TeleHealth Reimbursement – Driving Value-based Outcomes

Fee for Service, Value Based Purchasing, Shared Savings

Medicare, Medicaid, Private Pay, Self-Pay

 Balanced Budget Act of 1997  Federal Register 1998  BIPA 2000  Medicare Prescription Drug and Modernization Act of 2003  Medicare Fix Bills – 2006, 2007  Health Care Reform Act 2010  Accountable Care Act 2011

Two-way live interactive video and audio between the provider and patient. The patient must be present – if not required to be present – is not considered TeleHealth. It is not TeleHealth for the purposes of reimbursement if the connection between a provider and patient is on the same campus. Post-surgical updates to family Supervising residents Covering the inpatient units from ED Any other situation where walking takes away patient seeing time

Office or Other Outpatient Visits, Psychiatric diagnostic interview, Individual Psychotherapy, Pharmacological Management, Neuropsychological Testing Administered by Computer, Neurobehavioral Exam, Telehealth Consultations, emergency department or initial inpatient, G0425-G0426 Follow-up Inpatient Telehealth Consultation, G0406 – G0408 Subsequent Hospital Care, – (1 every 3 days) Subsequent Nursing Facility Care, (1 every 30 days in a skilled Nursing Facility only) Medicare Covered Services

Individual and Group Health and Behavior Assessment and Intervention (HBAI), ESRD Related Visits, G0308, G0309, G0311, G0312, G0314, G0315, G0317 and G0318 Individual and Group Kidney Disease Education, G0420 – G0421 Individual and Group Medical Nutrition Therapy, , G0270 Individual and Group DSMT services with a minimum of 1 hour in-person instruction in the first year, G0108 – G0109 Smoking Cessation Services, , G0436- G0437 Distant Site Facility Fee, Q3014

#1 Urban versus Rural Inside Metropolitan Statistical Area Outside Metropolitai n Statistical Area

#2 Originating Site Physician’s Office Hospital Critical Access Hospital Rural Health Clinic Federally Qualified Health Center Hospital-based or CAH-based renal dialysis center (including satellites) Skilled nursing facility (SNF) Community mental health center (CMHC) 1.Home 2.Assisted Living 3.Senior Housing 4.Other

Community health centers are local, non-profit, community-owned health care providers serving low income and medically underserved communities. For over 40 years, the national network of health centers has provided high- quality, affordable primary care and preventive services, and often provide on-site dental, pharmaceutical, and mental health and substance abuse services. Also known as Federally-Qualified Health Centers (FQHCs), they are located in areas where care is needed but scarce.

#3 CPT Code Coverage Telehealth Consultations, emergency department or initial inpatient, G0425-G0426 Follow-up Inpatient Telehealth Consultation, G0406 – G0408 Subsequent Hospital Care, – (1 every 3 days) Subsequent Nursing Facility Care, (1 every 30 days in a skilled Nursing Facility only) Office or Other Outpatient Visits, Psychiatric diagnostic interview, Individual Psychotherapy, Pharmacological Management, Neuropsychological Testing Administered by Computer, Neurobehavioral Exam, Individual and Group Health and Behavior Assessment and Intervention (HBAI), ESRD Related Visits, G0308, G0309, G0311, G0312, G0314, G0315, G0317 and G0318 Individual and Group Kidney Disease Education, G0420 – G0421 Individual and Group Medical Nutrition Therapy, , G0270 Individual and Group DSMT services with a minimum of 1 hour in-person instruction in the first year, G0108 – G0109 Smoking Cessation Services, , G0436-G0437 Any other codes: Speech, occupational, physical therapy

#4 Eligible Practitioner Physicians Physician Assistants Nurse Practitioners Nurse Midwives Clinical Nurse Specialists Clinical Psychologists Clinical Social Workers Registered Dietitians and Nutrition Professionals 1.Registered Nurse 2.Physical Therapist 3.Speech Pathologist 4.Occupational Therapist

…revise § (b) and § (a)(1) to include subsequent nursing facility care services as Medicare telehealth services, with the limitation of one telehealth subsequent nursing facility care service every 30 days. Federally-mandated periodic visits may not be furnished through telehealth, as specified currently in § (e)(2). Must know the status of the resident admission on the day of the appointment, not the day appointment was made.

