Flatiron support
during COVID-19

Together, the community oncology industry continues to monitor the COVID-19 pandemic. We’re inspired by the selfless work healthcare providers are doing on the front lines, and we’re committed to supporting practices as they deliver care to their patients during this time of unprecedented uncertainty.

This page provides recommendations gathered from Flatiron clinical and technology experts, as well as relevant third-party resources, that we hope will help support community oncology practices. We are continuing to make regular updates to reflect the latest information available.

We’re also offering complimentary consultations with our workflow experts to help you navigate the challenges your practice is facing as a result of COVID-19. Contact us to schedule a consultation.

Tracking the effects of COVID-19 on OncoEMR® practices

About a month into the COVID-19 response across the US, the data are revealing some trends and challenges community oncology will face in the coming months. In examining practices using OncoEMR beginning on March 16, we’re seeing a notable drop in visits when compared to the previous six months, broken down here1:

  • 13% drop in daily visits during which a chemotherapy infusion was administered
  • 33% drop in daily non-infusion visits 
  • 60% increase in appointment cancellations 
  • 50% decrease in new patient visits

Given this, practices will likely face financial pressures now and need to prepare to accommodate an influx of appointments in the coming months — including patients who are not yet diagnosed due to delayed testing. 

The administrative burden of this virus is mounting as well, such as challenges getting prior authorizations for cancer treatment.

For more on the emerging story that data can tell us about the impact of COVID-19 in community oncology, see the blog post from Flatiron’s CMO, Bobby Green, MD, What data tell us about the impact of COVID-19 in community oncology. 

1. Sourced from practices using OncoEMR® as of April 15, 2020.

The CARES Act: What community oncologists need to know

The Coronavirus Aid, Relief, and Economic Security Act, the “CARES Act”, is a $2 trillion economic stimulus bill signed into law on March 27, 2020. Here are some highlights from the CARES Act and Flatiron tips that could help your practice.



The new Paycheck Protection Flexibility Act was signed into law on June 5, 2020. The law amended the Paycheck Protection Program (“PPP”) to give greater flexibility to Borrowers in qualifying for Loan Forgiveness. Key changes are outlined below:

* The following is only a summary of key provisions. Please refer to the Government’s PPP resources or consult with an accountant or tax professional to ensure that you meet all requirements. 

Paycheck Protection Flexibility Act Changes

  • Borrower can extend eight-week period to spend funds to 24 weeks; new borrowers automatically have 24 weeks to spend funds for full loan forgiveness 
  • New Borrowers have 5 years to repay loan @ 1% interest rate 
  • Existing Borrowers can extend initial 2 year payback period to 5 years if both lender and Borrower agree 
  • 60% of funds are required to be spent on payroll for full loan forgiveness
  • Borrowers can delay payment of the employer portion of their 2020 Social Security payroll tax obligations (half due by Dec 31, 2021, half by Dec 31, 2022)
  • Borrowers can use the 24-week period to restore workforce levels and wages to pre-pandemic levels. This must be done by December 31, 2020
  • Borrowers can achieve full PPP loan forgiveness even if they don’t fully restore their workforce if:
    1. Employees turned down good faith offers to be rehired at the same hours and wages as before the pandemic 
    2. If Borrowers can document an inability to hire (or rehire) qualified employees
    3. If Borrowers can document that they are unable to restore business operations to Feb 15, 2020 levels, due to COVID-19 operating restrictions



Since April 10, 2020, HHS has been distributing $50 billion from the CARES Act. The first round of the Relief Fund was a $30 billion distribution to all providers that received Medicare fee-for-service reimbursement in 2019; the second round was a $20 billion distribution which required an application to receive funds. If you have received funding from either of the aforementioned distribution of funds, be sure to review the terms & conditions (linked above) to ensure compliance. 

If you received an initial payment as a part of the first round ($30 billion distribution), the terms & conditions of these funds note that recipients of payments are required to demonstrate the following: lost revenues and increased expenses attributable to COVID-19 exceed the total payment received from the CARES relief fund. HHS has stated that they will audit CARES funding and have the right to collect relief fund amounts that were made in error or exceed lost revenue and expenses from COVID-19. 

Here’s what your practice should do:

  • Calculate and document lost revenue and increased expenses from COVID-19
  • Compare lost revenue and increased expenses from COVID-19 to initial payment received from HHS (starting around April 13, 2020)

If HHS payment is greater than lost revenue and increased expenses from COVID-19, reject HHS payment via attestation portal and submit expenses/lost revenue to receive new payment.



