, the employee needs additional days, the EFMLA will be triggered. The existing FMLA provides 12 weeks of unpaid leave, but this emergency measure would provide that up to 10 weeks of that emergency eave that would be paid. The first two weeks under EFMLA would remain unpaid and during the following 10 weeks employees would be entitled to two-thirds of their pay.

Like the emergency paid sick leave provision, EFMLA would be for those diagnosed with coronavirus, caring for a family member diagnosed, and caring for a child without access to daycare or school. Unlike the paid sick leave provision, employees must have worked for 30 days and there is a hardship exemption for small business with under 50 employees. Under the hardship exemption, the US Department of Labor is given the authority to develop regulations to exempt a small business if EFMLA threatens the viability of the business. 

The United States Secretary of Labor has the authority to issue regulations for good cause to (1) exclude certain health care providers and emergency responders from the definition of eligible employee; and to exempt small businesses with fewer than 50 employees when the imposition would jeopardize the viability of the business. 

Tax Credit for Employers 

Employers would be eligible for a refundable tax credit of 100 percent of qualified sick leave wages paid and family leave wages paid against their employer-side payroll tax liability. Employers can claim a quarterly tax credit against payroll taxes for payments associated with these 2 provisions up to the total payroll taxes in that quarter.


The bill temporarily increases the Medicaid FMAP in all states by 6.2% beginning in the calendar quarter of the emergency and ending the quarter it is declared over. Coronavirus testing must also be provided with no cost sharing. Those eligible will only lose coverage if they leave the state.

The bill also creates a new Medicaid eligibility category for the uninsured. Uninsured individuals would only be eligible to receive diagnostic testing for coronavirus, no treatment, but that testing would be done at no cost and reimbursed at 100% FMAP.

Unemployment Insurance

As states expand the criteria for unemployment to include coronavirus reasons, the US Labor Department reported 281,000 new claims for unemployment insurance last week, a 70,000 jump over the previous week. The bill gives states $1 billion for unemployment insurance nationwide that will provide relief to those who are facing coronavirus-related job loss.  The unemployment aid would be broken in two separate payment structures. The first 50% of the grant would be sent to states for State Unemployment Agency staffing, technology, and other administrative costs so long as the states comply with three provisions in the bill. (1) Require employers to provide notification to the potential UI eligibility to laid off workers; (2) ensure that workers can apply for benefits in person, by phone, or online; two of the three must be available; (3) the state must notify applicants when an application is received and being processed and if the application cannot be processed, what information is needed to successfully process the claim.  Currently, the State of Alabama would meet the current requirements to receive their portion of the first $500 million package. The other $500 million would be reserved for an emergency grant package for those states that may have seen at least a 10% increase in unemployment. There is also flexibility built into the unemployment provision with the goal of making it easier for workers to access unemployment benefits by waiving waiting weeks and work search requirements.

States could potentially be eligible for Extended Benefits (EB) for unemployment compensation programs when the unemployment rate surpasses certain thresholds to trigger EB programs.  The first extended benefits trigger could allow for an additional 13 weeks of unemployment benefits after a claimant exhausts current state benefits (14 weeks of state UI benefits).

Food Assistance

The bill adds $500 million to provide access to nutritious foods to low-income pregnant women or mothers with young children who lose their jobs or are laid off due to the COVID-19 emergency through the Special Supplemental Nutrition Program for Women Infants and Children (WIC). There is also $400 million to assist local food banks to meet increased demand for low-income Americans during the emergency. The work requirement for the supplemental nutrition assistance program (SNAP) is also suspended. There are also provisions to provide funding and flexibility in the free and reduced lunch program if a school is closed for 5 consecutive days and for at home delivery of meals to the elderly. 

Posted in: Medicaid, Medicare, Members

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Telehealth in Alabama during COVID-19 Public Health Emergency (PHE)

Telehealth in Alabama during COVID-19 Public Health Emergency (PHE)

prepared by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

March 19, 2020

The most important thing to remember is that payers have differing definitions of what they consider telehealth.  I recommend checking with the applicable insurer for the most up-to-date information affecting requirements for coding and billing of telehealth services.  A few things to ask about: 

  • What are the effective dates?  Most insurers are limiting this exemption to a specific period of time. 
  • What services are covered? 
  • How are those to be billed? 
  • Do we use telehealth codes or office visit codes? 
  • What place of service? 
  • What modifiers are necessary?
  • For fee-for-service, traditional Medicare

The information below pertains to the major payers in Alabama as of 3/18/2020 –

Blue Cross Blue Shield of Alabama is allowing providers to bill for phone call treatment of existing patients under the established patient office visit codes from 3/16/2020 – 4/16/2020.  They are allowing codes up to 99213 with place of service code 02 (zero two) for telehealth. No modifier is required.  Many providers are concerned about reaching that level of service when no examination can be performed.  Remember that established patient office visits require only two of the three key components – history, examination, medical decision-making.  If the physician documents an expanded problem-focused history and low complexity medical decision-making, 99213 will be supported.  This must be the physician speaking with the patient, not the office staff.

