Telemedicine Reimbursement For Oregon

Why is it important? Telemedicine Reimbursement Encourages use of telemedicine services Provides mechanism to reimburse providers One tool to ensure sustainability of program

What is happening nationally? Telemedicine Reimbursement

Medicare First authorized in BBA of Fee splitting -Limited CPT code reimbursement -Limited eligible presenters

Telemedicine Reimbursement Medicare BIPA of 2000-some improvements -Eliminated fee sharing -Eliminated need for “telepresenter” -Expanded eligible services -Included payment to distant site physician only

Medicare BIPA of 2000-some improvements -Expanded definition of originating site -Expanded eligible geographical regions -Allowed originating site facility fee -Permitted use of store and forward Telemedicine Reimbursement

Medicare BIPA of 2000-some improvements But Still substantial limitations: -Eligible geographic locations -Eligible originating sites -Eligible services -Eligible providers Telemedicine Reimbursement

Medicare Eligible Geographical Locations -Must be a primary care Health Professional Shortage Area (HPSA) -Cannot be a Metropolitan Statistical Area (MSA) Telemedicine Reimbursement

Medicare Eligible Geographical Locations HPSA: Three Criteria -Rational area for delivery of primary care -<1 primary care physician per 3,500 people -Insufficient capacity of providers Telemedicine Reimbursement

Medicare Eligible Geographical Locations MSA: County or contiguous counties with: -One city with population of 50,000 or more -Census Bureau-defined urbanized area of at least 50,000 and metropolitan population of at least 100,000 Telemedicine Reimbursement

MSA December 2006 Oregon Bend, OR Corvallis, OR Eugene-Springfield, OR Medford, OR Portland-Vancouver-Beaverton, Salem Medicare Telemedicine Reimbursement

Medicare Eligible Originating Sites: Medicare includes: Office of a Physician Hospital Critical Access Hospital Rural Health Clinic Federally Qualified Health Center Additions Needed: Skilled Nursing Facilities Community Mental Health Centers County Mental Health Departments Public Health Departments Indian Health Service Sites Telemedicine Reimbursement

Medicare Eligible Medical Practitioners Telemedicine Reimbursement Medicare Includes: Physician Nurse Practioner Physician Assistant Nurse Midwife Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Nutrition Professional Recommended Additions: Dieticians Genetics Counselors Physical Therapists Occupational Therapists Speech Therapists

Medicare Eligible Services Telemedicine Reimbursement Covered BIPA - Consultations - Office or other outpatient visits - Individual psychotherapy - Pharmacologic management

Medicare Eligible Services Telemedicine Reimbursement Covered Added since BIPA - ESRD services, 2-3, or 4 or more visits per month - Individual nutritional therapy

Medicare Eligible Services Telemedicine Reimbursement Requested but not yet approved - Nursing facility care - Speech language pathology - Audiology -- Physical therapy services.

Medicaid Telemedicine Reimbursement State administered program, Federal Match Each state sets its Medicaid telemedicine reimbursement policy

Medicaid Telemedicine Reimbursement Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming. 35 States Reimburse for Telemedicine

Medicaid Telemedicine Reimbursement Reimbursement models vary among states: -Internal agency decision -Legislative initiatives -Regulatory initiatives -Other: SCHIP, Waivers

Medicaid Telemedicine Reimbursement Per 2004 Survey (Institute for Child Health Studies, U of Florida): 27 States have been reimbursed for telemedicine: -Medical consultations or treatments-22 states -Psychological consultations or treatment-12 states -Home health-2 states -Case management-2 states - Patient education (diabetes)-1 state

Private Payers -Less published information on private payer reimbursement -Progress is being made….. Telemedicine Reimbursement

States with government mandated legislation - California, Louisiana, Texas, Oklahoma, Kentucky All prohibit payers from excluding services solely because they are delivered telemedically Telemedicine Reimbursement Private Payers

Telemedicine Reimbursement Growing number of states enacting legislation: - Example: Kansas HB 2065: Private insurers should cover medical care provided via telemedicine as they do for in-person Coverage should include: -Office visits or consultations -Individual psychotherapy -Pharmacological management -Emergency services If passed, effective in 2008

Private Payers Telemedicine Reimbursement 2005 Survey:American (Telemedicine Association and AMD Telemedicine) - Phone survey of 72 programs as offering potentially billable services - 38 receiving reimbursement from private payers -Payers reimbursing in at least 25 states -Many are following lead of Blue Cross/Blue Shield

Private Payers Telemedicine Reimbursement 2005 Survey (American Telemedicine Association and AMD Telemedicine) - 3 programs receive reimbursement for store and forward - 7 programs receive reimbursement for facility fees - Over 100 private payers currently reimburse for telemedicine services

What is happening in Oregon Telemedicine Reimbursement

Oregon Oregon’s Landscape HJR4 What’s Next

Oregon’s Landscape

Oregon Telemedicine Reimbursement Oregon HJR4 passed in 2003 legislative session Three major goals: –Quality health care should be available to all Oregonians –To assure best access possible, Telehealth should be an appropriate tool for delivery of service –To reduce healthcare costs, Telehealth should be an appropriate tool for delivery of service

HJR4: Key Points:  Providers reimbursed for in-person services should receive same reimbursement for services delivered via telemedicine  Any service reimbursed on an in-person basis should be reimbursed if delivered via telemedicine  With exception of “store-and-forward”, reimbursable services should include clinician to patient services (not clinician to clinician) Oregon Telemedicine Reimbursement

HJR4: Key Points:  Informed consent document specific to telemedicine should be signed by patient prior to services  Patient should have the right to choose telemedicine or in-person services when both are available  Payers should consider reimbursing transmissions costs Oregon Telemedicine Reimbursement

Recommended contract language:  Matches existing Medicare language, with the following exceptions:  Originating sites are not specific to geographic locations  Eligible originating sites: Medicare includes: Office of a Physician Hospital Critical Access Hospital Rural Health Clinic Federally Qualified Health Center Additions: Skilled Nursing Facilities Community Mental Health Centers County Mental Health Departments Public Health Departments Indian Health Service Sites Oregon Telemedicine Reimbursement

Recommended Contract Language:  Matches existing Medicare language, with the following exceptions:  Payment is permitted for asynchronous “store and forward” technology  Eligible Medical Practitioners: Medicare Includes: Physician Nurse Practioner Physician Assistant Nurse Midwife Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Recommended Additions: Dieticians Genetics Counselors Physical Therapists Occupational Therapists Speech Therapists Oregon Telemedicine Reimbursement

Telemedicine Reimbursement Criteria By Payer

Oregon Telemedicine Reimbursement Convene workgroup to draft telemedicine reimbursement bill for 2009 legislative session. -Who should be at the table? -What is our strategy? What’s Next?

Telemedicine Reimbursement Convene workgroup to draft telemedicine reimbursement bill for 2009 legislative session. -What should language contain? Eligibel Services? Eligible Originating Sites? Eligible Providers? “Should” vs. “Will”? What’s Next?

Contact Us Catherine S. Britain CSBritain Consulting Secretary, Telehealth Alliance of Oregon gmail.com Kim Hoffman Outreach Coordinator, ITG, OHSU Senior Manager, HERON Telehealth Coordinator, ITG, OHSU 1515 SW 5th Avenue, 9th Floor Portland, Or Mail Code: MSB 9th Floor Office (503)