CMS Regulatory Waivers & Rule Changes

On April 30, 2020, CMS issued another round of regulatory waivers and rule changes to continue to enable care delivery during this emergency.

Key updates that could impact your practice: 

  • Expanded audio-only services: The list of services that can be conducted by audio-only telephone has been broadened to many behavioral health and patient education services. Additionally, CMS is increasing payments for these telephone services to match payments as if they were furnished in-person.
  • Reduced E&M video requirements: The video requirement for certain telephone evaluation and management (E&M) services will be waived. These CPT codes (99441-99443 and 98966-98968) have been added to the list of Medicare telehealth services. 
  • Continued frequent telehealth updates: CMS will add new telehealth services on an ad hoc basis during the extent of this emergency. The cadence of updates will be more frequent than the typical rulemaking process, and will leverage direct requests and feedback from practitioners. 

For more details, please reference CMS’ resources on these waivers.



Provider Relief Fund: Additional Funding

While $30 billion from the $100 billion fund has already been distributed via direct deposit to eligible providers, HHS is now distributing an additional $20 billion to providers who can supply certain information, including estimates of lost revenues in March and April. As a reminder, providers must sign HHS’ attestation form and meet all terms and conditions. Funds will not be distributed on a first-come-first served basis, and funds will not be required to be paid back as long as usage of funds abides by the attestation terms and conditions.

To apply for additional funds, we recommend that you complete the following steps: 

  1. Consolidate required application information
    • Tax identification number
    • Amount of payments received from initial Provider Relief Fund deposit
    • Relief Fund payment transaction numbers / check numbers
    • Copy of your most recently filed tax forms
  2. Calculate estimated lost revenue in March and April
    • You may estimate lost revenue using a “reasonable method of estimation,” for example:
      Estimated lost revenue = Budgeted revenue - actual revenue 
      Estimated lost revenue = 2019 revenue - actual revenue
    • The lost revenue estimation should be independent of the first round of Provider Relief Fund payments
  3. Access CARES Provider Relief Fund Payment Portal and submit above information to complete application for additional funding request. You will be directed to a DocuSign form.



Additional Funding for the Paycheck Protection Program

~$300 billion will be allocated to replenish the Paycheck Protection Program. If you did not have the chance to apply for the first round of funding, we highly encourage you to start discussions with your bank and submit your application form immediately

Read through COA’s guidance to determine if you're eligible for a Small Business loan (under 500 employees in most cases) and learn how to apply. If you’re eligible, submit your application as soon as possible. There will be a significant number of businesses applying for this assistance and it is our understanding they will be addressed on a first-come first-served basis.

To set yourself up for success ahead of time for the next round of Paycheck Protection Payments:

  1. Immediately contact your bank 
  2. Fill out the lender application form and submit as soon as possible 
  3. Touch base with your bank’s loan team frequently throughout the day for updates on loan review process 
  4. Request to involve bank leadership to ensure your loan is reviewed expeditiously



HHS Provider Relief Fund: Attestation Portal Open 

As of April 9, 2020, the Department of Health and Human Services (HHS) provided an update on the allocation of the CARES Act $100 billion relief fund to hospitals and other healthcare providers. Effective immediately, $30 billion will be distributed to eligible providers.

Look out for a direct deposit from HHS, then starting April 13, 2020, navigate to HHS' portal to review and sign the attestation terms and conditions.

More details on the relief fund below: 

How do I know if my facility or providers are eligible for a payment?
If your facility or providers received Medicare fee-for-service reimbursements in 2019, you are eligible for a payment. 

How much should I expect to receive?
Payment calculation is based off of 2019 Medicare fee-for-service reimbursements. To estimate your expected payment, see HHS’ payment calculator below: 

$(Insert Your 2019 Medicare FFS Payments Received) / $484,000,000,000 x $30,000,000,000 = $ (Expected Payment)

Is this a loan or grant?
This is a grant, and will not need to be repaid. 

How will I receive these payments?
HHS has partnered with UnitedHealth Group and payments will be made via Automated ClearingHouse account information (already on file with CMS). Payments will show as from Optum Bank with "HHSPAYMENT" as the payment description.

What if I do not typically receive payments electronically?
If you do not receive payments electronically, you will receive a paper check in the mail from CMS within the next few weeks. 

How and when do I sign the attestation form?
Providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment within 30 days of receiving the payment. Be on the lookout for this payment via direct deposit, and then starting April 13, 2020, HHS’ portal for attestation signing will be open. Of note, the terms and conditions include limits on how funds can be used, as well as recordkeeping and reporting obligations.

