Policy Issues inPolicy Issues in
TelehealthTelehealth
Catherine V. PalmerCatherine V. Palmer
University of PittsburghUnive...
Where is Dave Fabry?Where is Dave Fabry?
Policy BarriersPolicy Barriers
 ReimbursementReimbursement
 State Licensure and regulation (cross-State Licensure and re...
ReimbursementReimbursement
 Look to CMS to set the tone for reimbursementLook to CMS to set the tone for reimbursement
 ...
AsynchronousAsynchronous
 Does not meet the definition ofDoes not meet the definition of
telemedicine set forth by CMStel...
ReimbursementReimbursement
 CMS: reimbursed for medically coveredCMS: reimbursed for medically covered
services including...
 Partial Medicare reimbursement forPartial Medicare reimbursement for
telehealth services was authorized in thetelehealth...
 Unlike Medicare, Medicaid programs oftenUnlike Medicare, Medicaid programs often
provide reimbursement for health care-p...
 Federal Medicaid Statute (Title XIX ofFederal Medicaid Statute (Title XIX of
Social Security Act) does not recognizeSoci...
Examples of CoverageExamples of Coverage
 CPT 98966 Health Care ProfessionalCPT 98966 Health Care Professional
Phone call...
 CPT 99441 Phone E&M by Physician 5-CPT 99441 Phone E&M by Physician 5-
10 minutes10 minutes
 (not being reimbursed)(not...
 CPT 99444 online E&M by physicianCPT 99444 online E&M by physician
 (not being reimbursed)(not being reimbursed)
 CPT 93293 Pace maker eval by phoneCPT 93293 Pace maker eval by phone
 (Medicare = $56.98)(Medicare = $56.98)
DefinitionsDefinitions
 Originating or Spoke SiteOriginating or Spoke Site
 Location of the PatientLocation of the Patie...
 Facility fee to the originating siteFacility fee to the originating site
 HCPCS Q3014 (telehealth originated site)HCPCS...
 Technical support, transmission charges,Technical support, transmission charges,
equipmentequipment
 HCPCS T1014 (teleh...
 Physician fee at the distant sitePhysician fee at the distant site
 Bill as professional services (CPT code)Bill as pro...
 Modifier “GT” – via interactive audio andModifier “GT” – via interactive audio and
video telecommunication systems allow...
Medicare Conditions of ProvisionMedicare Conditions of Provision
(limit some telehealth practices)(limit some telehealth p...
Audiology ExamplesAudiology Examples
 LACELACE
 CPT 92626 (evaluation of auditory status –CPT 92626 (evaluation of audit...
Remote CI MappingRemote CI Mapping
 DoDDoD
 Private SectorPrivate Sector
LicensureLicensure
 Professional services take place where theProfessional services take place where the
patient is locat...
 States’ barriers are a restraint on trade inStates’ barriers are a restraint on trade in
violation of the Commerce Claus...
 Health care professional to health careHealth care professional to health care
professional may not require a localprofe...
LiabilityLiability
 www.telehealthlawenter.org/?c=1278a=1861www.telehealthlawenter.org/?c=1278a=1861
 Center for Telemed...
MalpracticeMalpractice
 Like professional licensing, malpracticeLike professional licensing, malpractice
insurance requir...
Internal RegulationsInternal Regulations
 When a manufacturer can take over yourWhen a manufacturer can take over your
co...
External Regulations: FDAExternal Regulations: FDA
 Does remote mapping of a cochlearDoes remote mapping of a cochlear
im...
ConsentConsent
 Recommend Consent to receive careRecommend Consent to receive care
through telehealth delivery systemthro...
Disclaimers/ConsentsDisclaimers/Consents
 Fax disclaimerFax disclaimer
 Email disclaimerEmail disclaimer
 Email Consent...
Support PersonnelSupport Personnel
 Who is responsible for training?Who is responsible for training?
 Are there safety i...
PrivacyPrivacy
 Health Insurance Portability andHealth Insurance Portability and
Accountability Act (HIPPA)Accountability...
Other barriers/challenge/solutionsOther barriers/challenge/solutions
 Technology…Technology…
Telehealth policy issues
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Telehealth policy issues

  1. 1. Policy Issues inPolicy Issues in TelehealthTelehealth Catherine V. PalmerCatherine V. Palmer University of PittsburghUniversity of Pittsburgh
  2. 2. Where is Dave Fabry?Where is Dave Fabry?
