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

Financial Resources Available to Assist Surgeons

The American College of Surgeons (ACS) continues to monitor federal actions intended to ease the financial burden of the COVID-19 response. Below, Fellows can find information on current and previously available resources including eligibility and responsibilities for those who have accessed these programs. ACS staff will continue to periodically update this information to reflect new information as it becomes available.

In addition, the ACS Practice Protection Committee has recently released a helpful guide entitled “Economic Survival Strategies in the COVID World”. This document includes a set of key principles and a suggested process for Fellows to undertake to shore up personal and business finances. It includes spreadsheets and suggestions to consider based on which of three specific scenarios most accurately describes the Fellow’s current financial situation. This resource can be found here.

HHS to Renew Public Health Emergency

The Department of Health and Human Services (HHS) June 29 announced that it intends to extend the COVID-19 public health emergency (PHE) declaration for 90 days to July 25.

Several payment policies and regulatory adjustments are linked to the PHE. Examples of policies linked to the PHE are the Medicare inpatient 20 percent add-on payment for COVID-19 patients, increased federal Medicaid matching rates, requirements that insurers cover COVID-19 testing without cost-sharing, and waivers of telehealth restrictions.

The Medicare Accelerated and Advance Payments Program

Surgeons who received Medicare Accelerated or Advanced Payments prior to the suspension of these offerings on April 26, should be aware of, and making plans for the repayment requirements of these advances. Starting 120 days from issuance of the advance, all billed Medicare charges will be automatically withheld and designated toward paying back the advance. All amounts must be paid back within 210 days of the date of issuance or they will incur interest.

CMS has noted 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 doctors, non-physician practitioners and durable medical equipment suppliers, CMS approved almost 24,000 applications advancing $40.4 billion in payments.”

The ACS is closely monitoring the situation and will provide an update to Fellows should CMS decide to reinstate the program or if ACS-supported legislative changes are enacted to ease the repayment timeline or reduce interest owed on balances remaining after 210 days.

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. Reports from the field indicate the application is somewhat complex and cumbersome. Accordingly, Fellows should consider enlisting the services of their professional tax advisor for the application process.

Since inception, and despite a rocky rollout, the PPP has approved more than $510 billion in loans and it has been recently reported that approximately $120 billion remains available. If you are considering applying for the PPP, you are encouraged to do so as soon as possible as there are no firm indications that the program will be replenished when it is expended.

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

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

On May 15, the SBA and the Treasury Department 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 loan forgiveness.

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 application and instructions.

PPP Loan Forgiveness

The President signed the Paycheck Protection Program (PPP) Flexibility Act, which will ease restrictions on the entirety of the $670 billion in loans intended to avert mass layoffs during the pandemic. Provisions of the law will relax rules for the PPP giving borrowers more time to spend funds received and to use those funds for a broader set of expenses while still qualifying to have all or a portion of the loan forgiven. Specifically, the PPP Flexibility Act does the following:

  • Extends the period for PPP loans from June 30, 2020, to December 31, 2020.
  • Extends the period for loan forgiveness to the earlier of either 24 weeks after the loan date or December 31, 2020.
  • Extends the rehire exemption date to December 31, 2020, from the previous date of June 30, 2020.
  • Decreases the forgiveness amount attributable to payroll costs from 75 percent to at least 60 percent and allows up to 40 percent to be attributable to non-payroll costs.

On June 17 the SBA and the U.S. Treasury Department announced a revised loan forgiveness application for the PPP. The intent of the changes is to significantly reduce the amount of paperwork required, making the application process more user friendly in accordance with the provisions of the PPP Flexibility Act.

The changes included apply to both the full forgiveness application, (reducing the total number of pages by more than half), and a newly announced three-page EZ application that requires less documentation and fewer calculations. The EZ form applies to borrowers that meet one or more of the following criteria:

  • Are self-employed and have no employees; OR
  • Did not reduce the salaries or wages of their employees by more than 25 percent, and did not reduce the number or hours of their employees; OR
  • Experienced reductions in business activity as a result of health directives related to COVID-19 and did not reduce the salaries or wages of their employees by more than 25 percent.

Both applications give borrowers the option of using the original eight-week covered period if the loan was made before June 5, 2020, or an extended 24-week covered period in accordance with changes made by the PPP Flexibility Act.

Read the SBA press release announcement.

The loan forgiveness application forms can be found here:

Note: The SBA and Treasury have announced that they plan to release information about borrowers who have participated in the PPP in the coming weeks. Plans are to publicly disclose the names of recipients, the amounts they received (broken into ranges of dollar amounts received), and demographic data on the loans exceeding $150,000. It should be noted that personal identification information will be withheld. 