What if my practice is part of a larger medical group?
Payments will be sent to a group's central billing office according to its Taxpayer Identification Number.


Provider Relief Fund Terms & Conditions: Key Points

Please see the full list of Terms and Conditions to ensure compliance with all requirements. We expect HHS to offer additional details on the terms and conditions in the coming weeks.

  • Recipients of funds must be able to certify that they billed Medicare in 2019 and are not currently excluded from participation in Medicare / other federal health care programs.
  • Funds must be used only to prevent, prepare for and respond to COVID-19 and can also reimburse the recipient for health care expenses or lost revenues attributable to COVID-19; we expect HHS to release additional guidance around this point. 
  • Funds received from multiple COVID-19 relief programs should be allocated to different expenses or losses; your practice should carefully track how funds are allocated.
  • Recipient is required to submit reports to the HHS secretary to ensure compliance; HHS indicates will clarify instruction in further program guidance. 
  • Recipients receiving more than $150,000 in total from all COVID-related payments and loans must submit report within 10 days of end of each quarter detailing use of funds.
  • Funds should not be used for executive pay.


Three tips from the CARES Act

  1. Start gathering the information you need to apply for Small Business Support loans, such as business owner financial information and debts.   
      • Read through COA’s guidance to determine if you're eligible for a Small Business loan (under 500 employees in most cases) and learn how to apply. If you’re eligible, submit your application as soon as possible. There will be a significant number of businesses applying for this assistance and it is our understanding they will be addressed on a first-come, first-served basis.
      • HHS has begun distributing $30 billion to eligible providers. Stay informed about the $100 billion emergency fund for health care entities. We are awaiting HHS guidance on whether this will apply to entities outside of hospitals, and will update this page with more information.
      • Track all COVID-19 related expenses in the meantime to get ahead, such as extra labor costs or shortages, protective gear or other supplies you have purchased as a result of COVID-19.. 
  1. Create cash flow projections to understand the effects that COVID-19 will have on your practice.
    • Update your forecasting models to include a 2 percent increase in Medicare payments. Starting May 1, 2020 through December 31, 2020, the 2 percent Medicare sequester will be temporarily lifted, with an extended sequestration period through 2030 after this temporary suspension.
    • Track and trend changes in your patient volumes, specifically treatments and visits, to inform your revenue forecasting and realign your staffing as needed. Consider  enabling remote patient care to stabilize your patient volumes.
    • Starting the week of March 16, we saw across the Flatiron network that 2,000 fewer patients per day were coming in for chemotherapy treatment compared to the week before (-16%) and overall about 8,000 fewer patients were coming to see the doctor (-22%).
  1. Review Flatiron’s more detailed telehealth guidance to learn how to set up and bill for remote visits.
    • The CARES Act has given HHS latitude to relax regulations around telehealth in light of COVID-19, and CMS has been releasing consistent updates since. See CMS’ most recent update from March 26, 2020.
    • Telehealth is now covered for patients with high-deductible health plans and health savings accounts prior to reaching their deductible. Update your teams, like your scheduling and eligibility staff, and patients accordingly.
    • Clinicians can provide remote patient monitoring services for new and established patients, regardless if treating COVID-19 or a chronic condition. If you are running a remote patient monitoring program, be sure to expand to include newly eligible patients.


CMS Expanded Advance Payment Program

Centers for Medicare & Medicaid Services (CMS) announced over the weekend that they will offer three months of payments upfront due to COVID-19, based on three months of historical Medicare reimbursement. CMS is seeking practice information based on requirements outlined per state specific Medicare Administrative Contractors.  In order to qualify for this benefit, a request form must be submitted to CMS that outlines provider information, amount requested and the reason for request. 

Additional details from CMS are found in the Accelerated and Advanced Payments Fact Sheet. 


MIPS flexibility

CMS recently announced that it would be granting exceptions to MIPS reporting requirements, as well as extending the 2019 data submission deadline from March 31, 2020 to April 30, 2020. 

See the CMS press release for more information on changes in quality reporting. 


COVID-19 FDA guidance on clinical trials 

The FDA recently released a draft guidance (“Conduct of Clinical Trials of Medical Products during the COVID-19 Pandemic”) of non-binding recommendations for proceeding with clinical trials during this time.

Clinical presentation 

Please see the CDC website for information on the evolving clinical picture of COVID-19. The impact of COVID-19 on immunocompromised patients is unclear, however the cancer population might be at higher risk. We recommend you refer to your state and local health departments for the latest information related to COVID-19 in your community.

