American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Financial Resources Available to Assist Surgeons

The American College of Surgeons (ACS) reminds Fellows that several federal programs are available to assist them in maintaining the financial viability of their practices during the pandemic. Below are updates, additional resources, and information related to some of these options.

The Medicare Advance Payments Program

IMPORTANT NOTE: On April 26, the Centers for Medicare & Medicaid Services (CMS) abruptly announced that it was suspending the Medicare Advance Payments Program. That announcement can be found here.

The reason for suspending the program is unknown. However, the announcement does note that since “expanding the Medicare Advance Payment program on March 28, CMS approved more than 21,000 applications totaling $59.6 billion in payments to Part A providers, which includes hospitals. For Part B suppliers, including physicians, non-physician practitioners, and durable medical equipment suppliers, CMS approved almost 24,000 applications advancing $40.4 billion in payments.”

The ACS is monitoring the situation and will provide an update to Fellows should CMS decide to reinstate the program.

More information about this program can be found here.

Paycheck Protection Program (PPP)

The Paycheck Protection Program is intended to help businesses with 500 or fewer employees maintain operations and keep their staff on payroll. If the loan funds are used for the specified allowable purposes such as payroll, mortgage interest, rent or utilities, up to the full amount may be forgiven. Congress initially included $349 billion for this program as part of a small business loan package in the $2.2 trillion coronavirus stimulus package that passed late last month. Since applications from small business and sole proprietorships began to be accepted on April 3, 2020, reports from the field indicate the application is somewhat complex and cumbersome. Fellows should consider enlisting the services of their professional tax advisor for the application process.

Application for the PPP is submitted through your local Small Business Administration (SBA)-affiliated bank or financial institution.

IMPORTANT NOTE: As reported April 16, the initial funding amount of $349 billion for the PPP was expended. However, over the course of the week of April 20, Congress and the President acted to replenish the fund with an additional $321 billion for loans and program administration and sent the bill to the House.

Since replenishment, the Practice Protection Committee has received multiple reports of Fellows’ applications proceeding through the process without needing to resubmit applications. There have also been multiple reports of Fellows receiving their funding amounts from the PPP.

A list of Frequently Asked Questions (FAQs) about the PPP, prepared by Hart Health Strategies for the American College of Surgeons, can be found here: Small Business – PPP FAQ

The ACS has heard multiple accounts of loans, either that were applied for before or after the second round of funding became available being approved. However, many have been funded at a lower amount than applied for. There are also reports that in general, the average amount per loan in the second round of funding is approximately half that of the first round. If you are considering applying for these loans, please consider doing so as soon as possible and ensure that you are accurately calculating and documenting the amount requested.

UPDATE: The SBA and the Treasury Department on May 15 released the application form and instructions for borrowers who received a loan under the PPP. Completion of this application will be required for loan forgiveness consistent with provisions of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  It is expected that the SBA will soon issue additional regulations and guidance to assist borrowers complete their applications. The documents released will assist small businesses seek forgiveness at the conclusion of the eight week covered period, which begins at the time of disbursement of their loans.

The form and instructions include:

  • Options for borrowers to calculate payroll costs using an “alternative payroll covered period” that aligns with borrowers’ regular payroll cycles
  • Flexibility to include eligible payroll and non-payroll expenses paid or incurred during the eight-week period after receiving their PPP loan
  • Step-by-step instructions on how to perform the calculations required by the CARES Act to confirm eligibility for loan forgiveness
  • Borrower-friendly implementation of statutory exemptions from loan forgiveness reduction based on rehiring by June 30
  • Addition of a new exemption from the loan forgiveness reduction for borrowers who have made a good-faith, written offer to rehire workers that was declined

View the PPP application and instructions.

Economic Injury Disaster Loans (EIDL)

IMPORTANT NOTE: It was reported on Thursday, May 7, that the SBA has resumed processing EIDL applications submitted prior to April 15 but will limit future applications to agricultural businesses. Furthermore, the maximum loan amount moving forward appears to have been reduced from $2 million to $150,000, although this has not yet been posted on the SBA website. At present, ACS staff is unaware of any plans to add additional funding to this program.

The SBA’s Economic Injury Disaster Loan program provides small businesses with working capital loans of up to $2 million for vital economic support designed to help overcome loss of revenue. Small business owners in all 50 states; Washington, DC,; and U.S. territories are eligible to apply. Note that while these loans have favorable terms, they are not forgiven.

