The American Association of Nurse Anesthetists (AANA) continues to monitor the Coronavirus Disease 2019 (COVID-19).
Excellence in care, safety, and continuous improvement of care are hallmarks of the anesthesia profession. Nurse anesthetists may be called upon to care for patients infected with COVID-19. The AANA is committed to supporting Certified Registered Nurse Anesthetists (CRNAs) and the healthcare team to safely deliver patient care while maintaining the health of the nurse anesthetist and the families and the community they serve.
What is the recommendation for LMA use?
- A risk assessment should be performed based on the COVID community-wide transmission. Currently, no studies exist that assess risk of various airway techniques and anesthetic choices. However, expert opinion suggests that LMA use may carry greater risk of generating aerosols when compared to tracheal intubation. While LMA usually seals the airway at low pressures, there is concern that higher positive pressure, if used, might create a leak with aerosol production. LMA may be an acceptable option with selected patients because of the lower risk of coughing. Non-airway MAC cases with spontaneous ventilation may be acceptable if fresh gas flows are low, but consider the anesthesia provider’s proximity for jaw lifts or potential intermittent positive pressure ventilation if brief apnea occurs. Therefore, PPE for aerosol-generating procedures should be worn.
How do we care for patients with known COVID-19?
- Place patients in an airborne infection isolation room.
- Upon entering the patient’s room, use airborne and contact precautions, including eye protection.
- Wear PPE, including:
- Fit-tested N95 mask or a powered air-purifying respirator (PAPR).
- Face shield or goggle.
- Gown, impervious if possible.
- Perform hand hygiene before donning and after doffing PPE.
- Use alcohol-based hand rubs or wash hands with soap and water.
- If hands are visibly soiled, wash hands with soap and water.
- When removing and disposing PPE, minimize self-contamination risk.
- To prepare, observe correct procedures for donning and doffing PPE and rehearse before patient care.
- For further details, see CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.
How do we transport a patient with known or suspected COVID-19?
- Transport patients only for essential procedures.
- Collaborate with local infection control experts for current advice.
- Insert a “high quality” viral filter between the bag-valve-mask breathing device for intubated patients.
- Non-ventilated patients should wear a surgical mask.
- Do not routinely wear gowns and gloves for transport. If direct contact with the patient or contaminated equipment is anticipated, one transport team member should perform hand hygiene, don a fresh gown and gloves, and wear appropriate PPE. Ideally, another member who is not wearing a gown and gloves should accompany the transport to interact with the environment.
How do we perform a procedure for a patient with known or suspected COVID-19?
- Consider postponing non-urgent procedures until the patient is non-infectious or not infected.
- Designate an operating room (OR) for this purpose and post appropriate signage to minimize personnel exposure.
- If postponing a procedure or performing the procedure at the bedside is not possible, minimize the number of healthcare team members and other patients present in the operative suite.
- Do not bring the patient to the holding area, induction room, or post anesthesia care unit (PACU).
- If respiratory support is necessary, prepare in order to avoid the need for rescue interventions (e.g., crash intubations), which increase COVID-19 transmission risk if barrier protections fail.
- If the patient has acute respiratory failure, proceed directly to endotracheal intubation; non-invasive ventilation (e.g. CPAP or biPAP) could increase the risk of infection transmission.
- If possible, perform the procedure in an airborne infection isolation room rather than an OR. Airborne isolation rooms have negative-pressure relative to the surrounding area. ORs generally have positive-pressure and incoming air is usually flow-directed, filtered, and temperature and humidity controlled.
- Collaborate with local infection control experts (e.g., state and county health departments, nearby healthcare systems and facilities) for additional guidance.
- For performing procedures without general anesthesia:
- The patient should continue to wear the surgical mask.
- For performing procedures with general anesthesia:
- Insert a “high quality” viral filter between the Y-piece of the breathing circuit and the patient’s mask, endotracheal tube, or laryngeal mask airway.
- For pediatric patients or patients that may experience problems with the additional space/weight of the filter, place the “high quality” viral filter on the expiratory end of the corrugated breathing circuit before expired gas enters the anesthesia machine.
- Ensure that the gas sampling tubing is protected with a “high quality” viral filter.
- For further details, see APSF FAQ on Anesthesia Machine Use, Protection, and Decontamination During the COVID-19 Pandemic.
- For laryngoscopy and intubation:
- To prepare for emergency intubations, ensure all emergency kits are equipped with the appropriate PPE.
- Double glove and shed the outer gloves after intubation and minimize subsequent environmental contamination.
- When possible, have the most experienced anesthesia professional available intubate the patient.
- Unless required, avoid awake fiberoptic intubation.
- When possible, avoid manual ventilation and perform rapid sequence induction (RSI).
- If manual ventilation is necessary, apply small tidal volumes.
- After extubation, turn down flows, if possible, to avoid contaminating the environment.
- After doffing PPE, immediately perform hand hygiene and refrain from touching your hair and face.
- For airway suctioning, use a closed suction system if available.
- To minimize surface contamination, use disposable covers (e.g., plastic surface sheets, ultrasound probe sheath covers).
- Recover the patient in the operating room or transfer the patient to an airborne infection isolation room.
- Once the patient leaves the OR, maximize the time before the next case. This time interval depends on the number of air exchanges per hour in that space. For further details see CDC - Air Guidelines for Environmental Infection Control in Health-Care Facilities.
- When using point-of-care ultrasound or other devices:
- Cover the ultrasound unit and cable with a long sheath.
- Cover non-essential parts of the ultrasound cart with drapes.
Since we don’t know if a patient is COVID-19 positive, do we treat all patients as positive?
- For details, see AANA, ASA, APSF, AAAA Joint Position Statement - The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.
- Due to close patient contact and the need for airway instrumentation, anesthesia professionals are at increased risk of exposure and infection for all diagnostic, therapeutic, and surgical procedures during this rapidly escalating COVID-19 pandemic in the U.S.
- AANA, ASA, APSF, AAAA recommend as optimal practice that all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients when working near the airway.
- Issuance of N95 masks or availability of PAPRs for all clinical anesthesia personnel should be a priority. If a facility has existing or projected shortages of N95 masks or PAPRs, however, temporary mitigation plans based on current CDC recommendations should be enacted. These plans should include facility and case-by-case reviews of the potential of patients and procedures to generate aerosolized particles, as well as assessments of respiratory pathogen characteristics (e.g., routes of transmission, community spread, prevalence of disease in the region, infection attack rate, and severity of illness) and local conditions (e.g., number of disposable N95 mask available, current respirator usage rate, and success of other PPE conservation strategies).
- If COVID-19 is known or suspected, please refer to How do we care for patients with known COVID-19?
- For further details, see Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States.
What should we do about MAC cases?
- The AANA and the ASA are in agreement regarding MAC cases:
- If dispersion of potentially contaminated exhaled gases from an open airway (e.g., “MAC”) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered.
- For further details, see ASA Committee on Occupational Health Clinical COVID-19 FAQs.
How do we manage an “open airway” case?
- The AANA and the ASA are in agreement regarding “open airway” cases:
- Originally, the Anesthesia Patient Safety Foundation (APSF) recommended elevated precautions for an “open airway” case. This was in large part due to an increased risk of aerosolization and disease transmission. The definition of “open airway” included cases such as tracheostomies and upper endoscopies that have a high degree of aerosolizing body fluids. APSF did not intend this definition to include all “MAC” cases.
