COMMENTARY
How to Start Doing Telemedicine Now (In the COVID-19 Crisis)
The world has changed for telemedicine.
A couple of months ago, only a very small percentage of physicians used video visits. Some were not interested, while others were apprehensive about navigating the complicated regulatory landscape. Restrictive laws limited telemedicine use to rural areas, specific locations where the patient could be during the visit, and to patients located in states in which the physician has an active medical license.
But the COVID-19 crisis has changed everything. Through an emergency declaration made March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) will pay providers to care for Medicare beneficiaries for office, hospital, and other visits furnished via telehealth anywhere in the country—not just rural areas—and including a patient's place of residence. These services can also be provided in nursing homes, hospital outpatient departments, and other settings, and across state lines.
This goes into effect retroactively to March 6, 2020, and will extend through the COVID-19 public health emergency. The providers listed include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutritionists.
Other details include waivers or reduction in copays without any reduction in rates as they relate to in-person visits. These televisits do require real-time audio video interaction but are more flexible in that the video solution has an exception for Health Insurance Portability and Accountability Act (HIPAA) security rules requiring a business associate agreement (BAA) for technology.
That being said, it would be best practice to use a HIPAA-compliant video solution and work toward a BAA as quickly as is reasonable. While these new waivers are intended for patients with whom the provider has an existing relationship, the Department of Health and Human Services (HHS) has stated that it will not audit claims to ensure that a prior relationship exists.
To be able to start to provide these services quickly, HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against healthcare providers who serve patients in good faith through everyday communications technologies such Zoom, Doxy.me, Skype, and FaceTime, among others.
Here's How to Start Practicing Telemedicine
Physicians who don't want to deal with complicated technology have little to fear about telemedicine. This is not like implementing a new electronic health record (EHR) system, which has left many doctors feeling technology-averse owing to complicated integration into daily practice.
To participate in telemedicine on the most basic level, doctors only need a computer, a camera, a headset with microphone, and a secure platform that can manage telemedicine information. In fact, as mentioned, during this public health emergency, now doctors can perform telemedicine simply by using a smartphone and an app such as FaceTime or Skype.
Should You Use a Smartphone or a Computer?
The hardware component of telemedicine is becoming less critical. You need access to your EHR and access to video. This might be a single desktop or laptop with multiple screens or it might be two devices—one device for the EHR and one for video, such as a laptop, tablet, or mobile phone.
Many EHR systems, including Allscripts, Cerner, and Epic, provide basic telemedicine functions. However, platforms that are part of EHR systems are usually not as robust as self-standing telemedicine software purchased separately.
Self-standing platforms may provide such features as appointment scheduling; managing upcoming patients waiting their turn; e-prescribing; sharing lab and imaging results; and controlling devices on the patient's end, such as a remote camera, a digital stethoscope, and other scopes.
Vendors include Doxy.me, Zoom, and companies that also function as telemedicine providers and share their own platform technology, such as American Well, eVisit, Sherpaa, and Teladoc. Platforms range in cost from free for relatively simple solutions to more robust software that starts at around $200 a month.
The more expensive self-standing products provide extra services, such as 24/7 customer support. Vendors charge extra for a "white label" option, which puts the practice's logo on everything the patient sees.
The downside of self-standing platforms is that they may not integrate with your EHR system or your patient portal, meaning that patient records have to be managed separately, and patients may need to download a second app to make a connection.
In these cases, you can manage your end of the transmission by setting up two screens for the telemedicine visit: one screen for the telemedicine connection and the other to enter documentation into your EHR.
Some telemedicine systems can be integrated into certain EHR products, however. For example, the American Well platform integrates with Cerner.
Use of Basic Teleconferencing Is Now more Permissible
Some doctors like to use basic videoconferencing tools, such as Skype, FaceTime, and Google Hangouts, for telemedicine. These modalities are free and easy to use. Previously they did not fully comply with HIPAA, but those concerns are no longer an issue in this time of crisis.
Consider that the workflows you put in place to start seeing patients virtually during this public health emergency are ones that you will probably want to develop in such a way that you can continue them once the crisis is over. Some of these platforms, while easy to use, are not designed for healthcare and may reveal your personal email address or phone number.
HIPAA requires that patient data be secure from hacking when they are transferred. All three of these services encrypt their data, but other HIPAA compliance issues remain under dispute. Specifically, HIPAA directs that the vendor must monitor data that are stored during transfer.
