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Telehealth

What is the difference between telehealth and telemedicine?

Many organizations use the terms interchangeably, such as the American Telemedicine Association. According to the National Consortium of Telehealth Resource Centers, telehealth refers to “the use of electronic information and telecommunications technologies to support distance clinical healthcare, patient and professional health-related education, public health, and health administration.” Telemedicine typically refers to the practice of medicine using technology to deliver care at a distance (i.e., remote clinical services). Therefore, telemedicine is a subset of telehealth.

Pennsylvania recently had a telemedicine bill vetoed, and still no regulation or guidelines govern the practice across the state. At this time, Pennsylvania supports telehealth through the PA Medicaid Program, which defines telemedicine as “the delivery of compensable behavioral health services at a distance using real-time, two-way interactive audio-video transmission. Telehealth does not include telephone conversations, electronic mail messaging, or facsimile (fax) transmissions.”

 

What type of telehealth modality will your practice use?

  • Live (synchronous) videoconferencing:  This involves a two-way (real-time) audiovisual link between a patient and/or caregiver and a provider using audiovisual telecommunications technology such as a computer with conferencing software. This is a live discussion and is the most commonly used and easiest to implement.
  • Store-and-forward (asynchronous) technology (SFT):  This mode uses videoconferencing and transmits recorded health history in the form of videos and digital images through a secure, electronic communications system. SFT is not a real-time visit; it communicates information after it has been collected. Generally, providers record or capture diagnostic information (like x-rays, CT scans, EEG printouts) at the patient’s care site. Then they send them to a specialist in another location.
  • Remote patient monitoring. This mode of telehealth uses electronic tools, such as Holter monitors, to record personal health and medical data in one location for review by a provider in another location, usually at a different time.
  • Communication-based technology, audio-only. This is considered telehealth under Medicare Part B during COVID-19. This may be the case for other payers as well. An example is a phone call between a patient and a provider.

 

Where must a healthcare professional be licensed to practice telehealth (prior to covid-19)?

Pennsylvania’s Medicaid program only speaks to licensure as related to telepsychiatry at this time. It states that when services are provided from a location in another state, the psychiatrist/ psychologist must be licensed in Pennsylvania.

No license exemption exists for physician-to-physician or out-of-state consultations. Additionally, Pennsylvania does issue extraterritorial telemedicine licenses to physicians residing or practicing in a neighboring state based on regional availability of services and policies of neighboring states.

During the March 2020 pandemic in the U.S., these licensing requirements have been significantly loosened. However, they will likely revert to pre-pandemic stringency when the declared state of emergency ends. This site provides updated state-by-state requirements: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

We recommend that you always check with the medical board in the state where a patient resides for information on its current licensing requirements.

Since Curi does not provide coverage in all 50 states, you should contact your underwriter or insurance broker/agent and let him or her know in which states you intend to practice.

Note that licensure requirements are in force among many healthcare disciplines, including medicine and nursing. Providers should consult the websites of their respective boards of medicine or nursing for further clarification and requirements.

 

What is teleradiology, and what are the licensure requirements?

Teleradiology allows radiologists to provide services in a different location than their patients. It can improve access to care because experts can be available 24/7. For instance, a patient living in a rural area can receive care in the evening from a sub-specialist such as a neuroradiologist or pediatric radiologist, when normally these experts would only be found in large urban areas during daytime hours.

To practice teleradiology, radiologists must be credentialed with a healthcare entity as well as properly licensed. Per the American College of Radiology (ACR), the policy is to require physicians interpreting images in other states to be licensed in both the state where the image was generated as well as the state where the interpretation takes place.

There can be variation state-by-state, to verify details for your state access this ACR link for (pre-COVID-19) teleradiology guidelines: https://www.acr.org/Advocacy-and-Economics/State-Issues/Licensure-Requirements

ACR has also issued a statement related to COVID-19 on teleradiology: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Teleradiology-during-the-COVID-19-Pandemic

 

What steps need to take place prior to starting the patient visit?

Before telemedicine services are delivered, the patient must have access to the licensure and board certification qualifications of the healthcare practitioners providing the care. Patients receiving telemedicine services by APPs must also have access to the names of the delegating physicians.