- Newer recommendations focus on the risk of exposure from aerosolization of the disease and emphasize attempting to minimize aerosolization of body fluids when caring for all patients. In situations with risk of high degree of aerosolization of body fluids, a properly fitted N95 mask, or PAPR provides the best protection from COVID-19 exposure. Traditional face masks do not provide protection against aerosolized small particles.
Are there specific recommendations for caring for obstetric patients?
- For details, see the Society for Obstetric Anesthesia and Perinatology (SOAP) Interim Considerations for Obstetric Anesthesia Care Related to COVID-19.
- Additionally, the CDC has an information page on COVID-19 and pregnant women and children and posted a webinar from March 12, 2020 discussing information for clinicians caring for children and pregnant women.
- Additionally, see Obstetric Anesthesia During the COVID-19 Pandemic, Anesthesia & Analgesia, 2020
What is AANA’s position when CRNAs are asked to assume critical care responsibilities during the COVID-19 pandemic?
- Please see the AANA position statements CRNAs Asked to Assume Critical Care Responsibilities During the COVID-19 Pandemic, published on 3/17/20, Utilizing CRNAs Unique Skill Set during COVID-19 Crisis, published on 3/21/20, and CRNAs as Advanced Practice Providers in Clinical Care Settings, published on 3/31/20. AANA’s position is that during this time, it is essential for each facility to optimize its healthcare workforce and utilize CRNAs as advanced practice nurses. Ultimately, the decision to assume new responsibilities is based on an array of considerations unique to the individual CRNA, facility, and state.
CRNAs are being asked to assume ICU APRN roles at our hospital. What are some resources to support us in this role?
- The AANA encourages CRNAs who are being asked to assume APRN roles in the ICU to utilize the resources provided by the Society of Critical Care Medicine (SCCM).
- Please see AANA’s position statements CRNAs Asked to Assume Critical Care Responsibilities During the COVID-19 Pandemic, published on 3/17/20, and Utilizing CRNAs Unique Skill Set during COVID-19 Crisis, published on 3/21/20.
- Hospitals are also sharing their resources online, such as Brigham and Women’s Hospital COVID-19 Critical Care Clinical Guidelines. Note, these are provided only as reference, not an endorsement by AANA.
Personal Protective Equipment (PPE)
Are there specific recommendations for EGD procedures, and other cases with a high risk of aerosolization?
- When deciding whether to cancel a case or use higher-level PPE, consider your local COVID-19 risk profile related to community spread.
- In addition, when making these decisions, consult with local infection control experts. This will inform your own risk assessment considering the patient, skill sets of the endoscopists, and local resources.
- For cases with a high risk of aerosolization, ETTs provide the most secure airway. Airway masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar masks may limit dispersion as an alternative when N95 supplies are low.
- Best practices may be in flux because of shortages of N95 masks and other PPE for patients with known COVID-19, as well as for those who are undiagnosed or asymptomatic.
My hospital thinks the AANA guidance is too strict or is inconsistent with CDC guidance. How should I discuss AANA guidance with my facility or department?
- AANA guidance focuses on patient and anesthesia professional health and safety and is based on current CDC and APSF recommendations for protecting healthcare providers if patients have known or suspected COVID- 19 infection.
- During the SARS outbreak in the 2000’s, CDC learned that SARS infected healthcare providers caring for SARS patients even though these providers followed contact and droplet precautions. Droplet particles from coughing, sneezing, or airway procedures (e.g., laryngoscopy, intubation, suctioning, bronchoscopy) could aerosolize into finer particles suspended in air currents and penetrate ordinary surgical masks.
- The AANA recommends taking steps to reduce the risk of droplet particle aerosolization, including:
- Having the most experienced anesthesia professional available intubate the patient, if possible.
- Wearing PPE including:
- Fit-tested N95 mask or a powered air purifying respirator (PAPR).*
- Face shield or goggle.
- Gown, impervious if possible.
- Double glove and shed the outer gloves after intubation and minimize subsequent environmental contamination.
- Avoid awake fiberoptic intubation unless necessary.
- Consider RSI. Apply small tidal volumes if manual ventilation is necessary.
- The AANA opposes healthcare facility policies that limit healthcare providers from self-supplying the PPE they need to be safe. See position statement.
When should we use a N95 mask?
- When the CRNA will be at an increased exposure risk, such as open-airway procedures, the N95 mask provides the best protection from the spread of COVID-19. During these procedures, it is prudent to consider all patients to be carriers of COVID-19, as patients may be asymptomatic at the time of their procedure.
- Issuance of N95 masks or availability of PAPRs for all clinical anesthesia personnel should be a priority.
- If appropriate resources are not available, the safety of the provider and the patient should be the most important factors in when to use masks and when to cancel elective procedures.
- Further detail, see the AANA, ASA, APSF, AAAA Joint Position Statement - The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.
Can we re-use PPE, including the N95 masks?
After treating a patient with known or suspected COVID-19, how do we clean the anesthesia machine?
- Cleaning procedures are the same for all patients if a high quality heat moisture exchange filter (HMEF) is placed between the circuit and the airway. Discard disposable items – breathing circuit, reservoir bag, gas sampling tubing, mask and wipe all exposed surfaces. Manufacturers’ cleaning recommendations are useful for individual devices.
- If appropriate breathing circuit filters were used as directed, internal components of the anesthesia machine do not need special cleaning.
- For further details, see APSF FAQ on Anesthesia Machine Use, Protection, and Decontamination During the COVID-19 Pandemic
Should we repurpose our anesthesia machines as ventilators for ICU patients?
- Please see the following resources:
- Using the Anesthesia Workstation as a Ventilator for Critically Ill Patients: Technical Considerations, AANA Journal, 2020
- APSF ASA Guidance on Purposing Anesthesia Machines as ICU Ventilators
- APSF FAQ on Anesthesia Machine Use, Protection, and Decontamination During the COVID-19 Pandemic
- HHS: Optimizing Ventilator Use during the COVID-19 Pandemic
- FDA OKs Anesthesia Gas Machines as Ventilators Amid Coronavirus Shortage Fears, MedTechDIve, 2020
- Manufacturer Letters
- Drager: Usage of Dräger anaesthesia devices for long-term ventilation, 2020
- Getinge: Customer Notification Letter - COVID-19 Pandemic Ventilating ICU patients using Flow-i, Flow-c and Flow-e anesthesia machines, 2020
- GE Healthcare: COVID-19 - Requests for information regarding the off-label use of GE Healthcare anesthesia devices for ICU ventilation, 2020
- Mindray: Mindray A-Series Anesthesia Delivery System Consideration for use as a Ventilator, 2020
- Please see regarding multiple patients per ventilator, please see APSF, SCCM, AARD, ASA, AACN, CHEST Joint Statement on Multiple Patients Per Ventilator
How does COVID-19 affect practicing pregnant CRNAs?
- For details, see the CDC Information for Healthcare Providers: COVID-19 and Pregnant Women. The CDC recommends that:
- Healthcare providers adhere to risk assessment and infection control guidelines for healthcare personnel exposed to patients with known or suspected COVID-19.