Subsequent hospital care services, with the limitation for the patient’s admitting practitioner of one telehealth visit every 3 days

 Develop a specific appointment type for TeleHealth/Telemedicine  Use standardized modifier on all claims (GT)  Electronics comment “Services provided by TeleHealth”  Bill the facility fee when appropriate Q3014 – 1500 form- need an appointment – billed under supervision physician  Do not include other procedures, test, services provided in-person in conjunction with the TH visit (peak flow, walking pulse ox, debridement)  Watch your reimbursement!

 Patient is physically present at the FQHC  Specialist is a provider not physically present at the FQHC  FQHC and specialist have agreement to provide services, but FQHC does not  compensate the specialist  Medical reason for a provider to be present with patient at the FQHC site  Patient ‘virtually’ enters specialist site via telemedicine  specialist is the provider site and can bill fee-for-service rate.  FQHC provided a medically necessary service, thus also a provider site, and can bill PPS for a face-to-face visit.

 Patient is physically present at a non-FQHC site  Specialist is physically present at and receives compensation from FQHC  Specialist and FQHC have agreement to provide services, but patient site does not pay FQHC  No medical reason for a provider to be present with the patient at the patient site  Patient ‘virtually’ enters FQHC site via telemedicine  FQHC is the provider site, and can bill PPS for a face-to- face visit.  Patient site did not provide a medical service and cannot bill for a visit, but is eligible for site fee and possibly transmission charges

 Patient is physically present at FQHC 1  Specialist is physically present at and receives compensation from FQHC 2  FQHC 1 and FQHC 2 have agreement to provide services, but FQHC 1 does not compensate FQHC 2  No medical reason for a provider to be present with the patient at the FQHC 1 site  Patient ‘virtually’ enters FQHC 2 site via telemedicine  FQHC 2 is the provider site, and can bill PPS for a face- to-face visit.  FQHC 1 did not provide a medical service and cannot bill PPS for a face-to-face visit.

 Patient is physically present at FQHC  Specialist is not physically present at the FQHC  FQHC and Specialist have an agreement to provide services, and FQHC compensates specialist.  The agreement should be in writing and clearly state: the time period during which the agreement is in effect; the specific services it covers; any special conditions under which the services are to be provided; and the terms and mechanisms for billing and payment. (see BPHC Policy Information Notice 98-23)  Provider ‘virtually’ enters ‘four walls’ of FQHC via telemedicine  FQHC becomes the provider site, and can bill PPS for a face-to-face visit.  Because an FQHC’s specialist’s time is accounted for in the FQHC’s PPS rate, an FQHC cannot contract to receive additional compensation from another FQHC or other patient site.

 Medicare hospital cost report Form CMS  The Refinement Act (BBRA) of 1999, requiring hospitals to report information on the uncompensated care they provide.  Provides Secretary of Health and Human Services with the data necessary to develop a Medicare disproportionate share hospital payment methodology that takes into account the cost of providing care to uninsured and underinsured patients as recommended by the Medicare  Payment Advisory Commission.

 Q3014 HCPCs code  Billed by the site with the PATIENT  Can be the same organization providing the consulting services  Billed on UB form (technical component)  Site of service is where the patient is  Billing entity is the facility linked to an on- site MD

The Centers for Medicare & Medicaid Services (CMS) has not formally defined telemedicine for the Medicaid program, and Medicaid law does not recognize telemedicine as a distinct service. Nevertheless, Medicaid reimbursement for services furnished through telemedicine applications is available, at the state's option, as a cost-effective alternative to the more traditional ways of providing medical care (e.g., face-to-face consultations or examinations). Many states are allowing reimbursement for services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs.

 Agreement between single entity and the health care provider  No restrictions unless agreed upon by the parties  Payment usually at a predetermined contract rate – look at your standard and customary rates  Contract for typical services

Medicaid “health home” option for chronic care (section 2703) Medicare “accountable care organizations” demonstration (section 3022) Medicare “independence at home” demonstration (section 3024) Center for Medicare and Medicaid Innovation (section 3021)

 Tell Them Who You Are – Centers of Excellent, Leaders in X  National Overview of TeleHealth  Demonstration of How It Works  VISUALS!!!!!  Testimonial by Enrollees of Health Plan who Have Used TeleHealth  Video Clips of Visits  Share Internal Data – Volume, Performance, Outcomes  Outline Program Description – Services, Quality Improvement, Sites  Specific Health Plan Data  Outline the Program Request

 Pay for Everything the Same as In-Person  Do Not Accept the Medicare Approach  If you get a NO –  Consider suggesting a one year pilot  Suggest a Two Year Population Specific Program

 Pay for Everything the Same as In-Person  Do Not Accept the Medicare Approach  If you get a NO –  Consider suggesting a one year pilot  Suggest a Two Year Population Specific Program  BEG

Your Other Money…..