The CDC recommends the following steps to prevent COVID-19:

  • Get the flu vaccine. 
  • Prevent the spread of illness through frequent handwashing, cover your cough or sneeze, and stay home if you are not feeling well. 
  • Avoid touching your face.
  • Avoid close contact with people who are sick.
  • Clean “high-touch” surfaces frequently (e.g., counters, doorknobs, phones, etc.). 

Evaluating and testing patients for COVID-19

Limited information is available to characterize the spectrum of clinical illness associated with COVID-19. Clinical criteria for considering COVID-19 testing have been developed based on what is known about COVID-19, and is subject to change as additional information is available. Clinicians should continue to work with their state and local health departments to coordinate testing. Please refer to the CDC website for additional information. 


Confirmation testing

Contact your local or state health department for more information about testing. 

Many practices are reviewing schedules in advance and converting office visits to telehealth appointments when appropriate. If your practice is interested in pursuing remote visits (telemedicine), the following configuration and workflow guidelines can help get you started, and contain links to payer and CMS billing guidance. This documentation is not intended to provide clinical, billing or coding recommendations for screening, diagnosis, or treatment of patients related to COVID-19.


Selecting a telehealth vendor

In order to get set up, you will need to choose a technology platform. As of March 17, 2020, CMS has adjusted guidelines for vendor requirements and recommendations. CMS’s guidelines do not require a specific vendor.

As of today, Flatiron Health is not recommending any specific telehealth vendor. Instead, our goal is to support practices with care delivery through your preferred telehealth provider or virtual communication channel. 


Documenting consent

As of March 17, 2020, Medicare outlines three different visit types; telehealth visits, virtual check-ins and e-visits. CMS or a third-party payer may require consent for these services. Please see CMS guidance as of March 17, 2020.


Place of service

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. 

Previously, the CMS guidance was to bill telehealth visits with POS 02 (telehealth). However, as of March 26, 2020, CMS updated their guidelines to allow practices to bill telehealth visits with POS 11 (office) and a 95 modifier (denotes a telehealth system that provides two-way, real time audiovisual conferencing between a patient in and the provider)  for Medicare claims in order to get reimbursed at the non-facility rate. 

Note, modifier requirements may change for commercial payers. Payers have been updating their guidance daily, so please check their direct guidance for details and your local payer websites.

Please see CMS guidance as of March 26, 2020.


Telemedicine CPT codes

The full list of codes can be found on the current CMS Fact Sheet and on Flatiron’s Help Center (accessible to OncoEMR users).


Billing information

Please review the links provided below for payer-specific guidelines on reimbursement for telehealth services as of the date of this email. As of March 20, 2020, some payers have moved to reimbursing for remote visits as though they happened in person. In many cases, payers are requiring either a place of service change (to 02), modifier addition, or both. 

Payers have been updating their guidance daily, so please check their direct guidance for details and your local payer websites. Blue Cross and Medicaid are making state-by-state decisions on this guidance as well, so we recommend checking your local intermediary. This guidance is subject to continual change and we will continue to monitor and provide updates. 

Insurance coverage options

If patients have recently lost their health insurance due to unemployment or reduced hours, they are eligible to enroll into a government or marketplace plan during a special enrollment period. Patients under these circumstances may have also been offered COBRA continuation coverage from their former employer. See HealthCare.gov for more information and resources to navigate these conversations with patients. 


COVID-19 patient support

Several patient assistance funds are pulling resources to help alleviate patient financial burdens associated with the current pandemic. TailorMed has compiled an ongoing list of available COVID-19 financial resources. 

Based on guidance from the APhA, many insurers are starting to waive or relax their insurance refill policies to avoid multiple trips to the pharmacy. For patients on oral medications, be sure to check if the number of doses filled at a one time can be increased. 

Patients may be struggling to find transportation to the clinic due to limited public transportation and the current pause on the Ride to Recovery program. There are a number of programs that may be a good alternative to ensure patients are able to make it to required in-person visits. For any practices who would like to establish this service for their patients, below are a few options that can limit the costs by defining a capped budget, with established guardrails on which rides get approved (based on cost, ride distance, etc.): 


Oncology financial assistance options

As deductibles reset, the first half of the year is always peak season for ensuring your patient population is financially covered. This is especially beneficial as patients and practices may be experiencing increased financial pressures. 

See our resources below to ensure you are maximizing benefits for your patients:

For additional guidance on these best practices, request a complementary consultation with our workflow experts.