- Facilities limit exposure of pregnant healthcare personnel to patients with known or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability.
- The American College of Obstetricians and Gynecologists (ACOG) Novel Coronavirus 2019 (COVID-19) Practice Advisory is consistent with the CDC recommendations.
Where can we report drug shortages?
- AANA wants to know if your facility is experiencing a drug shortage. Please inform us through the COVID-19 online submission form.
- Additionally, CRNAs can report to the FDA CDER Drug Shortage Staff directly at: DRUGSHORTAGES@fda.hhs.gov
- The FDA continues to take steps to monitor the supply chain. The Drug Shortage Staff within the FDA’s Center for Drug Evaluation and Research (CDER) has asked manufacturers to evaluate their entire supply chain, including active pharmaceutical ingredients, finished dose forms, and any components that may be impacted in any area of the supply chain due to the COVID-19 outbreak.
- To report a drug shortage, contact CDER Drug Shortage Staff at: DRUGSHORTAGES@fda.hhs.gov
- For further details, see:
What are the current recommendations for canceling or rescheduling elective surgeries?
- The Centers for Medicare & Medicaid Services (CMS) recommend that all elective surgeries and non-essential medical, surgical, and dental procedures be delayed during the COVID-19 pandemic. For further details, see CMS: Non-Emergent, Elective Medical Services, and Treatment Recommendations and CMS Adult Elective Surgery and Procedures Recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice.
- For facilities located in areas with expected or increasing spread of COVID-19, please see the CDC Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States to reduce non-urgent surgical, diagnostic, and interventional procedures. The CDC recommends facilities:
- Reschedule non-critical procedures for the future when community transmission of COVID-19 has ceased.
- Prioritize critical procedures according to patient need and facility resources.
- Consider outpatient settings to alleviate depletion of hospital resources and allow for resource allocation, such as training healthcare providers on proper protective practices (e.g., donning and doffing PPE, fit testing N95 masks).
- For further details, see ASA - APSF Joint Statement on Non-Urgent Care during the COVID-19 Outbreak.
- Other organizations positions include:
- ACS, AORN, ASA: Joint Statement Recommending a Surgical Review Committee for COVID-19-Related Surgical Triage Decision Making
- ASCA: Statement from the Ambulatory Surgery Center Association regarding Elective Surgery and COVID-19
- ACS: COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures
Where can a retired CRNA find volunteering opportunities?
- The AANA recommends reaching out to organizations directly regarding opportunities to volunteer your services. We also suggest using Google or other search engines for state or city-specific information, utilizing searches such as “covid healthcare volunteer opportunities Illinois.”
In addition, executive orders from state governors may include specific provisions concerning retired healthcare providers, including expedited reactivation of licensure for recently retired healthcare providers and opportunities for volunteering. Please check your state board of nursing website for postings with more information; website and contact information for all boards is at https://www.ncsbn.org/contact-bon.htm.
Please also check COVID-19 State Government Affair Resources, which provides information on state emergency declarations, legislation, and regulations that may affect state licensure requirements for volunteers. For example, state government action may authorize use of out-of-state nursing licensees and/or facilitate use of in-state inactive licensees and retired healthcare providers.
Some state boards of nursing are also auto-renewing active licenses that are about to expire. Information regarding your current licensure status is available on most board of nursing websites (see link above), and also at nursys.com. Please utilize internet resources as much as possible, as board of nursing telephone and staff resources are likely to be inundated with calls and questions.
About These FAQs
The international and national guidance is changing frequently, sometimes daily, so please follow this page. We are trying to provide updated information as quickly as possible.
Because this is a pandemic and there may be shortages of personal protective equipment (PPE), facility capacity, and staff, it may not be possible to follow anesthesia best practices. Instead, facilities, with anesthesia team input, may need to develop policies, procedures, and practices based on a risk assessment weighing several factors, including the extent of community COVID-19 transmission, patient population, extent of supplies on hand, reliability of supply chain, available staff, and intensive care capacity.
The responses provided to these FAQs are for information only and are not medical or legal advice. They are not official AANA policy (unless indicated) or peer-reviewed clinical practice guidelines, and they do not supersede laws, regulations, or government directives or dictate the decisions of the individual CRNA or facility. Please consult with appropriate healthcare and legal counsel to guide determinations to apply in the specific practice setting.
Medicare Reimbursement for Critical Care During the COVID-19 Pandemic
Can CRNAs be paid for providing critical care services during the Covid-19 pandemic?
Under current Medicare reimbursement policy there is nothing that expressly precludes CRNAs from being paid under Medicare Part B for critical care services provided in the intensive care unit (ICU) setting. In CMS’ recent guidance, COVID-19 FAQs, the agency did not address the issue of paying specialty clinicians (e.g. CRNAs) for critical care services. This is also true regarding the CMS’ recent telehealth waiver, which includes critical care telehealth codes.
CMS’ general policy regarding payment for Critical Care is available in the Medicare Claims Processing Manual for codes (codes 99291 - 9292) can be found at: Section 30.6.12 – Critical Care Visits and Neonatal Intensive Care. It is important to note that although Medicare may technically pay Part B claims for critical care services, actual reimbursement will depend on your Medicare Administrative Contractor’s (MAC) local coverage determinations (LCDs) AND whether your state’s scope of practice laws supports CRNAs providing critical care outside of the perioperative setting.
As CMS provides updates to its COVID-19 FAQs, we will post links and update this document on AANA’s Covid-19 webpage. For specific questions regarding CMS policy, please contact AANA’s Federal Government Affairs (FGA) at firstname.lastname@example.org or (202) 484-8400 and for questions regarding state scope of practice please contact AANA’s State Government Affairs (SGA) at email@example.com or (847) 655-1130.
I am interested in finding out what am I allowed to do as a CRNA under my state’s Scope of Practice (SOP) laws?
Under Medicare Part B regulations (42 C.F.R. §410.69 (b)) Medicare will pay for reasonable and necessary medical or surgical services furnished by CRNAs if they are legally authorized to perform these services in the State in which the services are furnished. State scope of practice laws will vary in its support for CRNAs providing critical care services outside of the perioperative setting. AANA’s Professional Practice Division has prepared a Scope of Nurse Anesthesia Practice document that provides an overview of issues that include but are not limited to: education, licensure, certification, accountability and clinical anesthesia practice.
In addition, AANA’s SGA Division has prepared various SOP summaries based on each state’s statutes and regulations obtained from its regulatory agencies and AANA’s legislative and regulatory tracking services. The SGA Division works diligently at keeping these documents current; however, SGA cannot guarantee their accuracy and therefore these summaries do not constitute legal advice. For legal advice, please consult an experienced healthcare attorney.
I am interested in finding information on my Medicare Administrative Contractor’s (MAC) local coverage determinations (LCDs) regarding reimbursement for critical care services. Where may I find this information?
Medicare contracts its administrative functions out to entities known as Medicare Administrative Contractors or (MACs) for processing claims. Each MAC is given wide latitude to administer the Medicare program for its designated region. The MACs also have discretionary authority to establish which services are reasonable and necessary and therefore considered a covered Medicare benefit. These covered benefits are documented in policy documents know as Local Coverage Determinations (LCDs). Find the MAC for your region here. Each MAC’s LCDs may be accessed through the MAC’s website under its medical policy page. For other questions please contact AANA’s FGA Division at firstname.lastname@example.org or (202) 484-8400.