Ask the patient where he or she is located at the beginning of each visit. This identification step is important for a few reasons, including that for proper licensure, the provider must be licensed in the state where the patient is receiving the service. Second, you as the provider must have an emergency plan if the patient have a medical emergency during the virtual session. You need the patient’s physical address. Remember 911 is a local call, so a physical address is important. Knowing a patient’s location will allow you to call for emergency assistance if necessary and direct them to the exact patient location.

 

What other items should we have in place for telehealth in our practice?

Every practice should incorporate a telehealth policy into its specific practice. See Curi’s sample Telehealth Practice Policy. This policy will help your practice organize many items, such as how the clinical workflow will take place, a list of qualifying patient care types appropriate for telehealth, training for all staff (both clinical and non-clinical), and quality improvement. Procedures should be in place regarding how all telehealth encounters will take place within your practice.

 

With so many vendor options, how do we identify the best one for our practice?

Identifying a vendor for your practice is one of the biggest decisions you may make. This step will require due diligence and vetting including checking for compatibility of vendor products with your existing EMR. Contact your current EMR vendor and ask what type of modules they may have already developed for telehealth. If they do not have any, then they may be able to make recommendations on telehealth vendors who do.

Consider the reputation of the vendor and seek legal review of the contract terms. The vendor must sign your Business Associate Agreement (BAA) (view Curi’s BAA here). Access our vendor selection guidance for more information on this topic.

 

What is the consent requirement for telehealth visits?

Not all state medical boards require a telehealth informed consent, so you must determine whether the patient’s state of residence requires one. At this time, only Pennsylvania’s Medicaid program requires providers to obtain a patient’s consent before a telehealth visit. As a best practice, Curi also recommends using a telehealth consent form prior to any telehealth encounter. Curi’s consent form can be accessed here.

Prior to the visit, send the consent to the patient electronically—either through the patient portal or email. The patient must send back an electronic confirmation that he or she has read and agrees with the consent. Place all electronic communications in the patient’s medical record.

If the patient is unable to send back an electronic confirmation, then after reviewing the consent with the patient, document that the consent was reviewed with the patient, that the patient was unable to respond electronically, and that, as a result, verbal consent was obtained. If possible, include a second witness to the verbal consent conversation.

If obtaining consent by telephone, have two employees witness the verbal consent conversation and document the same (who witnessed, the date and time, and substance of the consent) in the patient’s record. To avoid sharing phones, use either a speakerphone or two separate phones. The consent form can be valid for up to one year.

 

Are HIPAA requirements the same under telehealth?

HIPAA rules have not changed because of the pandemic; however, the Office of Civil Rights (OCR) has altered its enforcement of privacy requirements during telehealth encounters. In the OCR’s initial announcement, it provided a list of vendors that use HIPAA-compliant video products and who agreed to enter into BAAs with each practice using their products:

  • Skype for Business / Microsoft Teams
  • Updox
  • VSee
  • Zoom for Healthcare
  • Doxy.me
  • Google G Suite Hangouts Meet
  • Cisco Webex Meetings / Webex Teams
  • Amazon Chime
  • GoToMeeting
  • Spruce Healthcare Messenger

Note: Neither the OCR nor Curi endorses these vendors, and this information is intended for educational purposes only. If you have introduced new technology, make sure you conduct a HIPAA security risk assessment. You can download the most recent assessment from HealthIT.gov: https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool.

To ensure privacy and security during the visit:

  • Confirm the patient’s identity and have the patient display a picture ID next to his or her face. As a provider, you can also show your identification (or work badge).
  • Inform the patient if another staff member is in the room with you during the virtual visit. In turn, ask the patient if he or she is alone or if anyone can hear the conversation.

 

What are the key components of documentation after a telehealth visit?

The telemedicine provider must have the patient’s medical history available at the time of the visit. The provider must maintain patient records of the encounter and must document the evaluation and treatment. If there is a referring practitioner, the telemedicine provider must send a copy of this record to the referring practitioner.

The AMA advises that the patient’s medical history must be collected as part of providing any telemedicine service. The service must be properly documented and should include a visit summary to be given to the patient.

