Policy Issues in Policy Issues in TelehealthTelehealth

Catherine V. PalmerCatherine V. Palmer

University of PittsburghUniversity of Pittsburgh

Where is Dave Fabry?Where is Dave Fabry?

Policy BarriersPolicy Barriers

ReimbursementReimbursement State Licensure and regulation State Licensure and regulation

(cross-border care)(cross-border care) Liability concernsLiability concerns PrivacyPrivacy

ReimbursementReimbursement

Look to CMS to set the tone for Look to CMS to set the tone for reimbursementreimbursement

www.cms.hhs.gov/telehealth/www.cms.hhs.gov/telehealth/ Telemedicine is the use of medical Telemedicine is the use of medical

information exchanged via electronic information exchanged via electronic communication to improve a patient’s communication to improve a patient’s health, use of interactive health, use of interactive telecommunications equipment, two-way, telecommunications equipment, two-way, real time. A cost-effective alternative to real time. A cost-effective alternative to face-to-face care. (42 CFR 410.78)face-to-face care. (42 CFR 410.78)

AsynchronousAsynchronous

Does not meet the definition of Does not meet the definition of telemedicine set forth by CMStelemedicine set forth by CMS

ReimbursementReimbursement

CMS: reimbursed for medically CMS: reimbursed for medically covered services including those with covered services including those with telemedicine applications…must telemedicine applications…must satisfy federal requirements of satisfy federal requirements of efficiency, economy, and quality of efficiency, economy, and quality of carecare

Partial Medicare reimbursement for Partial Medicare reimbursement for telehealth services was authorized in telehealth services was authorized in the Balanced Budget Act of 1997.the Balanced Budget Act of 1997.

Benefits Improvement and Protection Benefits Improvement and Protection Act of 2000 removed some prior Act of 2000 removed some prior constraints yet maintained constraints yet maintained substantial limitations to geographic substantial limitations to geographic location, originating sites, and location, originating sites, and eligible telehealth serviceseligible telehealth services

Unlike Medicare, Medicaid programs Unlike Medicare, Medicaid programs often provide reimbursement for often provide reimbursement for health care-related transportation health care-related transportation costs costs

Federal Medicaid Statute (Title XIX of Federal Medicaid Statute (Title XIX of Social Security Act) does not Social Security Act) does not recognize telemedicine as a distinct recognize telemedicine as a distinct service. service.

States may choose to cover these States may choose to cover these services.services.

27 states offer some reimbursement 27 states offer some reimbursement for telehealth servicesfor telehealth services

Examples of CoverageExamples of Coverage

CPT 98966 Health Care Professional CPT 98966 Health Care Professional Phone call 5-10 minutes Phone call 5-10 minutes

(not being reimbursed)(not being reimbursed)

CPT 99441 Phone E&M by Physician CPT 99441 Phone E&M by Physician 5-10 minutes 5-10 minutes

(not being reimbursed)(not being reimbursed)

CPT 99444 online E&M by physician CPT 99444 online E&M by physician (not being reimbursed)(not being reimbursed)

CPT 93293 Pace maker eval by CPT 93293 Pace maker eval by phone phone

(Medicare = $56.98)(Medicare = $56.98)

DefinitionsDefinitions

Originating or Spoke SiteOriginating or Spoke Site Location of the PatientLocation of the Patient

Distant of Hub SiteDistant of Hub Site Where the health care provider is at the Where the health care provider is at the

time of the servicetime of the service TelepresenterTelepresenter

Person needed to facilitate the servicePerson needed to facilitate the service

Facility fee to the originating siteFacility fee to the originating site HCPCS Q3014 (telehealth originated HCPCS Q3014 (telehealth originated

site)site) Medicare $23.35; MA $15.72Medicare $23.35; MA $15.72

If they just have to set up the patient If they just have to set up the patient or stay with the patient the whole or stay with the patient the whole timetime

Technical support, transmission Technical support, transmission charges, equipmentcharges, equipment HCPCS T1014 (telehealth transmission HCPCS T1014 (telehealth transmission

per minute)per minute) Unclear what the reimbursement isUnclear what the reimbursement is

Physician fee at the distant sitePhysician fee at the distant site Bill as professional services (CPT code)Bill as professional services (CPT code)

Modifier “GT” – via interactive audio Modifier “GT” – via interactive audio and video telecommunication and video telecommunication systems allowed with code 99201-systems allowed with code 99201-99205 (office or other outpatient 99205 (office or other outpatient services) and 99241-99245 (Office or services) and 99241-99245 (Office or Other Outpatient Consultations) Other Outpatient Consultations)