As a CRNA, how will I be reimbursed for providing critical care services?
CRNAs should be utilized as advanced care providers to expand the Nation’s critical care workforce, see Medicare Reimbursement for CRNAs Serving as Advanced Practice Providers in Critical Care Settings.
FAQs on Medicare Telehealth Services and How They Impact CRNA Services
Note: Telehealth services provided must be within state scope of practice. Ability to provide services via telehealth does not authorize scope of practice elements or prescriptive authority that are not already included in state scope of practice.
How has the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services for providers?
The use of Telehealth under Medicare has been historically low because it was limited to rural areas, but due to the coronavirus crisis, CMS is expanding this benefit on a temporary and emergency basis under the Section 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act (HR 6704). Under this new waiver, Medicare can pay for office, hospital and other visits furnished via telehealth across the US and including patient’s homes starting on March 6, 2020. CRNAs have been eligible to be telehealth providers prior to this expansion, but this wavier expands the circumstances for CRNAs to provide telehealth. Before this waiver, Medicare would only pay for telehealth on a limited basis such as when the person receiving the service lives in a rural area and then they leave their home to go to a clinic, hospital or certain other types of medical facilities for that service.
Are CRNA telehealth services covered?
Under the CMS 1135 Waiver, CRNAs are included in the list of providers that can care for patients using telehealth services. Reimbursement is dependent on your Medicare Administrative Contactor (MAC) and their Local Coverage Determinations (LCDs), on state scope of practice laws, and existing Medicare policy.
What are the five types of telehealth services can be provided to Medicare beneficiaries?
There are five types of telehealth services physicians and other professionals (including CRNAs) can provide: Medicare telehealth visits, virtual check-ins, e-consults, remote patient monitoring and e-visits. There are now 171 new telehealth codes that can be billed for under the Medicare Physician Fee Schedule. To the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) would otherwise require a face-to-face visit for evaluations and assessments, clinicians would not have to meet those requirements during the public health emergency.
What are the common telehealth services and codes CRNAs can use to treat patients?
Please see the document released by CMS on March 30, 2020 entitled Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, which lists in great detail the services that providers can now provide under the five categories of telehealth services so that clinicians can take care of their patients while mitigating the risk of the spread of the virus. These codes include services such as critical care services, emergency department visits, initial hospital care and hospital discharge day management and initial and continuing intensive care services. Under
the public health emergency, all beneficiaries across the country can receive Medicare telehealth and other communications technology-based services wherever they are located. Providers can provide these services to new or established patients. In addition, providers can waive Medicare copayments for these telehealth services for beneficiaries in Medicare.
Where can telehealth services be provided?
Telehealth services can be provided to both new and existing beneficiaries in any location, in both urban and rural areas, including a private home. This applies to all existing Medicare telehealth services. The visits can be via telephone call and also the visits do not have to contain both an audio and a visual component as was previously required.
What is the frequency of certain telehealth services that can be provided?
The following services no longer have limitations on the number of times they can be provided by Medicare telehealth: a subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days; a subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days; and critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation.
How can I find out if I can offer my services in another state?
With the 1135 waivers, governors have been making state licensure and telehealth requirements more flexible by allowing out of state providers to treat patients across state lines. The requirements that are waived are at federal level and not at the state level.
Providers must look at each state law and executive orders to see what the state licensure requirements are. Check state boards of nursing for these requirements also, because each state is unique and may have different licensure requirements.
What technology can I use to provide telehealth services, if I don’t have dedicated audio/visual equipment?
Telehealth visits can be conducted over the phone and do not need to include both an audio and a video component. Furthermore, the OIG is providing flexibility for providers to reduce cost sharing for telehealth. Also, physicians and other practitioners will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations Federal health care program beneficiaries may owe for telehealth services furnished consistent with then applicable coverage and payment rules. See OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19).
Could I be subject to penalties under HIPAA for using devices like smartphones to provide telehealth services?
The Office of Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients (e.g. Apple Face Time or Facebook Messenger). See Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.
Can certain medications be prescribed to patients evaluated using telehealth?
DEA registered practitioners may issue prescriptions for controlled substance to patients for who they have not conducted an in-person meeting with. Here is the press release.
DEA-registered practitioners may continue this telemedicine practice for as long as the designation is in effect, if all required conditions are met:
- The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
- The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.
- The practitioner is acting in accordance with applicable Federal and State law.
Will traditional malpractice insurance cover me if I offer telehealth consultation services during COVID-19?
Consult your malpractice insurance carrier. Traditional Medical malpractice insurance coverage depends on your carrier.
Have commercial insurance plans expanded their benefits to cover COVID-19 related services?
Yes, we have heard that commercial health plans are expanding their benefits and/or relaxing requirements to cover services such as testing, cost sharing, prior authorization requirements, expanding access to telehealth and nurse/provider hotlines.
Can providers be reimbursed under CMS while they are physically in the home (under quarantine)?
CMS doesn't limit where providers can practice. They can add their own home address to their Medicare Enrollment by reaching out to their Medicare Administrative Contractor (MAC). It would be effective immediately so providers can provide care without a disruption. See 42 CFR 424.516 for more information. If a CRNA reassigns his/her billing rights to a clinic or group practice that clinic or group practice must add the individuals home address to their Medicare enrollment by reaching out to their MAC.
CMS 1135 Waiver for National Disaster and Emergency
What are Section 1135 waivers?
Section 1135 waivers provide a temporary relaxation of certain, healthcare regulatory requirements in the event of a declared disaster or emergency. In the past, the waivers have been issued for natural disasters and pandemics, such as Hurricane Katrina and H1N1 influenza, and focused on specific concerns related to those events and their impact on the healthcare system and provision of care. Section 1135 Waivers are useful in addressing any Medicare/Medicaid provider enrollment-related issues and flexibilities questions or concerns. They are meant to allow sufficient health care items and services to be available to meet the needs of Medicare, Medicaid and CHIP beneficiaries and allow health care providers that provide such services in good faith can be reimbursed for them and not subjected to sanctions for noncompliance, absent any fraud or abuse.
What Medicare and Medicaid flexibilities can states seek through a Section 1135 waiver request?
See the flexibilities below (these are federal flexibilities and not regarding state licensure):
- Provider Locations: Temporary waiver of the requirement that out-of-state providers be licensed in the state where they provide services when they are licensed in another state. This temporary waiver applies to Medicare and Medicaid reimbursement requirements but not to CHIP or state licensing requirements.
- Provider Enrollment: Establishment of a toll-free hotline for non-certified Part B suppliers, physicians and non-physician practitioners to enroll and receive temporary Medicare billing privileges. Waiver of the application fee, finger-based criminal background checks and site visit are typically part of the screening requirements. Postponement of all revalidation actions. Ability for licensed providers to render services outside of their state of enrollment, and expedited handling of any pending or new applications from providers.