This program is administered directly through the SBA, not your local bank or SBA-approved lender. It should be noted that the EIDL program is also limited to entities with 500 or fewer employees.

Fellows may learn more about Economic Injury Disaster Loans here.

Relief Funds from the Public Health and Social Services Emergency Fund

CMS began disbursing $30 billion in grants directly to providers on April 10. No action was necessary on the part of providers to receive those funds. The $30 billion in funds disbursed is just a portion of the $100 billion Public Health and Social Services Emergency Fund. Payments to providers were deposited into accounts based on Taxpayer Identification Numbers. The payment amount received was calculated based on a percentage of the provider’s 2019 Medicare receipts.

On April 22, HHS announced that it would begin disbursing payments of an additional $20 billion to providers on April 24 bringing the total amount available to $50 billion. The specific announcement can be found here. In a statement HHS Secretary Alex Azar said, “The $20 billion will be allocated so that providers’ share of the whole $50 billion is based on the net patient revenue they received from all sources in 2018. This will entail a significant rebalancing for many providers: For example, one large children’s hospital received an initial distribution of $233,000; this new general allocation will send that provider an additional $32 million.” Since this announcement, there has been confusion over the process of submitting the necessary attestation and information necessary to access this funding. The process as currently understood is summarized below:

Summary of Key Information: Second Disbursement - $20B

Date of disbursement

Starting April 24, or 10 days after submission of application

How to apply?

Currently, you must have received a disbursement from the first round of funding to qualify. If you have received the first disbursement and attested, then use HHS/HRSA portal.

What information is needed?

  • TIN that received prior Provider Relief Fund payments
  • TINs of subsidiary organizations that received Provider Relief Fund payments that do not file separate tax returns
  • Amount of payments received
  • Lost March 2020 revenues and estimated lost April 2020 revenues
  • Relief fund payment transaction numbers/check numbers
  • Copy of most recently filed tax forms

Resources


ACS staff have received multiple reports from Fellows who appear to meet all criteria but who have not received funds from either payment. Surgeons who believe they are eligible but have not receive a payment should contact UnitedHealth Group’s Provider Relations line at 866-569-3522 about eligibility, whether a payment has been issued, and where the payment was sent.  Alternately, you can email COVID-19@cms.hhs.gov detailing your concerns and any steps you have taken to qualify.

If you are employed by a hospital or other entity, please note that your payment will be sent to the taxpayer identification number (TIN) responsible for billing for your services and will not necessarily be passed along to you. The ACS encourages surgeons concerned about how payments are being allocated to enquire about this with their employer. Since this is an unusual situation it may be beneficial to have an attorney review the terms of your contract to see if situations like this might be covered.

UPDATE: On May 7, HHS Announced that the deadline to attest to meeting theTerms & Conditions for these payments through the online portal was extended to 45 days after receipt of payment. Originally, physicians and hospitals that received funds were given 30 days to make this attestation. Note: Failure to return amounts received within 45 days will be viewed as acceptance of the Terms & Conditions.

Tax Provisions Could Help Ease Financial Stress

In addition to loans and advance payments through the SBA and CMS, there may be flexibility available through the Internal Revenue Service (IRS) that could temporarily free operating capital or even offset prior years’ profits with losses caused by COVID-19. Below are a number of questions and tax provisions that Fellows should consider discussing with their tax professional to see if they apply to their individual situation.

  • Is my practice eligible for the employee retention tax credit? This is a refundable Social Security tax credit equal to 50 percent of qualified employee wages (up to $10,000 of wages for each employee), however small businesses that take SBA loans like those made available by the Paycheck Protection Program are not eligible. More information may be found here.
  • Does it make sense for me to defer the Social Security portion of employer payroll taxes owed for the period between March 27, 2020 and December 31, 2020? (Note that the deferred amount must be paid back, with 50 percent of the deferred amount due by December 31, 2021 and the remainder to be paid by December 31, 2022.)
  • Do any of the modifications of net operating loss (NOL) rules (such as allowing them to offset 100 percent of taxable income or to be carried back for 5 years) apply to my practice?
  • Can I benefit from the temporary increase of the business interest expense limitation to 50 percent of adjustable taxable income for tax years 2019 and 2020?
  • Does my practice have excess business losses for tax years 2018, 2019, and 2020 that can be used due to the suspension of limitations for pass-through entities and sole proprietorships?
  • Can I claim 100 percent bonus depreciation for real estate and leasehold improvements placed in service in after 2017?
  • Are there other less common flexibilities such as greater limits on charitable deductions, AMT credit refunds, or funding of defined benefit pensions that might apply to my situation?

