Telemedicine offers convenience for patients and providers to improve patient health, but the field still has many rules and restrictions blocking its optimal potential, according to Jesse Overbay, JD, who reviewed the current pros/cons of telehealth and guidelines to be aware of before starting a practice.
“[Telemedicine] is really exciting to me as an up-and-coming thing, but it just still feels very up and coming,” said Overbay, Senior Management Consultant and General Counsel with DoctorsManagement, LLC, during his talk “Telehealth in Rheumatology Practice” Saturday as part of the Premeeting Course Practice Matters: Navigate A Path to Success! “It still feels like there’s not a great way for our practices, especially our specialty practices, to take advantage of telehealth. It still currently works best in academic medical centers, hospitals, and universities.”
In order to bill and receive payment for telemedicine for original Medicare patients, the patients must meet several requirements, including being in a county outside of a Metropolitan Statistical Area or in a rural health professional shortage area in a rural census tract and in an authorized originating site, such as a physician and practitioner office, hospital, or rural health clinic. For Medicare, patients cannot be “seen” in their home unless they have end-stage renal disease getting home dialysis. If a patient meets the location and site requirements, being seen in real time is the next requirement. Medicare doesn’t allow the store-and-forward method of telehealth.
Starting in 2019, Medicare started paying for virtual check-ins (G2012) or “brief communication technology-based services,” basically phone triaging or pre-screening patient problems, Overbay noted. It doesn’t reimburse much, he said, but it at least allows providers to see a patient before or after coming to the office, to answer some questions, and to potentially refill medicine. However, if the check-in is related to a visit from the past week or results in the next 24 hours, it will be bundled into a typical office code. Overbay briefly explained that providers need to learn the codes for telehealth, which are the same as a normal patient visit but with modifiers.
Coming in 2020, Medicare Advantage should be able to take advantage of patients using telehealth from home, unlike original Medicare, which is a big change.
“The hope is that if Medicare Advantage is allowing that in 2020, by 2021 Medicare will also follow suit and start allowing the originating site to be homes for patients, which would make it much easier for our providers to take advantage of telehealth services,” Overbay said, noting right now only 14 states allow it for Medicaid.
Medicaid is actually ahead of Medicare in many aspects of telehealth, he noted, reviewing stats provided by Center for Connected Health Policy. Fifty states and Washington, DC, provide reimbursement for some form of live video in Medicaid fee-for-service telehealth, 21 state Medicaid programs provide reimbursement for remote patient monitoring, and 39 states and DC currently have a law that governs private payer telehealth reimbursement policy.
“Some states do mandate some sort of reimbursement, some states mandate reimbursement on the same level as in-person care, that’s pretty rare. … But that’s ultimately the hope. That’s the end goal – that we get to a place where telehealth is easily accessible for everyone and that it’s reimbursed on a level that’s at least close to in-person visits.”
Informed consent is another hurdle. Although Medicare does not require that informed consent be obtained from a patient prior to a telehealth-delivered service, many states require it to be obtained within their Medicaid program.
Overbay also noted that telemedicine in rheumatology can be tricky because of the nature of the complex diseases and patient visits, noting it’s not like seeing a patient with a common cold in an urgent care visit.
“The patient and the provider have to understand what the patient is going through and the possible diagnosis and consequences of diagnosing the patient,” he said.
Most commonly seen tele-rheumatology patients are those who have been diagnosed with arthritis and can be monitored over time.
“In the telemed visit, the rheumatologist is at his office or at home or able to log on to the screen and is able to talk with the patient the entire visit,” he said. “The doctor would perform the history, direct the physical exam in real time, discuss the diagnosis, review in great detail the treatment plan and go through the medications, talk to the patient about how the medication is working, and give the patient some information about the disease and medication. The big key here is training a clinical facilitator. The limiting factor in rheumatology, in my opinion, is having someone on the other end with the patient who at least has enough experience and knowledge in rheumatology to help the patient and talk to the doctor on the other end about what the patient is experiencing and what the symptoms are, and what needs to be done.”
To start a telehealth practice, it’s important to remember these various guidelines, he said, and provided a checklist to consult while setting it up. On that list included establishing a business plan, establishing scheduling parameters, choosing a HIPPA-compliant software, and making sure the equipment is available.