- Medicare Appeals in Fee-for-Service, Medicare Advantage and Part D: Extension of time to file an appeal and waiver of timeliness for requests for additional information to adjudicate the appeal. Appeals will be processed even with incomplete Appointment of Representation forms, but communicating only to the beneficiary. Requests for appeal that do not meet the required elements will be processed using information that is available. All flexibilities available will be used in the appeal process as if good cause requirements are satisfied.
- Skilled Nursing Facilities (SNFs): Waiver of the three-day prior hospitalization requirement for coverage of an SNF stay. Beneficiaries may be transferred because of the emergency without a prior qualifying hospital stay, and certain beneficiaries’ SNF coverage, once benefits are exhausted, may be renewed. CMS also waived the timeframe requirements for Minimum Data Set assessments and transmission.
- Critical Access Hospitals (CAHs): Waiver of the 25-bed limit requirement for CAHs and waiver of 96-hour limit on length of stays.
- Housing Acute Care Patients in Excluded Distinct Part Units: Waiver to allow acute care hospitals to house acute care inpatients in excluded distinct part units. The Inpatient Prospective Payment System hospital is instructed to annotate in the medical record that the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the emergency.
- Durable Medical Equipment (DMEPOS): Authorization for contractors to waive the face-to-face visit, new physician’s order or medical necessity requirements for replacement of DMEPOS when the DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency.
- Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: Ability for acute care hospitals to relocate inpatients from excluded distinct part psychiatric units to acute care beds and units if necessary. The affected hospital is instructed to annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or exigent circumstances related to the emergency.
- Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital: Ability for acute care hospitals to relocate inpatients from excluded distinct part rehabilitation units to acute care beds and units if necessary. The affected hospital is instructed annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or exigent circumstances related to the emergency.
- Supporting Care for Patients in Long-Term Care Acute Hospitals (LTCHs): Ability for LTCHs to exclude patient stays where an LTCH admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement otherwise applicable to LTCHs.
- Home Health Agencies (HHAs): Relief to HHAs regarding the timeframes related to OASIS Transmission and allowing Medicare Administrative Contractors to extend the auto-cancellation date of Requests for Anticipated Payment during emergencies (note that this is an extension of time and not a waiver of completion).
- Part B Prescription Refills: Medicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable or unavailable due to the emergency.
Do Section 1135 waivers affect State laws or regulations?
Under section 1135, only certain Federal requirements relating to Medicare, Medicaid, CHIP, and HIPAA may be waived or modified. An 1135 waiver does not affect State laws or regulations.
Is there a list of states who have applied for Section 1135 waivers?
The Centers for Medicare and Medicaid Services has an up to date list of states who have applied for these waivers. This can be found on the CMS Current Emergencies web page. In addition, Kaiser Family Foundation has posted a list of state data and state health care policy actions regarding coronavirus. See State Data and Policy Actions to Address Coronavirus.
What brought about Section 1135 Waivers?
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 COVID-19. On March 13, President Trump declared a national emergency due to COV-19. As a result of these declarations, the Secretary of HHS may exercise the authority under section 1135 of the Social Security Act to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the COVID-19 outbreak.
How can CMS implement these waivers?
CMS may implement Section 1135 waivers in several ways, although all require that CMS determine that a provider has been affected by the disaster or emergency that prompted the issuance of the waivers. CMS has the option to issue Section 1135 waivers that require providers to request and receive approval for relief on a case-by-case basis, or CMS can implement “blanket” waivers. Blanket waivers may be issued when CMS has determined that all similarly situated providers in an identified emergency area need such a waiver or modification. Often, as with natural disasters, the “emergency area” is limited. In other cases, such as pandemics, the emergency area may be much more expansive. CMS considers several factors when determining whether to provide a specific or blanket waiver or modification, including the scope and severity of the emergency, the expected duration, feedback from the state survey agency and state and federal emergency response officials, and supporting data gathered by state provider associations. Any waivers or modifications issued by CMS pertain only to federal requirements, and providers must ensure that any steps they take in accordance with the waivers also comport with state law.
Did CMS release guidance on how these waivers affect CRNA practice?
The current CMS guidance does not focus on specific areas that affect CRNA anesthesia practice such as working in ICUs ORs and triaging incoming COVID-19 patients. However, the agency releases guidance almost daily and the AANA is tracking the CMS coronavirus web page to see if there is information that can be added to this FAQ.
Approximately how long will the process take for approving/denying a waiver request?
CMS will review and validate the 1135 waiver requests utilizing a cross regional Waiver Validation Team. The cross-regional Waiver Validation Team will review waiver requests to ensure they are justified and supportable. HHS anticipates that requests to operate under 1135 Waiver flexibilities should be responded to within three business days of receipt.
What do the Section 1135 waivers not do?
1135 waivers are not a grant or financial assistance program. They do not allow for reimbursement for services otherwise not covered. They do not allow individuals to be eligible for Medicare who otherwise would not be eligible. And they do not last forever - they last 30-60 days or the duration of the emergency.
How does a state apply for a Section 1135 waiver?
There is no specific form or format that is required to submit the request for a Section 1135 waiver, but the state should clearly state the scope of the issue and the impact. States and territories may submit a Section 1135 waiver request to email@example.com.
CMS Temporary Supervision Removal
What does the Centers for Medicare & Medicaid Services’ action to waive the requirement for supervision mean for CRNAs?
The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, or CoPs, are federal regulations with which particular healthcare facilities must comply in order to participate – that is, receive funding from – the Medicare and Medicaid programs, the largest payors for healthcare in the U.S. As part of the CoPs, CMS requires that CRNA anesthesia services be under the supervision of a physician. This waiver temporarily removes this CoP, which is a federal requirement. State laws in place regarding supervision or other physician involvement will still remain in effect, meaning that CRNA services may still need to be under the supervision of a physician. CRNAs will not have to be under the supervision of a physician in states without any supervision requirements. State law requirements concerning supervision are available on the AANA's Opt Out Toolkit. (requires member login).
When does this waiver become effective and how long will it apply?
This waiver becomes effective immediately. Waivers such as this one typically end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published. The waiver would then end unless the Secretary of Health and Human Services extends the waiver by notice for additional periods of up to 60 days, up to the end of the emergency period.
Does this only remove supervision for Medicare patients/cases?
No. This waiver of supervision requirements applies to all patients/cases within Medicare-certified facilities, regardless of payor. Please note, however, that this CMS waiver does not affect existing requirements that may imposed by private payors, e.g., Aetna, Blue Cross, etc.
How does this affect Medicaid?
This applies to Medicaid to the extent that the Part A facility conditions of participation also apply to Medicaid. However, Medicaid is a federal/state hybrid program, and Medicaid requirements under state law will still apply. This CMS waiver also does not affect participation or direct reimbursement to healthcare providers under Medicaid.
How does this affect CRNA ability to bill QZ?
Billing under Part B, including modifiers like QZ, etc., are not affected by this CMS waiver.
Are we covered by malpractice insurance if we are asked to function in the capacity of a registered nurse (RN)?
- Due to the challenges faced by the healthcare community during the COVID-19 pandemic, the AANA and AANA Insurance Services understand that nurse anesthetists may be asked to function in the capacity of RNs.