Recipients of PPP loans should note that those business expenses forgiven under PPP loan forgiveness provisions are not business expenses for tax purposes. While the PPP loan program has already noted that amounts forgiven would not count as taxable income to the borrower, the question remained unclear as to the impact on business expense deductions. However, the IRS recently reiterated its guidance that business expenses paid for through PPP loans which would otherwise qualify as tax deductions cannot be ducted if they are paid for using PPP funds which are later forgiven. The ACS continues to urge Fellows who received PPP loans or other assistance to consult with their accountant or attorney.

Economic Injury Disaster Loans (EIDL)

On June 15, the SBA announced that it would begin taking and processing new applications for the EIDL. The EIDL is a two-part program that allows for rapid advances of up to $10,000 (based on the number of employees) as well as loans with favorable terms.  It is recommended that interested parties apply as soon as possible, as funds for this program are limited.  

It had been previously reported on May 7 that the SBA would resume processing EIDL applications submitted before April 15, but would limit future applications to agricultural businesses. The new announcement seems to reopen the program to most businesses with fewer than 500 employees as well as sole proprietorships. There appears to be some uncertainty as to the maximum loan amount moving forward. That amount had been $2 million but was reportedly reduced to $150,000, although this information has not been posted on the SBA website. ACS staff is unaware of any plans to add additional funding to this program. Learn more about EIDL here.

Relief Funds from the Public Health and Social Services Emergency Fund

UPDATE: CMS has announced an additional $15 billion distribution from the CARES Act Provider Relief fund. This distribution is the third available to surgeons to date and is specifically targeted at those who have seen Medicaid and CHIP (Children’s Health Insurance Program) populations in 2018, 2019, and/or 2020 and who have not received funds from earlier distributions. Payments are intended to be at least 2 percent of reported gross patient care revenue. To apply for funding, eligible surgeons should visit this portal. Instructions are available here and the application form here.

This $15 billion allotment follows two previous disbursements totaling $50 billion that were distributed beginning on April 10 and April 24 respectively. In an announcement last month, HHS set June 3, as the deadline to take the steps necessary to receive additional funds as part of the prior distributions.

HHS continues to update the FAQs and the Terms & Conditions for these payments frequently as it has adapted to the challenges of implementation and announced additional funding opportunities and requirements. We recommend visiting the CARES Act Provider Relief Fund website for the most up-to-date information. Recently, attestation through the online portal has been extended to 90 days after receipt of payment. Originally, physicians and hospitals that received funds were given 30 days to make this attestation. Please note: That failure to return amounts received within 90 days will be viewed as acceptance of the Terms & Conditions.

ACS staff have received multiple reports from Fellows who appear to meet all criteria but ave not received funds from either program. Surgeons who believe they are eligible but have not received 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 TIN responsible for billing for your services and will not necessarily be passed along to you. Also note that only one application per TIN is accepted. The ACS encourages surgeons concerned about how payments are being allocated to inquire and discuss this with their employer. It may also be beneficial to have an attorney review the terms of your contract to see if situations like this are addressed.

Commercial Insurance Coverage for Telehealth Services

Telehealth and other virtual services are critical to reducing exposure to the COVID-19 virus and ensuring continuity of care 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.

Economic Survival Strategies in the COVID World

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 the ACS Practice Protection Committee has developed to assist Fellows maintain financial viability. The Practice Protection Committee has recently released its work in this area in the form of a resource document entitled Economic Survival Strategies in the COVID World. The webinar discussing the document can be found here:

The Practice Protection Committee would emphasize the following key points found in the document:

  • Because numerous tax provisions are available to assist in freeing capital, Fellows are encouraged to make an appointment with your tax professional and or financial advisor and seek their advice.
  • Consider speaking to your medical liability 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.
  • If funds have been received from the Medicare Advance Payment Program or SBA loans (PPP or EIDL) treat those funds as general receipts and carefully document where they are expended.
  • For those applying for a loan through the PPP, engagement of your tax professional has been found to be extremely helpful. The application is complex, and true benefit is obtained by seeking professional assistance.
  • For those who receive a loan through the PPP, keeping accurate records on expenses that can be counted toward the loan forgiveness provisions is imperative. Those expenses include payroll, mortgage interest, rent and utilities. Up to the full loan amount may be forgiven if the proceeds are used to keep staff on payroll and proper documentation is maintained.
  • To preserve your personal assets and retirement savings, avoid loans that use those as collateral.
  • Reassess your personal budget via the Excel spreadsheet exercise in the conomic Survival Strategies in the COVID World document and make appropriate adjustments.
  • Develop a cash account and work toward accruing a three-month personal expense cushion.
  • Do not miss your life insurance or disability insurance premium payments.
  • Look for payment 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 ACS Employed Surgeon handbook and the ACS Private Practice Surgeon handbook are also great resources.