How to Implement a Telemedicine Program in Your Practice

As the United States shifts from a fee-for-service (FFS) to a valued-based healthcare system, healthcare IT will become an increasingly important component in fostering patient engagement, coordinating care, increasing access to services, and decreasing overall costs. Telemedicine is making healthcare more accessible than ever, with both physicians and patients seeing benefits.

This year, CMS added even more services to its approved telemedicine list, and it is expected that the agency will continue this trend in coming years. Whether you are thinking about adding telemedicine services into your practice, or already offer these services, you need to have a firm grasp on the benefits to your patients, practice, daily scheduling, legal requirements, and risks.

Policymakers are passing more favorable legislation to enable telemedicine to spread throughout the country’s healthcare system.

In the past, physicians looking to adopt telemedicine faced many barriers to implementation, especially those posed by restrictive policies and legislation. However, as telemedicine continues to prove itself a viable alternative to in-person visits, policymakers are passing more favorable legislation to enable telemedicine to spread throughout the country’s healthcare system. Be aware, though, that telemedicine reimbursement varies tremendously depending on your state, practice, services provided, and third-party payers.

Properly implementing telemedicine can reap benefits. Improperly implementing telemedicine, on the other hand, can wreak havoc and cause your bottom line to suffer. This article guides you through the basics of implementing telemedicine in your practice and provides guidance regarding billing and reimbursement for telemedicine services.

Benefits for Physicians and Patients

Telemedicine can provide many benefits to physicians and their practices:

• More frequent contact with patients;

• Improved patient outcomes and better treatment adherence;

• Fewer gaps in care;

• More patient appointments in one day;

• Fewer no-shows and late cancels;

• Flexibility and better work–life balance;

• Increased practice revenue and competitive edge;

• Happier and more engaged patients; and

• Better ability to compete with retail care.

• Your patients also will benefit, through:

• More regular contact with their doctor;

• Extended access to specialists;

• Savings of time and money on travel to the appointment (especially rural patients);

• The ability to speak to their doctor from the comfort of their own home;

• Shorter wait times;

• Convenient, on-demand care; and

• Encouragement to be more involved with treatment decisions

Telemedicine is especially well suited to improve access to care for patients in geographically underserved areas or in areas where some specialists are not available.

First Steps

Learn the vocabulary! The following list explains the basic terminology used in the Medicare guidelines:

• Synchronous communication (real-time): Telemedicine service using interactive audiovisual equipment (video conferences between a patient and the provider).

• Asynchronous communication (store-and-forward): Telemedicine service without video conferencing between provider and patient. Uses telecommunication equipment to upload and store prerecorded patient data (video, images, data) for the physician or qualified healthcare provider (QHP) to access later.

• Remote patient monitoring: Allows a provider to track important patient data after the patient has been released home or to another care facility, potentially reducing the need for readmission (e.g., pacemakers, cardioverter-defibrillators).

• Originating site: The location of the beneficiary (patient) at the time of the telemedicine service.

• Distant site: The location of the physician or QHP at the time of the telemedicine service.

• Telehealth parity laws: Require payers to reimburse telemedicine services at same rate as in-person or on-site services.

Telemedicine Reimbursement

Getting reimbursed for telemedicine services can be tricky, because reimbursement guidelines vary greatly based on your state as well as your practice services and payers. Further, the guidelines are still changing as more of the healthcare industry jumps on the telemedicine bandwagon.

How to Implement a Telemedicine Program in Your Practice

To get started, you must define your care. How will you be using telemedicine? Will you be using it to check in with patients after hospital discharge, or to treat patients with minor acute conditions like infections? Will you consult as a specialist during a patient visit? Reimbursement will be easier if you have a specific use in mind.

Navigating the Medicare Maze

Here are a few things that you must know about Medicare and reimbursement for telemedicine services:

• Medicare will pay only for telemedicine services offered by the healthcare provider at the distant site, to a Medicare beneficiary (the patient) at an originating site within a health professional shortage area (HPSA).

• The patient must be in a HPSA and needs to be receiving virtual care at one of the authorized clinical settings.

• The patient’s home is not an authorized originating site (the only exception to this is the Comprehensive Care for Joint Replacement Model, which allows it). The types of originating sites authorized by law are:

  • A physician’s or QHP office;

  • A hospital;

  • A critical access hospital (CAH);

  • A rural health clinic;

  • A federally qualified health center;

  • A hospital-based or CAH-based dialysis center;

  • A skilled nursing facility; or

  • A community mental health center.

