Sorting Out an 1135 Waiver- Practical Application and Best Practices

By Chuck Humphrey, B.A., EMT-B, CAC, CADS*

What is an 1135?

“When the President declares a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act, the Secretary is authorized to take certain actions in additional to his/her regular authorities. For example, under section 1135 of the Social Security Act, the Secretary may temporarily waive or modify certain Medicare, Medicaid and Children’s Health Insurance Program (CHIP) requirements…”

This is how the Centers for Medicare and Medicaid Services (CMS) defines an 1135 Waiver in their document 1135 Waiver- At A Glance

And then…the phone started to ring…

When the coronavirus pandemic finally took its grip on America, not long after the extent of this crisis came into focus, the 1135 waivers…, both blanket national in nature and individual state-by-state program-specific waivers, began to be issued.

And…then rightfully so, the phone rang.

Sorting Out an 1135 Waiver- Practical Application and Best Practices

Billing companies know (or should) that there’s more to this job than pushing paper each day. We have a responsibility to support our clients and understand the issues that impact their bottom line. Understanding the impact of waivers during this world’s most prolific emergency in a century, is part of that responsibility.

Here at Quick Med Claims, we fielded all types of inquiries from our clients. (It’s largely why I’m proud to work for such a fine organization.) If you are out there evaluating billing company options, choose a company that truly cares about the clients they serve and one that fully understands the peripheral issues versus the mechanics of sending out bills, like we do.

One of the questions

So, one of the questions that rolled in from a client involved a bit of digging into the philosophy and intent of the 1135 Waiver. The question was submitted to us regarding a patient transport from home to a doctor’s office for some routine services. The patient requires ambulance transport due to his condition and typically pays out-of-pocket for the service, given that a doctor’s office does not meet the CMS destination requirements.

The patient’s primary coverage was Medicare Fee-for-Service or “regular Medicare” invoking that Medicare guidelines must be followed.

However, when considering that the 1135 waiver was issued and origin and destination parameters were modified in the face of the pandemic; our client was astutely asking if during this waiver period there may be a window of opportunity to submit a claim for this transport series to receive payment from the Medicare Administrative Contractor.

Philosophically speaking.

The question boiled down to this, philosophically speaking.

  • Is the intent of the 1135 waiver to relieve a patient from any out-of-pocket due to the overall impact of the public health emergency?

-OR-

  • is the purpose of the waiver strictly limited to the task of moving patients between Point A to Point B in order to force the quarantine of patients and stop the spread of the virus?

Alright then…we set out to land on an answer.

The task at hand invoked such an interesting brain teaser that we took the added step of convening our dedicated Compliance Team into session. Following that meeting of our in-house subject matter experts, we decided to go one step further by and reached out for an opinion from our compliance legal counsel.

With careful, deliberate, input from all persons considered, it became clear to us that the letter and intent of the waiver landed squarely in the movement of COVID-affected patients and not to grant a sudden out-of-pocket relief to patients who normally would not meet either a medical necessity or reasonableness test.

The compliance lawyers offered this advice.

“Ask yourself before billing. Would this patient normally have gone to the hospital for this scenario?”

With careful consideration, we were able to boil this complex scenario down to one litmus test sentence which we then rolled up to our Operations people as a guideline to apply over multiple questionable pandemic scenarios.

Take your time!

So, what’s the ultimate lesson learned from this scenario?

Take your time!

When evaluating a complex compliance question, like was poised to us, it is always best practice to do the following…

  1. Take a step back and pump the brakes before billing any set of claims out when there are underlying questions.
  2. Call together your in-house and outside subject matter experts and talk it out
  3. Arrive at a simple set of compliant directives that will drive future billing procedures.
  4. When possible, communicate an easy litmus test statement that is easily remembered.

*Chuck Humphrey is the Senior Director of Compliance and a Territory Sales Manager for Quick Med Claims. He is one of our industry experts with over 30 years of experience in the EMS industry.

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