With the standard of care being the same for an office setting and a virtual setting; the same is true for documentation—follow your usual protocol. Along with your clinical impression, include complete details of the visit (avoid using autofill since it will populate verbiage as if the patient was in the office). Providers should also document the following:

  • the patient’s request for telehealth services,
  • the patient’s consent,
  • the patient and provider locations, and
  • the duration of the visit (which may be needed for billing).

The American Medical Association (AMA) along with the American Health Information Management Association (AHIMA) have created coding resources for practices.

 

What are some additional suggestions you can offer our practice?

  1. Consider appointing a superuser who will assist with continuing training and support. This role is ideal for someone who has advanced knowledge of both the technology and workflow. This individual should be comfortable fielding questions from users, providers, and non-clinical staff, as necessary.
  2. Remember to address any technology challenges before any virtual session. These may include:
    • unclear patient instructions,
    • user (patient or provider) error,
    • inadequate bandwidth/Internet upload and download speed (recommended speed is 1.5Mbps*), and
    • technical support (will the superuser be able to assist, or will you need vendor support).

View Curi’s guidance on common administrative telehealth concerns here.

*The National Telehealth Technology Assessment Resource Center is a useful resource for technology recommendations.

 

We are currently offering telehealth services. What type of information should we have ready when we contact our Curi Underwriter, insurance agent, or broker?

Our Underwriting Department will request the following information from your practice if you are offering telehealth. There may be additional questions post-pandemic.

  1. Are you using telehealth services to deliver care to your patients today?
  2. Were you using telehealth prior to COVID-19?
  3. What percentage of your patient visits are via telehealth?
  4. Who is conducting the telehealth visits?  Physicians (%)? APPs (%)?
  5. Which vendor or applications are you using for telehealth?
  6. Are you using telehealth-specific consent forms?
  7. Post-pandemic; will you continue to offer telehealth services to your patients?
    • If yes, do you expect to continue with your existing vendor?
    • If, no, which vendor do you plan to use (or are considering)?
  8. Post-pandemic, do you plan to expand your practice using telehealth in other states? If so, which state(s)?

Curi’s Medical Professional Liability policy does not provide coverage for medical care provided without proper licensure, so it is critical to ensure your practice is appropriately licensed in the states in which your telehealth patients reside.

 

Can you provide any guidance on best practices for patient workflow when using telehealth in our practice?

Several models outline workflow in different practice settings:

 

Which metrics should we measure for our telehealth program?

A practice can choose many metrics to measure the success of its program, including:

  • staff satisfaction,
  • patient satisfaction (via an online survey tool post-encounter),
  • patient compliance with treatment plans,
  • efficient and timely care,
  • utilization rates,
  • patient engagement with technology,
  • population management outcomes, and
  • consultation times.

If using a Triple Aim framework performance improvement approach, then consider how your telehealth program will improve the patient experience (access and engagement) while reducing (controlling) costs and improving quality in an identified population health.

 

We have heard about telehealth etiquette. How could we incorporate this into our program and improve patient satisfaction?

Telehealth etiquette attempts to make the patient telehealth encounter a pleasant patient experience. It involves patient needs and working to improve every aspect of patient satisfaction through a particular model of delivery. We recommend rolling out the service line while reviewing every workflow step to ensure an easy patient transition to care.

The Telehealth Resource Centers have created a checklist to help practices learn more: https://www.telehealthresourcecenter.org/wp-content/uploads/2019/07/Telehealth-Etiquette-Checklist.pdf

The AMA Telehealth Implementation Playbook offers telehealth etiquette recommendations in their resource guide (see pg. 114; Appendix G.4): https://www.ama-assn.org/system/files/2020-04/ama-telehealth-playbook.pdf

 

Can you provide some insight into reimbursement and billing for telehealth?

Telehealth reimbursement policies during the COVID-19 pandemic have been confusing at best. CMS and private payers have changed documentation requirements and coding requirements. They also promised a level of coverage, but then adjudicated the claims under a different set of guidelines.  One consistency is the desire to pursue reimbursement parity after the state of emergency. This is a top priority for the officials at the American Telehealth Association (ATA).