  3. 3. Policy BarriersPolicy Barriers  ReimbursementReimbursement  State Licensure and regulation (cross-State Licensure and regulation (cross- border care)border care)  Liability concernsLiability concerns  PrivacyPrivacy
  4. 4. ReimbursementReimbursement  Look to CMS to set the tone for reimbursementLook to CMS to set the tone for reimbursement  www.cms.hhs.gov/telehealth/www.cms.hhs.gov/telehealth/  Telemedicine is the use of medical informationTelemedicine is the use of medical information exchanged via electronic communication toexchanged via electronic communication to improve a patient’s health, use of interactiveimprove a patient’s health, use of interactive telecommunications equipment, two-way, realtelecommunications equipment, two-way, real time. A cost-effective alternative to face-to-facetime. A cost-effective alternative to face-to-face care. (42 CFR 410.78)care. (42 CFR 410.78)
  5. 5. AsynchronousAsynchronous  Does not meet the definition ofDoes not meet the definition of telemedicine set forth by CMStelemedicine set forth by CMS
  6. 6. ReimbursementReimbursement  CMS: reimbursed for medically coveredCMS: reimbursed for medically covered services including those with telemedicineservices including those with telemedicine applications…must satisfy federalapplications…must satisfy federal requirements of efficiency, economy, andrequirements of efficiency, economy, and quality of carequality of care
  7. 7.  Partial Medicare reimbursement forPartial Medicare reimbursement for telehealth services was authorized in thetelehealth services was authorized in the Balanced Budget Act of 1997.Balanced Budget Act of 1997.  Benefits Improvement and Protection ActBenefits Improvement and Protection Act of 2000 removed some prior constraintsof 2000 removed some prior constraints yet maintained substantial limitations toyet maintained substantial limitations to geographic location, originating sites, andgeographic location, originating sites, and eligible telehealth serviceseligible telehealth services
  8. 8.  Unlike Medicare, Medicaid programs oftenUnlike Medicare, Medicaid programs often provide reimbursement for health care-provide reimbursement for health care- related transportation costsrelated transportation costs
  9. 9.  Federal Medicaid Statute (Title XIX ofFederal Medicaid Statute (Title XIX of Social Security Act) does not recognizeSocial Security Act) does not recognize telemedicine as a distinct service.telemedicine as a distinct service.  States may choose to cover theseStates may choose to cover these services.services.  27 states offer some reimbursement for27 states offer some reimbursement for telehealth servicestelehealth services
  10. 10. Examples of CoverageExamples of Coverage  CPT 98966 Health Care ProfessionalCPT 98966 Health Care Professional Phone call 5-10 minutesPhone call 5-10 minutes  (not being reimbursed)(not being reimbursed)
  11. 11.  CPT 99441 Phone E&M by Physician 5-CPT 99441 Phone E&M by Physician 5- 10 minutes10 minutes  (not being reimbursed)(not being reimbursed)
  12. 12.  CPT 99444 online E&M by physicianCPT 99444 online E&M by physician  (not being reimbursed)(not being reimbursed)
  13. 13.  CPT 93293 Pace maker eval by phoneCPT 93293 Pace maker eval by phone  (Medicare = $56.98)(Medicare = $56.98)
  14. 14. 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 timeWhere the health care provider is at the time of the serviceof the service  TelepresenterTelepresenter  Person needed to facilitate the servicePerson needed to facilitate the service
  15. 15.  Facility fee to the originating siteFacility fee to the originating site  HCPCS Q3014 (telehealth originated site)HCPCS Q3014 (telehealth originated site)  Medicare $23.35; MA $15.72Medicare $23.35; MA $15.72  If they just have to set up the patient orIf they just have to set up the patient or stay with the patient the whole timestay with the patient the whole time
  16. 16.  Technical support, transmission charges,Technical support, transmission charges, equipmentequipment  HCPCS T1014 (telehealth transmission perHCPCS T1014 (telehealth transmission per minute)minute)  Unclear what the reimbursement isUnclear what the reimbursement is
  17. 17.  Physician fee at the distant sitePhysician fee at the distant site  Bill as professional services (CPT code)Bill as professional services (CPT code)
  18. 18.  Modifier “GT” – via interactive audio andModifier “GT” – via interactive audio and video telecommunication systems allowedvideo telecommunication systems allowed with code 99201-99205 (office or otherwith code 99201-99205 (office or other outpatient services) and 99241-99245outpatient services) and 99241-99245 (Office or Other Outpatient Consultations)(Office or Other Outpatient Consultations)  Medicare does not recognize this modifierMedicare does not recognize this modifier in PAin PA
  19. 19. Medicare Conditions of ProvisionMedicare Conditions of Provision (limit some telehealth practices)(limit some telehealth practices)  Face-to-face visit in long-term careFace-to-face visit in long-term care facilities on a regular schedulefacilities on a regular schedule (telemedicine as a supplement)(telemedicine as a supplement)  Home health requires some face-to-faceHome health requires some face-to-face visits (telemedicine as a supplement)visits (telemedicine as a supplement)
  20. 20. 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 theAssessment in the clinic or as part of the LACE program?LACE program?  What would an audit show?What would an audit show?