Medicare has specific guidelines that must be followed and follows full parity federal laws for reimbursement. All Medicare beneficiaries are eligible to receive telemedicine services if:

• They live in a metropolitan statistical area or rural HPSA located in a rural census tract;

• They present at an originating site for the service;

• They interact with an authorized provider (properly enrolled in Medicare and credentialed at both the distant and originating sites);

• The authorized provider is at an approved distant site (registered with Medicare);

• One of the approved telemedicine services is performed;

• The provider properly performs and documents the service; and

• Correct codes with correct modifiers are reported to Medicare.

Some telemedicine visits have limitations on quantities and require some “in-person” or “on-site” encounters. Patients receiving a telemedicine encounter who then see a provider at the same clinic and same specialty/subspecialty later within a three-year period are considered established patients. The only consultations Medicare pays for are emergency department or inpatient telemedicine consultations. The telemedicine consultant cannot be the physician of record or attending physician, and the consultation would be distinct also. All documentation requirements for the CPT/HCPCS code(s) must be met for the service being provided via telemedicine to qualify for reimbursement, in addition to the specific telemedicine information.

OIG Work Plan Updates for 2018: Originating Sites

Originating site payment is approximately $25 and is subject to the patient’s deductibles and coinsurance based on Part A/B coverage and location. An unauthorized originating site should append modifier GY to allow for formal denial (e.g., Q3014-GY). Identify and address the proper use and reporting for and advanced beneficiary notice associated with an unauthorized distant provider, originating site, or service provided.

Auditing Telemedicine

Auditing is about knowing the rules, but the parity laws vary from state to state, and several states do not have any such rules in place at this time. Auditors must follow federal guidelines for Medicare, individual state guidelines for Medicaid and commercial payers (e.g., parity laws, qualified provider types), and, finally, individual beneficiary benefits.

The telemedicine landscape experienced significant changes over the past year, primarily at the state level. I expect additional changes in the near future as the healthcare market incorporates telehealth into population health strategies, making it critical for practices to stay abreast of evolving regulations.

Covered Changes for 2018

As expected, the telemedicine landscape has experienced significant changes, primarily at the state level, in 2018. We can expect additional changes in the near future as the marketplace incorporates telehealth into population health strategies, making it crucial that medical providers stay abreast of evolving healthcare regulations. Two probable changes are the adoption of remote health apps into patient care and patient wellness.

Summary

If you are ready to add telemedicine to your practice, follow these steps:

1. Determine your objectives. What are you goals? Do you want to increase your revenue by seeing patients at night? Or would you like to monitor your elderly patients better? Whatever they are, telemedicine will improve your patient outcomes, and provide additional revenue.

2. Appoint a telemedicine champion in your practice to promote its benefits to your staff, and to select and implement the technology, plan the telemedicine work flow, and train and coach patients during the initiation phrase.

3. Market the benefits of telemedicine to your patients. Use emails and text reminders to create awareness of the telemedicine option to fill empty spots in your schedule and to reduce no shows.

4. Practice telemedicine visits in the roles of both provider and patients. Providers need to learn how to present well on camera, and they may be intimidated. Be aware of their backgrounds and body languages. You want your staff to come across as professional and credible before you go live with real patients. Everyone should practice.

5. Make sure you meet state licensing requirements. If the patient is located in another state, the originating state in which the patient is located is considered the “place of service.” Therefore, the physician must comply with that state’s licensing rules and regulations. Each state’s medical board has its own rules governing the delivery of telemedicine services across state lines Some are easing restrictions on providers in contiguous states, so check state regulatory requirements frequently.

CPT and HCPS Codes Are Eligible for Reimbursement

Medicare has a specific list of CPT and HCPCS codes that are covered under telemedicine services. You can obtain a cheat sheet on the CMS website (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf ). Because this list is subject to change each year, I recommend you check the CMS website yearly at a minimum. The following list presents the codes for 2017.

When billing for telemedicine services you need to include the GT modifier with the relevant CPT code to indicate that service was provided virtually. You can also bill Medicare a facility fee as a reimbursement for hosting the telemedicine visit. You should look up HCPCS code Q3014, Facility Fee GO438-G0439.