 Typically payment for clinical services  Set or negotiated fees  Medicare, Medicaid, County, Private Payers, Self-Funded Payers, Patients, Families  Endowments, Charity  Purchasing Groups – Under, Non-insured  State Budget Line Item

 Organization bills professional fees  Bills and collects independent of third party  Typically for specific service rendered: software, maintenance, single specialty  Direct Bill to organization for patient care  Cash, credit card payments  Usually contractually based  State Budget Line Item

 Store-and-forward services  Occupational Medicine  School Clinics  Dermatology  Self – Insured Employers  Workers Compensation Carriers  Insurance Plans  Primary Care Services  Specialty Care Services  Diabetes Services

 All types of business arrangements and TeleHealth organizations – clinical, network, vendor  Typically outlines services to be delivered  May be based on RFPs  Outlines detailed arrangement  Schedule of Fees  Provide off-site services: billing, coding, network management  Don’t forget to go after contracts: State, Feds, DOD, etc.

 Ancillary Services  Patient Visits – Practice Productivity  Use of other departments: R/D, Technology, Helpline

 Testing of new markets  Component of a package of services  Relationship builder  Grant partner

Decrease in cost of other services or initiatives:  Mobile Services  MD and supportive personnel  Advanced and allied practitioners versus MDs  Reduction in white space and no-shows  Reduction in cost of outreach

 Look at average revenue per visit  Identify lost time in schedule  Calculations: $164 for Level III Office visit 15% white space in schedule 37 hours per week productive time 5.6 hours of white space = $164 x 2 visits/hr x 5.5 hours = $164 x 2 visits/hr x 5.5 hours =$1,836.80

 NP Clinic uses TeleHealth to enroll health plan patients with Congestive Heart Failure Primary diagnosis  Entered into standardized program that includes regular NP visits, education, and coaching  Use of TeleHealth to get all patients enrolled at low cost to organization and without additional staff.  Savings to the health plan led to a $216 per month per member payment (+ prof component

 HgA1c levels  Blood Pressure  Foot Exams  Appropriate hyperglycemic therapy  How many Endocrinologists are there in your service area?  Tele-Endocrinology  Patients have better HgA1c control, blood pressure control, meet annual foot and eye exam requirements, when seen via TeleHealth Better patient compliance No loss to follow-up Fewer cancellations and no show

 Average number of RVUs per day on campus  Average number of RVUs per day on outreach  Interventionalists going to sites without procedure resources (Cardiology, Ortho)  Cardiology Example  Outreach 5-11 RVUs  On campus + TeleHealth = 37 RVUs

 health outcomes  clinical processes  patient safety  efficient use of health care resources  care coordination  patient engagements  population and public health  adherence to clinical guidelines The 6 NQS domains are: 1. Patient and Family Engagement 2. Patient Safety 3. Care Coordination 4. Population/Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Process/Effectiveness

Identifying patients at highest risk for hospitalization, based on specific criteria, and put those patients on remote monitoring, safety measures, and in-home video. Value? = Bonus and incentive payments

 Care Coordination Model  Transitional Care Model  Extends the care team into the home  Objectives of reduced hospitalizations and avoidance of rehospitalization within 31 days  Keeping people healthier and happier

Following a patient from discharge from acute care admission for 60 days to prevent re-admission. Use remote monitoring and care coordination staffwith interactive video consultations as a tool.

 Average cost of hospitalizations - $17- 22,000  Average hospitalizations per year for high risk patients 3-15  Shared savings contracts – 50%  Based on 100 high risk patients

Number of Patients Average Cost of Hospitalization # of Hospitalizations per Year Cost BurdenShared Savings Program Average Cost Of Remote Monitoring* 1$17,0003$51,000$25,500$1, $17,0007$5,100,000$2,550,000$190, RN $17,0007$5,100,000$2,550,000$290,000 1$22, 0003$66,000$33,000$1, $22,0007$6,600,000$3,300,000$190, RN $22,0007$6,600,000$3,300,000$290,000 *Assumes one kit per patient *Add-in cost of RN for 100 high risk patients = $ ,000 salary and benefits (regional)

# of Hospitalizations x % Reduction x # of High Risk Patients = Cost Savings Cost Savings – Cost of Remote Monitoring/Patient = Net Savings

Don’t Take this approach!

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