To be clear, neither the AANA nor AANA Insurance Services are suggesting that nurse anesthetists should be mandated to function as RNs. However, if a nurse anesthetist decides to function as an RN (e.g., in the ICU or emergency department), we want to assure you that if you have your malpractice liability insurance through AANA Insurance Services, your Medical Protective (MedPro) policy provides you with coverage not only for the work you do as a nurse anesthetist, but also any work you do as an RN.
There is a specific endorsement on your MedPro policy titled Expanded Professional Services Endorsement. This endorsement expands the definition of "Professional Services" on your policy to include any professional services you provide as an RN. With your MedPro policy, you can work to the full licensure and scope of practice as both a nurse anesthetist and an RN.
If you purchased your own malpractice liability insurance policy from a company other than AANA Insurance Services, there is a real possibility that your policy does not include coverage for any professional services you provide as an RN. Even if your agent tells you that you will be covered for RN work, be sure your agent puts that in writing to you.
If you have any questions or need any additional information about malpractice insurance, contact AANA Insurance Services.
How do I file for unemployment?
Unemployment insurance is a joint state-federal program that provides cash benefits to eligible workers. Each state administers a separate unemployment insurance program, but all states follow the same guidelines established by federal law. Generally, you should file your claim with the state where you worked. If you worked in a state other than the one where you live or if you worked in multiple states, the state unemployment insurance agency where you now live can provide information about how to file your claim with other states.
The CARES Act expanded unemployment to self-employed individuals who would otherwise not qualify for regular unemployment compensation benefits. These workers may receive up to 39 weeks of federally-funded unemployment benefits but must apply through the state’s unemployment agency. In order to demonstrate eligibility, an individual must provide self-certification that the individual is otherwise able and available to work, except for the fact that the individual is unemployed, partially unemployed, or unable or unavailable to work due to COVID-19-related circumstances.
Before you file, check with your state unemployment for details on the documentation you need to file to open a claim
Go to CareerOneStop to look up your state’s unemployment site.
I have a contract with a large anesthesia company. The contract has not been cancelled, there have been no layoffs, but the facility is currently closed. Can I apply for assistance under the CARES Act or any other government program?
You should contact your state’s unemployment office to determine whether you are eligible for unemployment through the state or the expanded federal unemployment.
Go to CareerOneStop website to look up your state’s unemployment.
Should CRNAs that do not qualify for CARES Act or PPP apply for unemployment?
Yes, there is no harm in applying when you are unemployed or underemployed and those denials may be based on particular circumstances that do not apply to your situation.
How does a locum tenens CRNA apply for unemployment?
You should contact the unemployment agency in the state where you live for instructions about how to apply given that you have not worked in that state. You should also contact the agency through which you work for guidance.
Can self-employed CRNAs, who are out of work, apply for unemployment?
You should apply for unemployment in the state where you live. The CARES Act has expanded benefits to certain self-employed individuals. You should also check whether you are eligible for small business loans through the SBA.
There is concern around reduction in hours and underemployment – are there benefits CRNAs qualify for?
States generally provide some partial benefits for qualified unemployed workers who accept part-time employment while looking for their next full-time job. Many states also have underemployment provisions to assist full-time employees with reduced hours. Check with your state’s unemployment agency.
If I decide not to work because I am fearful about the working conditions at my place of employment, am I entitled to unemployment?
It depends. You should check your state unemployment website to see if that falls within the parameters of unemployment for your jurisdiction.
Does my employer need to provide me notice if I am furloughed?
Generally, yes, your employer should provide you with written notice of a furlough. You should ask your employer how long the furlough will last; if you are entitled to use PTO during the furlough; and how long benefits will continue.
I am a locum employee and have been furloughed, can I apply for unemployment?
You should apply for unemployment through your state’s agency as soon as possible. You may also consider having an attorney review your contract to see whether the company breached your agreement.
What are my options for obtaining health insurance if I lose my employment as a result of the COVID-19?
If you are uninsured, or are losing your insurance due to recent unemployment, you have options to regain health coverage.
State health insurance exchanges are where you can directly buy family and individual health insurance plans. If you experience a qualifying life event, such as losing employer-sponsored health insurance, you can shop for health plans through your state’s insurance marketplace. You have 30 to 60 days to sign up after a qualifying life event before the special enrollment period closes.
If you miss this sign up period, you will need to wait for the period of open enrollment (usually from November to January). But due to COVID-19, some states that operate their own health exchange are reopening their enrollment period so check with your state.
If you live in a state that operates through the federal marketplace at Healthcare.gov, federal legislation will determine whether or not you have a new opportunity to enroll.
You might also qualify for Medicaid or CHIP. There is no enrollment period for either, as long as you’re eligible, you can sign up any time. The Medicaid Planning Assistance website provides links to each state’s Medicaid program.
If you recently lost your employer-sponsored health insurance, you are eligible for coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA gives you an option to continue the same health insurance coverage you had under your employer, but you will be responsible for the costs your employer used to cover. It can last for up to 18 to 36 months.
Finally, you may be able to obtain coverage through your spouse’s or family’s insurance plan.
What Federal Programs are there to help CRNAs?
There are two major programs in the CARES Act that can help CRNAs. One is the Paycheck Protection Program (PPP), a small business loan that helps businesses maintain payroll and cover other business expenses with conditions for loan forgiveness. The other is the Health & Human Services Provider Relief funds, which are direct payments (not loans) to those who bill Medicare Fee for Service (FFS).
What if I am still working but I’ve seen my hours cut?
You can still apply for assistance under the paycheck protection program. Unemployment is not a criterion for loan consideration. The loan funds however will only help make up a portion of your salary, limited to $100,000/year.
What other options are available to me if I don’t qualify for PPP or HHS Provider Payments?
- Small Business Tax Credits: Tax credits are available to help small businesses and the self-employed offset the costs of paid sick leave, and family leave for their employees.
- Unemployment Expansion: The CARES Act significantly expands existing unemployment benefits in three ways:
- Recipients receive an extra $600 per week.
- More workers are eligible for benefits, including self-employed, independent contractors, furloughed workers, and workers affected by COVID-19.
- Recipients are eligible for an additional 13 weeks beyond the typical 26 weeks offered.
Employment: Government Programs
What does the COVID-3 relief package do for me? How do I apply for benefits under this package?
As noted above, the CARES Act expanded unemployment to self-employed or IRS form 1099 individuals. To receive these benefits, you must apply through your state’s unemployment agency.
Go to the CareerOneStop website to look up your state’s unemployment.
For more see the AANA Infographic: How the CARES Act Helps CRNAs.
Am I eligible for the Paycheck Protection Program (PPP),or the small business loans?
Are independent contractors eligible for COVID-19 government loans?
Go to the U.S. Small Business Administration website to check your eligibility for CARES Act loans and for information about applying.
Are employers giving CRNAs hazard pay?
Hazard pay means additional pay for performing hazardous duty or work involving physical hardship. Work duty that causes extreme physical discomfort and distress which is not adequately alleviated by protective devices is deemed to impose a physical hardship. Hazard pay is addressed by the employer and not by federal regulation.
If we contract COVID-19 while caring for patients, are we eligible for worker’s compensation?
You should check with the worker’s compensation agency for your state. Whether this is covered may depend on how you contracted the virus and the nature of your occupation. Generally, communicable diseases like COVID-19 are not workers’ compensation claims because people are exposed in a variety of ways. However, if you work in a job that poses a special hazard or risk and contract COVID-19 from the work exposure, the agency will likely allow your claim (subject to variations in state law). Receiving a recovery will vary according to the adjudication of your claim.