  21. 21. Remote CI MappingRemote CI Mapping  DoDDoD  Private SectorPrivate Sector
  22. 22. LicensureLicensure  Professional services take place where theProfessional services take place where the patient is locatedpatient is located  National Council of State Boards of Examiners inNational Council of State Boards of Examiners in SLP and Audiology indicates that the audiologistSLP and Audiology indicates that the audiologist should be licensed in the state in which theshould be licensed in the state in which the consumer is receiving the service.consumer is receiving the service.  In 2003, 17 states adopted an InterstateIn 2003, 17 states adopted an Interstate Compact for Licensed NursingCompact for Licensed Nursing  Allows nurses licensed in their home state to practiceAllows nurses licensed in their home state to practice in any other party statein any other party state
  23. 23.  States’ barriers are a restraint on trade inStates’ barriers are a restraint on trade in violation of the Commerce Clause of theviolation of the Commerce Clause of the United States Constitution.United States Constitution.  There is a strong legal presumptionThere is a strong legal presumption against federal preemption of stateagainst federal preemption of state licensure lawslicensure laws
  24. 24.  Health care professional to health careHealth care professional to health care professional may not require a localprofessional may not require a local licenselicense
  25. 25. LiabilityLiability  www.telehealthlawenter.org/?c=1278a=1861www.telehealthlawenter.org/?c=1278a=1861  Center for Telemedicine LawCenter for Telemedicine Law  ……because uncertainty about legal andbecause uncertainty about legal and regulatory issues often serves as a deterantregulatory issues often serves as a deterant to the maximum utilization of telemedicine…to the maximum utilization of telemedicine…
  26. 26. MalpracticeMalpractice  Like professional licensing, malpracticeLike professional licensing, malpractice insurance requires a provider to beinsurance requires a provider to be licensed in each state in which they deliverlicensed in each state in which they deliver services.services.  Subject to the jurisdiction of where theSubject to the jurisdiction of where the patient is locatedpatient is located
  27. 27. Internal RegulationsInternal Regulations  When a manufacturer can take over yourWhen a manufacturer can take over your computer in order to assist in patient carecomputer in order to assist in patient care or to train personnel…or to train personnel…  DIACAPDIACAP  DoD Information Assurance Certification andDoD Information Assurance Certification and Accreditation ProcessAccreditation Process
  28. 28. External Regulations: FDAExternal Regulations: FDA  Does remote mapping of a cochlearDoes remote mapping of a cochlear implant have to be approved by the FDA?implant have to be approved by the FDA?  Is this a new use?Is this a new use?  CI companies do not provide directCI companies do not provide direct support from a customer support linesupport from a customer support line  What about remote hearing aidWhat about remote hearing aid programming?programming?
  29. 29. ConsentConsent  Recommend Consent to receive careRecommend Consent to receive care through telehealth delivery systemthrough telehealth delivery system  Consent implies choiceConsent implies choice
  30. 30. Disclaimers/ConsentsDisclaimers/Consents  Fax disclaimerFax 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
  31. 31. 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?
  32. 32. PrivacyPrivacy  Health Insurance Portability andHealth Insurance Portability and Accountability Act (HIPPA)Accountability Act (HIPPA)  Privacy and confidentiality of protectedPrivacy and confidentiality of protected health information (PHI)health information (PHI)
  33. 33. Other barriers/challenge/solutionsOther barriers/challenge/solutions  Technology…Technology…

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