Alabama Medicaid normally requires separate credentialing for providers performing telehealth; however, that restriction has been waived 3/16/2020 – 4/16/2020 (dates of service).   Medical providers may bill established-patient evaluation and management codes 99211, 99212 and 99213 for telephone consultations.   Psychologists and behavioral health professionals should bill 90832, 90834, 90837, 90846, 90847 and H2011. A dental provider should bill D0140.  Place of service code 02 (zero two) for telehealth and modifier CR are required.  Verbal consent must be obtained and documented in the medical record.  These visits will count against the patient’s office visit limit of 14 visits per year.

United Health Care is waiving originating site restrictions for their commercial, Medicare Advantage, and Medicaid plans.  The patient may be at home or at another location.  All the other requirements for telehealth must be met – real-time audio and video communication system required. These include the place of service 02 and the GQ (asynchronous telecommunications system) or GT (interactive audio and video telecommunication system) modifier.  This waiver is only in effect until April 30, 2020.


Fee-For-Service Medicare DOES NOT allow telephone calls to be billed as telehealth.  The PHE waiver provides three specific exceptions to the existing telehealth regulations:

  1. the patient can be in their home or other location – they do not have to be in a healthcare facility in a HPSA.
  2. the audio-video link can be something as simple as Skype or FaceTime or Facebook Messenger video calls – but it has to be a real-time audio AND video one-to-one connection, not something public-facing
  3. costshare can be waived – it is not automatically, but it can be waived at the providers’ discretion.

CMS also stated that they will not audit to verify that there is an established patient relationship.  Services are limited to the list of telehealth services at:

This does include office visits, consultations, Transitional Care Management, and Annual Wellness Visits.  Place of service is 02 (zero two) for telehealth.  No modifier is necessary unless you are billing from a CAH Method II hospital (GT) or you are treating the patient for an acute stroke (G0).  There is also a modifier for a telemedicine demonstration project in Alaska or Hawaii (GQ).

NOTE: Although CMS stated that no modifier is necessary, Palmetto GBA is requesting modifier CR be appended for tracking purposes.

For services that have a site of service differential, payment will be made at the facility rate.

CMS has not specified an end date for these exceptions, just that they will be allowed as long as the Public Health Emergency declaration is in effect.

If there is not a real-time audio-video connection, then you are limited to one of the following:

Virtual Check-In

  • G2012 – Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
  • G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Please note the following restrictions:

  • Established patients only (same definition as for other E&M services)
  • Verbal consent required and must be documented in the patient’s medical record
  • No service-specific documentation requirements but medical necessity must be documented.
  • May only be billed by those providers who can perform and bill E&M services

To clarify – G2012 has been in effect since 1/1/2019 – it is supposed to be for an established patient, but CMS has said they will not audit for that requirement during this time.  It does not require the video link, so it is really the only option for phone calls.  It cannot be related to an office visit within the past 7 days, as that would be considered part of the work of the already-billed office visit.  And if the doctor tells the patient to come in at the first available appointment, it can’t be billed as it would be considered the pre-work for the upcoming office visit.  As it specifies 5-10 minutes of medical discussion, time should be documented.

For email or portal communication, we also have these codes, new for 2020:

  • #99421 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • #99422 – …11-20 minutes
  • #99423 – … 21 or more minutes

Please note the following restrictions:

  • Patient-initiated digital communications requiring a clinical decision that would otherwise be made during an office visit
  • Physician/Qualified Healthcare Professional (QHP) time only
  • Not billable if patient seen in person or through telehealth within 7 day period

For All Payers –

There have been questions on how to perform a visit by phone or audio-video without being able to examine the patient.  First of all, established patient visits require two of the three key components:  history, examination, and medical decision-making.  A visit can be billed based on history and medical decision-making.  However, some examination can be done without laying hands on the patient.  Observation can be done through video, and sometimes just through audio.  A physician can observe skin tone, abnormal movements, respiratory effort and many other exam elements without being able to necessarily touch the patient.  A complete Psychiatric exam can be accomplished through talking with the patient.

For example, the patient calls in with complaint of dysuria. The physician documents the complaint (Duration, Timing) and further asks questions about fever, nausea and vomiting (Constitutional and Gastrointestinal Review of Systems).  He also reviews the patient’s Past Medical History and Allergies.   Based on her previous history, he suspects that the patient has a urinary tract infection and orders an antibiotic.

A patient with asthma calls in with an exacerbation – the physician can actually hear the patient wheezing over the telephone – that would be documented as a problem-focused examination.

The key point is that the physician himself must have the conversation with the patient on the phone or through the audio-video link.  This may be something that a nurse may have handled previously, but now it must be performed by the physician to be billable. 

Posted in: Blue Cross Blue Shield of Alabama, CMS, Medicaid, Medicare, Members, Technology

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