Medicare does not recognize this Medicare does not recognize this modifier in PAmodifier in PA

Medicare Conditions of Provision Medicare Conditions of Provision (limit some telehealth practices)(limit some telehealth practices)

Face-to-face visit in long-term care Face-to-face visit in long-term care facilities on a regular schedule facilities on a regular schedule (telemedicine as a supplement)(telemedicine as a supplement)

Home health requires some face-to-Home health requires some face-to-face visits (telemedicine as a face visits (telemedicine as a supplement)supplement)

Audiology ExamplesAudiology Examples

LACELACE CPT 92626 (evaluation of auditory status CPT 92626 (evaluation of auditory status

– first hour)– first hour) Reimbursed at about $76.41 ($91.61)Reimbursed at about $76.41 ($91.61) Assessment in the clinic or as part of the Assessment in the clinic or as part of the

LACE program?LACE program? What would an audit show?What would an audit show?

Remote CI MappingRemote CI Mapping

DoDDoD Private SectorPrivate Sector

LicensureLicensure

Professional services take place where the Professional services take place where the patient is locatedpatient is located

National Council of State Boards of National Council of State Boards of Examiners in SLP and Audiology indicates Examiners in SLP and Audiology indicates that the audiologist should be licensed in the that the audiologist should be licensed in the state in which the consumer is receiving the state in which the consumer is receiving the service.service.

In 2003, 17 states adopted an Interstate In 2003, 17 states adopted an Interstate Compact for Licensed Nursing Compact for Licensed Nursing Allows nurses licensed in their home state to Allows nurses licensed in their home state to

practice in any other party statepractice in any other party state

States’ barriers are a restraint on States’ barriers are a restraint on trade in violation of the Commerce trade in violation of the Commerce Clause of the United States Clause of the United States Constitution.Constitution.

There is a strong legal presumption There is a strong legal presumption against federal preemption of state against federal preemption of state licensure lawslicensure laws

Health care professional to health Health care professional to health care professional may not require a care professional may not require a local licenselocal license

LiabilityLiability

www.telehealthlawenter.org/?c=127www.telehealthlawenter.org/?c=1278a=18618a=1861

Center for Telemedicine LawCenter for Telemedicine Law ……because uncertainty about legal and because uncertainty about legal and

regulatory issues often serves as a regulatory issues often serves as a deterant to the maximum utilization of deterant to the maximum utilization of telemedicine…telemedicine…

MalpracticeMalpractice

Like professional licensing, Like professional licensing, malpractice insurance requires a malpractice insurance requires a provider to be licensed in each state provider to be licensed in each state in which they deliver services.in which they deliver services.

Subject to the jurisdiction of where Subject to the jurisdiction of where the patient is locatedthe patient is located

Internal RegulationsInternal Regulations

When a manufacturer can take over When a manufacturer can take over your computer in order to assist in your computer in order to assist in patient care or to train personnel…patient care or to train personnel…

DIACAPDIACAP DoD Information Assurance Certification DoD Information Assurance Certification

and Accreditation Processand Accreditation Process

External Regulations: FDAExternal Regulations: FDA

Does remote mapping of a cochlear Does remote mapping of a cochlear implant have to be approved by the implant have to be approved by the FDA?FDA?

Is this a new use?Is this a new use? CI companies do not provide direct CI companies do not provide direct

support from a customer support linesupport from a customer support line What about remote hearing aid What about remote hearing aid

programming?programming?

ConsentConsent

Recommend Consent to receive care Recommend Consent to receive care through telehealth delivery systemthrough telehealth delivery system

Consent implies choiceConsent implies choice

Disclaimers/ConsentsDisclaimers/Consents

Fax disclaimer Fax disclaimer Email disclaimerEmail disclaimer Email Consent (2 pages)Email Consent (2 pages)

E-mail risks and your responsibilityE-mail risks and your responsibility Conditions for the use of e-mailConditions for the use of e-mail InstructionsInstructions Patient Acknowledgment and agreementPatient Acknowledgment and agreement

Support PersonnelSupport Personnel

Who is responsible for training?Who is responsible for training? Are there safety issues?Are there safety issues? Who pays these people?Who pays these people?

PrivacyPrivacy

Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPPA)Accountability Act (HIPPA)

Privacy and confidentiality of Privacy and confidentiality of protected health information (PHI)protected health information (PHI)

Other barriers/challenge/solutionsOther barriers/challenge/solutions

Technology…Technology…