How is the stimulus pay explained under the CARES Act?
The amount of your stimulus check will be based on your adjusted gross income from your 2019 federal tax filing or -- if you haven't filed this year -- your 2018 filing. You will qualify for a stimulus check if:
- If you're a single U.S. resident and have an adjusted gross income less than $99,000.
- If you file as the head of a household and earn under $146,500.
- If you file jointly without children and earn less than $198,000. For each child age 16 or younger in the family, parents will get a payment of $500.
In your situation, if you filed jointly and the combined salary was more than $198,000, you will not receive a stimulus check. However, there may be other relief available such as expanded unemployment benefits.
In the case where you contract COVID-19 and your employer refuses to allow worker’s compensation claims, what should you do?
You should contact the worker’s compensation agency for your state. You may also qualify for paid sick leave under the new Family First Coronavirus Response Act.
My company is offering CRNAs to be voluntarily reassigned to other areas of the hospital. However, we are told that there should be no expectation for the hospital to cover CRNAs for workman’s compensation or professional liability.
You should carefully consider whether or not you wish to be employed under these circumstances. If you are not covered for any liability, you will likely be opening yourself up to potential claims.
Some states, like Illinois, have provided immunity for volunteers, but this issue is going to be specific to your community and your situations and requires thoughtful analysis.
Am I entitled to leave under the new COVID-19 laws?
If your employer employs less than 500 employees, they may provide sick leave and also leave to care for a child. You should inquire into whether or not your employer offers such leave. If they do not, you should feel free to ask for the basis for this assessment.
Who is Eligible to Apply for the Paycheck Protection Program (PPP) Loans?
This program is open to small businesses under 500 employees, including sole proprietorships, independent contractors and self-employed persons as well as 501(c)(3) non-profit organization, 501(c)(19) veterans’ organization, or Tribal business concern.
How Do I Apply for a loan through the PPP?
There are four main steps you need to follow to apply for a PPP loan:
- Download and complete the SBA PPP loan application. You will need your business information (address, contact info, etc.) as well as your business TIN (EIN, or SSN). You must also certify that your business was in operation prior to February 15, 2020.
- Determine your Average Monthly Payroll Costs. This will be the basis for your loan amount. For purposes of calculating “Average Monthly Payroll,” most Applicants will use the average monthly payroll for 2019, excluding costs over $100,000 on an annualized basis for each employee.
- Answer the 8 eligibility questions for you and your business, these require a simple yes or no check mark. Also complete the 8 certifications that you are required by simply initialing regarding eligibility and loan use.
Once your form is complete, submit your form to your SBA participating lender. You can find SBA participating lenders in your area through the SBA website.
What if I’m a W2 CRNA and not eligible to apply?
If you are not eligible to apply for a Paycheck Protection Program (PPP) loan yourself (If you are a W2 CRNA for example) your employer can still apply for funding to help keep you on the payroll. This funding is forgivable for your employer. If your employer receives funding from the program and does not rehire you, they will be required to pay back the loan with applicable interest.
What if I’m a 1099 Independent Contractor?
If you are a 1099 Independent Contractor, you are eligible to apply for a loan through PPP. The PPP program specifically covers independent contractors, with loans to cover salary costs up to an equivalent of $100,000/year.
Can I use PPP loan funds for things other than salary?
Yes, PPP loan funds can be used to cover other business expenses, including lease or mortgage interest, rent, and utilities. It’s important to note that salary can include wages, commissions, or similar compensation; payment for vacation, parental, family, medical, or sick leave; allowance for separation or dismissal; payment for the provision of employee benefits consisting of group health care coverage, including insurance premiums, and retirement; payment of state and local taxes assessed on compensation of employees; and for an independent contractor or sole proprietor, wage, commissions, income, or net earnings from self-employment or similar compensation. 75% of the loan must be used for salary in order to be eligible for forgiveness, however.
What if my bank or lender rejects my application?
You should ask the lender that you applied to for the reasoning for rejecting your application. Some banks may prioritize applications from individuals and groups with whom they have a prior relationship. Some banks may have already exhausted their allotment of funding. Many financial intuitions are struggling with overwhelming demands and may themselves being struggling with understanding how to administer this new program. The SBA offers local assistance for those who still have questions regarding the program. You can find local SBA Assistance here.
What is the Health & Human Services Provider Relief Funding?
The U.S. Department of Health and Human Services (HHS) is delivering $30 billion in relief funding to providers in support of the national response to COVID-19. CRNAs will receive relief funding based on their share of 2019 Medicare fee-for-service (FFS) reimbursements. If facilities are the ones who bill Medicare, then they will receive the relief funding. This $30 billion is the first disbursement of $100 billion made available in the CARES Act. The relief funding is intended to help providers and facilities keep their lights on during the COVID-19 pandemic. This relief funding is not a loan, so it does not need to paid back.
Who is eligible to receive this funding?
In short, if a CRNA already bills Medicare for FFS reimbursements, then they will receive a payment. Here is what to expect, based on a CRNA’s employment type:
- CRNAs practicing solo, such as 1099 employees, who bill Medicare will receive a payment under the tax identification number (TIN) used to bill Medicare. CRNAs who normally receive a paper check for reimbursement from the Centers for Medicare & Medicaid Services (CMS) will receive a paper check in the mail for this payment as well within the next few weeks.
- Employed CRNAs should not expect to receive an individual payment directly. The employer organization will receive the relief payment as the billing organization.
- Hospital-employed CRNAs should not expect a direct payment. Facilities that bill Medicare will receive the relief funding.
- CRNAs working as part of a larger medical group will see their payment sent to the group's central billing office.
How are Payment Amounts Determined?
CRNAs, their hospital, or their medical group, will be distributed a portion of the initial $30 billion based on their share of total Medicare FFS reimbursements in 2019.
- A CRNA can estimate their payment by dividing their 2019 Medicare FFS (not including Medicare Advantage) payments they received by $484,000,000,000 and multiply that ratio by $30,000,000,000. Providers can obtain their 2019 Medicare FFS billings from their organization's revenue management system.
- As an example: A community hospital billed Medicare FFS $121 million in 2019. To determine how much they would receive, use this equation:
- $121,000,000/$484,000,000,000 x $30,000,000,000 = $7,500,000
What should I expect if I’m eligible?
HHS has partnered with UnitedHealth Group (UHG) to provide rapid payment to providers eligible for the distribution of the initial $30 billion in funds.
- Eligible CRNAs, their hospitals, or their medical group, will be paid via Automated Clearing House account information on file with UHG or the CMS.
- The automatic payments will come to providers via Optum Bank with "HHSPAYMENT" as the payment description.
- CRNAs who normally receive a paper check for reimbursement from CMS, will receive a paper check in the mail for this payment as well, within the next few weeks.
- Within 30 days of receiving the payment, CRNAs must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13, 2020, and will be linked from hhs.gov/providerrelief.
- HHS' payment of this initial portion of funds is conditioned on the CRNA’s acceptance of the Terms and Conditions - PDF, which acceptance must occur within 30 days of receipt of payment. If a CRNA receives payment and does not wish to comply with these Terms and Conditions, the CRNA must do the following: contact HHS within 30 days of receipt of payment and then remit the full payment to HHS as instructed. Appropriate contact information will be provided soon.