To vouch for this and other HIPAA compliance requirements, vendors provide customers with a BAA, which takes responsibility for any breaches under their watch. Note that Skype, FaceTime, and Google Hangouts do not offer BAAs for basic service. They say that they don't need to because they merely act as a "conduit" of data and do not store data.
There are no known lawsuits challenging this contention, and many small practices still use these platforms or telemedicine. However, some insurers won't pay for telemedicine care that uses the non-BAA platforms, and some large organizations don't allow their doctors to use these platforms. Look for no-cost and low-cost alternatives that do issue BAAs available to physicians. Again, this issue is currently waived during the public health emergency, but keep in mind that after the crisis, you will probably want to keep doing telemedicine. Select a platform with which you will eventually be able to sign a BAA.
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.
Medicare Advantage Reimbursement
Medicare Advantage plans offer somewhat more robust coverage than traditional Medicare. These managed care plans, which now cover about one third of Medicare beneficiaries, can do this because they are run by commercial insurers contracted with Medicare.
Medicare Advantage plans embraced telemedicine quite recently. In 2018, 88% of Medicare Advantage plans offered telehealth supplemental benefits, a 77% increase over 2017, according to a recent analysis.
Even now, Medicare rules restrict Medicare Advantage plans' spending on telemedicine to a relatively small part of their budgets. But starting in plan year 2020, these plans will be able to use any part of their budget for telemedicine. With this change, Medicare Advantage plans will see telemedicine becoming a very common way for doctors to see patients.
Medicaid Reimbursement May Be Promising
State Medicaid programs are relying a great deal on telemedicine to reduce expenditures. In addition, Medicaid is often a better payer for telemedicine than Medicare or commercial insurance. This is because most Medicaid programs pay the same rates as face-to-face services.
Medicaid programs in virtually all states and the District of Columbia cover telemedicine, though some programs limit coverage to real-time audio-video. Only 11 Medicaid programs reimburse for asynchronous telemedicine, and 20 Medicaid programs cover remote patient monitoring, according to the Center for Connected Health Policy (CCHP).
Telemedicine delivered to a patient who is at home tends not to be reimbursed by Medicaid programs. Of the eight Medicaid programs reviewed in one study, none reimbursed for at-home service. Medicaid programs may also bar out-of-state medical licensing, require a preexisting relationship with the patient, and limit coverage to specific diagnostic codes.
Many Medicaid programs exclude some providers for low-income patients. Only 10 Medicaid programs cover telemedicine for both Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), whereas two programs cover just RHC and one covers just FQHC, according to the CCHP.
Reimbursement From Commercial Payers
Commercial reimbursement for telemedicine is very common, thanks to state laws that require private payers to cover at least some aspects of telemedicine. As of mid-2019, 40 states and Washington, DC, had so-called telemedicine parity laws.
"Parity" means "equality," but many of these states do not require commercial payments to be equal to those for face-to-face visits. Also, requirements are limited to real-time audio-video visits in many states and not to other modalities, and there can be other loopholes.
For example, some commercial insurers limit coverage to providers they have approved. This has been the stated policy of Anthem and Cigna, barring state laws to the contrary. In addition, Texas and Colorado have laws that bar health plans from limiting telehealth coverage to a specific vendor or technology.
Meanwhile, the American Medical Association (AMA) has been creating new Current Procedural Terminology (CPT) codes so that doctors and others can charge payers for more telehealth services—that is, once payers have agreed to pay for them. For example, in 2018, the AMA issued new CPT codes to carry out remote patient monitoring.
Conclusion
The technology for telemedicine is very simple: a secure telemedicine platform that creates the telemedicine connection. Many EHR systems provide a simple telemedicine platform. Independent vendors provide platforms that are usually more robust, but they may not integrate with your medical records.
To be secure, telemedicine data need to be encrypted, and it is a good idea to obtain a BAA from the vendor to comply with HIPAA. Patient verification software is not necessary if telemedicine is limited to existing patients using the practice's secure patient portal.
Regarding reimbursement, many Medicare Advantage plans, Medicaid programs, and commercial insurers provide extensive coverage for telemedicine. Traditional Medicare generally restricts use of telemedicine, but some of these restrictions have been loosened.
This article has been updated and adapted from Medscape's Physician Business Academy course Telemedicine: Can It Help Your Practice? Making Video Visits Successful for You and Your Patients
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