In the meantime, there are some key points to consider when billing for telehealth services:

  • Know your top payers and understand what their policies are regarding documentation and coding (including place of service [POS]). It is likely that these policies will change, so check back frequently to ensure you are following the most current guidelines.
  • Develop and share guidance documents for your physicians and other providers so that they know exactly what to document. If they do their own coding, they must know how to code properly. Due to the rapidly changing telemedicine coding rules, your practice may consider centralizing all telemedicine claims for review prior to filing with the payer. Practices who have done this report that the extra quality control effort has reduced their denied telemedicine claims.
  • Assess your return on investment (ROI) for telemedicine to determine your desire to continue the program beyond the state of emergency.
  • Consider potential revenue loss:
    • Medicare promised patients it would waive copays for telemedicine during the pandemic. This can represent up to a 20% reduction in revenue as compared to an in-office visit.
    • The original telemedicine POS code that CMS advised practices to use initially resulted in a reduction of reimbursement of 30% in some cases. This was eventually eliminated for the duration of the pandemic, but it is unclear which POS code will be required post-pandemic.
    • There may be revenue lost to procedures that cannot be done via telemedicine.
    • Policy ambiguity regarding reimbursement related to Medicaid programs, federally qualified health centers, and rural clinics, etc. can have an impact on ROI.
    • Some insurance carriers are covering telemedicine but are requiring their beneficiaries to use specific telemedicine vendors versus their primary physicians.

Many believe telehealth will continue to evolve because of its appeal to many patients as well as to employers. When looking towards the future, each physician will need to determine the feasibility and contribution that telehealth can make to his or her practice.

 

Do any specialty organizations have specific information on coding for telehealth?

Many specialty-specific organizations have guidance documents that address coding and billing questions. These documents were developed for specific professions/specialty areas as a result of COVID-19:

 

How are emergencies handled in a telehealth session?

The AMA states that when a service is delivered using telemedicine, mechanisms to ensure continuity of care, follow-up care, and referrals for emergency services must be in place. According to the Federation of State Medical Boards (FSMB), an emergency plan is required. The physician must provide the plan to the patient when it is determined during the telemedicine session that a referral to an acute care facility or emergency department is necessary. The emergency plan should include a formal, written protocol appropriate to the services being rendered via telemedicine technologies.

 

What are the prescribing standards?

In Pennsylvania, there are no prescribing standards at this time. However, during COVID-19, the Drug and Enforcement Administration (DEA) disclosed new information.

“…DEA has posted information on its website stating that it will not enforce restrictions on prescribing controlled substances via telemedicine during the national state of emergency related to the coronavirus disease 2019 pandemic. Find this information on DEA’s COVID-19 page, under the heading ‘Telemedicine’. Licensees are strongly encouraged to read the DEA’s guidance before implementing any changes to how they manage patients.”

 

Are there specific privacy and security guidelines for telehealth?

AMAThe AMA acknowledges that the delivery of telemedicine services must abide by laws addressing the privacy and security of patients’ medical information. Written policies and procedures should be maintained at the same standard as for traditional face-to-face encounters. Such policies and procedures should address:

  • privacy,
  • healthcare personnel who will process messages,
  • types of transactions that will be permitted electronically,
  • required patient information to be included in the communication, such as patient name, identification number, and type of transaction,
  • archival and retrieval of medical information, and
  • quality oversight mechanisms of the privacy and security process.

Policies and procedures should be periodically reviewed, evaluated, and maintained in an easily accessible location.

ATAThe ATA advises healthcare professionals who are providing telehealth services to ensure that workspaces are secure, private, reasonably soundproof, and have a lockable door to prevent unexpected entry. Efforts should be made to ensure privacy so provider discussions cannot be overheard by others outside of the room where the service is provided. If other people are in either the patient’s or the professional’s room, both the professional and patient must be made aware of the other person and agree to his or her presence.

 


Resources

References

  • PA Department of Public Welfare, Medical Assistance Bulletin OMHSAS-20-20, p.2, Feb. 20, 2020.
  • PA Department of Public Welfare, Medical Assistance Bulletin OMHSAS-20-20, p.3, Feb. 20, 2020.