COMMENTARY

How to Start Doing Telemedicine Now (In the COVID-19 Crisis)

Neal Sikka, MD

Disclosures

March 25, 2020

Important Technology Issues For Your Televisit

Verifying the patient's identity. This is an issue for telemedicine companies, who have never met the patient, but it is not an issue if you are dealing with current patients who access telemedicine through a secure patient portal. If patients are unknown, they can be assigned a username and password to access your telemedicine site.

Internet speed. Your Internet connection must be fast enough to handle video visits and ensure that your sessions won't be interrupted. A connection that is shared with others can reduce upload and download speeds and cause interruptions at busy times. So purchasing a business-grade service is advisable.

Store-and-forward interactions. This method does not require video or a real-time interaction between physician and patient. Patients access the service through the practice's patient portal. The patient then answers prepared questions, adds comments, and may even send images. The doctor then reviews the patient's transmission, makes a diagnosis, and sends it to the patient.

Point-of-care devices for the patient. If you designate a health facility for patients to use for telemedicine, you can furnish it with pan-tilt-zoom video cameras and special devices, such as a remote blood pressure monitor, stethoscope, and otoscope. If patients are in their homes, they can buy an inexpensive blood pressure monitor to use in the telemedicine visit. You'll need to discuss this with them before the online visit.

Remote patient monitoring. Data from pulmonary, cardiac, diabetes, and other measurement devices in the patient's home can be synched to software platforms with algorithms that alert your practice for certain events or findings.

Reimbursement From Medicare

Traditional Medicare still pays for synchronous visits only—real-time video sessions. In Hawaii and Alaska, though, Medicare additionally pays for asynchronous telemedicine—text and photos—under a demonstration program.

Medicare makes two payments: a Part B payment to the doctor making the telemedicine visit, and a facility fee to the healthcare site hosting the patient at the other end (if the patient is connecting from a healthcare site).

Because of Medicare's prior restrictions on use, fewer than 1% of beneficiaries in traditional Medicare have been using telemedicine each year, but Medicare has been broadening coverage. Physicians are now able to "see" patients without a face-to-face visit. Medicare also reimburses for telestroke services, regardless of where a patient receives treatment. Telestroke services involve using mobile units that provide telemedicine with doctors at a distant hospital so that stroke victims get initial treatment as soon as possible.

In January 2019, Medicare added a reimbursement that is available to all beneficiaries, called "virtual check-ins."

Virtual check-ins are made through telemedicine and even by telephone. They are available to patients anywhere in the country, not just in rural areas, and patients can be in their homes.

There is no limit on the number of virtual check-ins that a patient can make, but the visits cannot be related to services that were provided within the past 7 days or 24 hours afterwards.

Unfortunately, virtual check-ins provide a relatively low reimbursement, quoted at $14 per visit. That's because the visit is supposed to be just a quick check-in with the patient, lasting only 5-10 minutes.

In addition, Medicare started covering remote patient monitoring (RPM) in 2015, and has been very slowly improving that coverage since then.

This coverage started with new payments for chronic care management for patients with two or more life-threatening chronic conditions. However, few physicians billed for these services because the payment was relatively low, the work had to done by the physicians or other qualified providers, and filing for reimbursement was complicated.

Recently, Medicare has tried to meet some of these concerns. For example, it has established new payment codes that allow practices to bill for setting up RPM services, and Medicare will now pay for clinical staff to monitor patient-reported data.

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