Commercial Insurance Coverage for Telehealth Services

The use of telehealth and other virtual services is critical to reducing exposure to the COVID-19 virus and ensuring continuity of care for individuals with chronic conditions during this public health emergency (PHE). To help surgeons navigate and integrate virtual services into their practices and enhance their ability to safely care for patients during the COVID-19 pandemic, the ACS has developed resources that describe coverage and reimbursement rules for virtual services from both Medicare and private payors; Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules applicable to telehealth during the PHE; and various telehealth products available for use by physicians.

Practical Suggestions and Options to Consider in Weathering the Storm

The American College of Surgeons has been closely monitoring both the development of the federal response to the COVID-19 epidemic and how the programs and regulations coming out of DC are being utilized by surgeons. In addition to the federal response, there are a number of tips and strategies that Fellows have developed for their practices. Below is a collection of practical suggestions, tools, tactics and options that other surgeons have used as part of their own individual response to the financial circumstances created by the ongoing COVID-19 pandemic.

  • Make an appointment with your tax professional and or financial advisor and seek their advice. (Consider bringing the list of tax questions provided above with you.)
  • Try to keep staff on the payroll by limiting the number of staff in the office at any one time.
  • Take advantage of and apply for financial resources made available to small businesses by recent congressional action taken in response to the pandemic. (See Financial resources section above)
  • Consider speaking to your malpractice insurance provider and ask about reducing and/or deferring payment of premium for a negotiated period of time based on reduced surgical activity during the period of declared emergency within your state. The ACS has prepared a resource document for the many major malpractice carriers and the accommodations they have made during the pandemic. It can be found here.
  • When funds from the Medicare Advance Payment Program or Small Business Administration loans (Paycheck Protection Program or Economic Injury Disaster Loans) are received, treat those funds as general receipts and carefully document where they are expended.
  • The current experience of surgeons indicates that the Medicare Advance Payment Program likely represents the best option for receipt of funds in the shortest period of time after application.
  • The Paycheck Protection Program could be extremely beneficial for those who qualify, because proceeds from the loan used for approved purposes may be forgiven. This week, Congress increased the amount available for these loans by more than $321 billion. The initial allotment of $349 billion was expended very quickly, so if you are interested in applying for this program it is imperative that you do so as soon as possible. For more up to date information and application instructions, Fellows should contact their local SBA affiliated institution.
  • For those applying for a loan through the Paycheck Protection Program, engagement of your tax professional has been found to be extremely helpful by those who have already completed applications. The application is complex, and true benefit is obtained by seeking professional assistance.
  • For those who receive a loan through the Paycheck Protection Program, keeping accurate records on expenses that can be counted toward the loan forgiveness provisions is imperative. Specifically, those expenses include payroll, mortgage interest, rent and utilities. Again, it should be noted that up to the full loan amount may be forgiven if the proceeds are used to keep staff on payroll and proper documentation is maintained.
  • If receiving Medicare Advance Payment, create a plan for payback based on conservative projected AR and practice expenses.
  • Consider applying for SBA's Economic Injury Disaster Loan in case it is needed to support cash flow for your practice when Medicare Advance payment paybacks are due. Simply, pay off the loan if you do not need to use it.
  • In order to preserve your personal assets and retirement savings through this crisis, consider avoiding loans that use those assets as collateral.
  • Reassess the personal budget and make accommodations. It is easier to add back as the cash flow improves than to take more drastic steps down the road if necessary
  • Have/develop a cash account working towards a 3-month personal expense cushion
  • Do not miss your life insurance or disability insurance premium payments
  • Look for deferral and leniency possibilities - rent, mortgage, student loan repayment, malpractice premiums, other loans, etc.
  • Keep track of work RVUs in the ramp-up period, even if you are not on a production model. You may be in a position later to negotiate recovery of some of your lost revenue, but only if you know that you have produced above the baseline. The current situation highlights the issues of pure RVU-based contracts. In “good times” with a decent conversion factor this type of contract can be great, but in times like these they can cause financial difficulty.
  • The ACS Employed Surgeon handbook and the ACS Private Practice Surgeon handbook are great resources and can be found on the ACS website.
  • This may be only the first shock to our system. Things will be different, and it will be a while before we get to a new normal. Therefore, plan for the possible “second surge” that may impact professional practice and its resultant impact on personal income. The unexpected happens, plan for it.