Is this different than the CMS Accelerated and Advance Payment Program?
Yes, the CMS accelerated and advance payments are a loan that providers must pay back. These advanced payments to providers are to ensure that providers, such as CRNAs, have the resources needed to combat the pandemic.
Do I need to apply to receive this funding?
No, you do not need to apply to receive this funding as it will be applied automatically. You will need to go to the portal to sign the attestation statement the week of April 13th at the link available at: hhs.gov/providerrelief.
How can I guarantee that I see this money if the funds are distributed to someone else on my behalf?
If you are employed by a hospital or a medical group, there is no real way of guaranteeing that you will see this funding.
For more information on your state's unemployment benefit program, visit the U.S. Department of Labor's website for more information on your state. For more information on unemployment benefits expanded by the CARES Act, please see this government fact sheet for full details.
Does the disaster declaration have ability to cancel any contracts or specific provisions of the contract?
This will depend on the specific terms of the agreement. In order to cancel a contract due to a disaster declaration, there must be a term in the agreement that allows for this, such as a force majeure term. You should also look through the termination provisions of the agreement.
My contract got terminated with no explanation. What should I do?
You should review the agreement to determine if the terms have been violated by the termination, and if so, reach out to your employer to inform them that they have violated the agreement. You should also consider filing for unemployment as soon as you can.
Is there guidance around company’s referring to contract provisions that I don’t believe are stated within my contract?
You should request a detailed explanation as to which exact clause the company is referring to and consider whether the company has breached the agreement. If you believe that the company breached the contract, consider consulting an attorney.
Will non-compete provisions in contracts be enforced?
Terms of restrictive covenants are enforced under state law. You could consider reaching out to the company and asking whether they would waive or modify enforcement of the non-competition clause due to the unprecedented situation. There are also legal arguments that could be made. For example, you could also point out that the terms relating to time, geography and scope are over-broad and that you have not received sufficient consideration for the restrictive covenant. If your former employer agrees to waive or modify your obligations, make sure that you execute an amendment to the agreement in writing. Without this release in writing, working for a competitor in the capacity that is prohibited in your agreement may put you (and your new employer) at risk of being sued for breach of the contract. Even with a restrictive covenant agreement, you still may be able to work for another employer in a different capacity, depending on the specific terms of your agreement.
In the effort to supplement income due to reduced salaries and hours, can non-compete clauses be enforced by large groups?
This will depend on the specific terms of the agreement. You should ask your employer to waive or modify enforcement of the non-compete provision given the circumstances and always get the waiver in writing as an amendment to the agreement. If it is not in writing (and done as an amendment to the agreement) it may not be enforceable.
My contract includes travel and housing expenses provision. Can the anesthesia company terminate this contract effective immediately?
This will depend on the specific terms of the contract, including whether these benefits are promised throughout the term of the contract or can be amended at the company’s discretion. The company may have breached your agreement.
I am a contract employee who wasn’t given 90-day notice that services were no longer needed. Is this a breach of contract?
If you believe that the employer breached the contract, you should request a copy of your personnel file from your employer and inform the employer that they have breached the contract. If you believe that the company breached the contract, consider consulting an attorney.
Is there guidance for CRNAs under contract whose hours are reduced?
This depends on the specific terms of the agreement, such as whether the agreement sets a minimum number of hours worked. If you believe the terms of your agreement have been violated, you should inform your employer right away. This may also depend on whether you are a salaried, exempt employee or hourly, nonexempt pursuant to the Fair Labor Standards Act.
How will the courts approach the breach of contract issues considering the COVID-19 crisis?
If you believe the terms of your agreement have been breached, it might be worthwhile to consult with an attorney. However, please understand that these are unprecedented times and there is no certainty as to how the legal system is going to handle issues that have arisen amidst the COVID-19 outbreak and response. It is important to assess what is the likelihood of your claim “succeeding,” whether you will be able to obtain the relief you are seeking, and whether the cost (in money and emotionally) make the undertaking worthwhile. A good lawyer should be able to help you walk through that evaluation.
I was fired for refusing to work without proper Personal Protective Equipment (PPE). Do I have any recourse?
If your employer retaliates against you for refusing to perform dangerous work, you may have a whistleblower claim against your employer depending on the claim and where you work. You should also contact the Occupational Safety and Health Administration (OSHA). To contact OSHA call 1-800-321-OSHA (6742) and ask to be connected to your closest area office.
If I volunteer in a state, do I have to notify my employer, and would I have to quarantine for 14-days?
This depends on your employer’s policies as well as state law. Some states are requiring individuals traveling from other states to self-quarantine.
Can my employer reduce my compensation if I am a salaried employee? If I am an hourly employee?
If you are a salaried employee, your employer can reduce your salary on a prospective basis due to financial concerns, if it does not violate an employment agreement that you currently have. However, as a salaried employee, you have a right not to have your salary adjusted on a daily or even weekly basis due to a financial downturn. As an hourly employee, an employer has more freedom to reduce your hourly rate, but some states and localities limit this right with predictive scheduling and show up to work laws. With both salaried and hourly employees, many states require advance notice of the reduction.
My employer is mandating that we continue to do elective cases despite the advisory to stop elective procedures in the state. Can I be fired as a result of refusing to do these cases?
It depends. If the work explicitly violates a state order, then there is a right not to work. However, if the order is merely advisory, then your employer could deem your refusal to work to be insubordination and put you on a unpaid or paid leave. You also could be terminated. If you are truly uncomfortable, the best initial course of action is to negotiate with your employer.
Can my employer take my temperature and/or ask me about any physical symptoms I might have?
During this time of a pandemic, an employer may take your temperature and may inquire into any physical symptoms to assess your risk for COVID-19; however, an employer must keep that information confidential.
Is there guidance around CRNAs working for large anesthesia companies being asked to voluntarily take a 90-day furlough or a 90-day 50% pay cut?
Unfortunately, unless you have an employment agreement addressing these reductions in pay or furloughs, your employer can take these actions (with some limitations, such as not paying less than minimum wage) in these unprecedented times. If you are furloughed, you likely qualify for unemployment and may even retain your employer provided benefits (depending on the specific terms set by your employer and/or the benefit plans). You could also look for other employment but keep in mind any noncompetition provisions from your current employer.
Do large anesthesia companies have a plan for CRNAs? What are they doing to protect our practice?
The AANA is continuing to coordinate with all market participants, including large anesthesia companies, to both advocate for CRNAs and assure that the value of CRNAs is understood and CRNAs are protected.
Some anesthesia companies posted information on their websites related to COVID-19:
- NorthStar Anesthesia
- North American Partners in Anesthesia
- Envision Physician Services
About these Employment FAQs
Nothing contained in any of the resources on this page constitute legal advice. No Attorney-Client relationship is established by use of any of the documents herein. Each CRNA utilizing this website or any resources included herein should consult with legal counsel in his or her state (or the State in which you practice) to be properly advised on any laws or regulations governing business and employment practices in that state. State laws vary and certain provisions or considerations provided in the resources on this page may or may not be applicable or enforceable.
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