As health care becomes more accepting of and reliant on technology, the concept of telemedicine has caught the attention of long term care facilities. Increasingly, skilled nursing and assisted living settings have adopted telemedicine programs in an effort to reduce hospital readmissions, increase access to practitioners, differentiate themselves from competition, improve overall quality of care, decrease costs, and increase revenue. Recent studies confirm that telemedicine is a powerful tool for transforming health care and can positively impact the quality of care for long term care patients. This presentation will feature Rebecca Miller, attorney and Senior Telehealth Project Manager at Michigan Medicine and Andrea Lee, post-acute care health care attorney from Honigman Miller Schwartz and Cohn, LLP, on the key operational and legal considerations when implementing a telemedicine program.

1. Building a Telemedicine
Program
Operational and Legal
Considerations
Rebecca Miller
Michigan Medicine
Andrea Lee
Honigman

2. We’re in the Middle of a
Digital Revolution.

3. Increase of
technology use
Provider
shortages
Rising health
care costs
Aging baby
boomers

4. What is Telemedicine?

5. State Law Definitions
• Telehealth (MCL 333.16283)
The use of electronic information and telecommunication technologies
to support or promote long-distance clinical health care, patient and
professional health-related education, public health, or health
administration.
• Telemedicine (MCL 500.3476)
The use of an electronic media to link patients with health care
professionals in different locations. The health care professional must be
able to examine the patient via a real-time, interactive audio or video, or
both, telecommunications system and the patient must be able to interact
with the off-site health care professional at the time the services are
provided.

6. Telehealth
Telemedicine

7. Methods
• Synchronous
“Real time” communication (e.g.,
TeleICU)
• Asynchronous
“Store and forward” (e.g.,
Teleradiology)
• Telemonitoring/Remote Patient
Monitoring

8. Telemedicine
is taking off!

9. After-hours
acute event
On-site nurse
calls patient’s
primary care
physician
Physician
must make
judgment call
Physician errs
on side of
hospitalization
?

10. After-hours
acute event
On-site nurse
calls
telemedicine
physician and
gives report
directly to
telemedicine
physician
Nurse transports
telemedicine unit to
patient’s bedside
(physician
accesses
physician’s
computer)
Physician and
nurse “meet” in
the patient’s
room
Telemedicine
physician
contacts
attending
physician, if
needed

12. • 365-bed nonprofit SNF
• 1 year; 313 patients
• 91 avoided hospitalizations
• Cost $60,000; Net $20,000 above costs
• Fee offset by:
• Preventing hospitalizations;
• Helping the facility maintain census (especially in its short-term
rehabilitation unit);
• Capturing lost Medicaid days while patient was hospitalized; and
• A decrease in transportation costs.
• Facility continues to support clinical service
The American Journal of Managed Care, Vol. 24,
No. 8

15. Explore your needs and potential use cases:
- Telestroke
- Teleneurology
- Telemental health
- Teledentistry
- Telepalliative care
- Etc.

16. Legal
Revenue
cycle
Patient/provider
experience
representatives
Operations
IT
2
3
4
1

17. Draw up your
plan of attack

18. User friendly=sustainable

19. Innovation is all about selling change.
You need to know the market.
You need to know the customer.
You need to listen.
It’s about image.
It’s about reliability.
It’s about quality.

21. Reimbursement

22. Medicare Reimbursement
• Covers synchronous, not asynchronous telemedicine
• Geographic Location
• Originating site (where the patient is) must be in either:
• a rural Health Professional Shortage Area (HPSA) or
• a county outside of a Metropolitan Statistical Area (MSA)
• Federal telehealth demonstration project qualifies regardless
of location
• Medicare Telehealth Payment Eligibility Analyzer
https://datawarehouse.hrsa.gov/tools/analyzers/geo/Telehealth
.aspx

23. Medicare Reimbursement (Cont.)
Originating Sites
Offices of physicians or practitioners
Hospitals
Critical Access Hospitals
Rural Health Clinics
Federally Qualified Health Centers
Hospital-based or CAH-based Renal Dialysis
Centers (including satellites) (historically not
Independent Renal Dialysis Facilities)
Skilled Nursing Facilities
Community Mental Health Centers
Distant Site Practitioners
Physicians
NPs
PAs
Nurse-midwives
Clinical nurse specialists
Certified registered nurse anesthetists
Clinical psychologists and clinical social workers
Registered dietitians or nutrition professionals

24. • Covered Services
• CY 2018
• Telehealth consultations, emergency department or initial inpatient
• Follow-up inpatient to beneficiaries in hospitals or SNFs
• Office or other outpatient visits
• Kidney disease education
• ESRD related services (must furnish at least one “hands on” visit each month to
examine the vascular access site)
• Nutrition therapy
• Behavioral therapy
• Psychoanalysis/psychotherapy
• Critical care consultations
• Full list - https://www.cms.gov/Medicare/Medicare-General-
Information/Telehealth/Telehealth-Codes.html
Medicare Reimbursement (Cont.)

25. OIG Report
•April 2018 OIG report found that 31% of
audited telemedicine claims did not meet
Medicare conditions of payment for
telemedicine services.
•OIG recommends that CMS conduct
telemedicine periodic post payment reviews.

26. Bipartisan Budget Act of 2018
• Telestroke (2019). Geographic and type requirements waived for
telehealth consultations
• ESRD (2019). Patients can receive telehealth visits without
geographic requirements if face-to-face is once every three months
• MA Plans (2020). May offer additional telehealth benefits
• ACOs (2020). May expand telehealth services and allow the home
to be an originating site – eliminates geographic location criteria

27. SNF Value-Based
Purchasing Program 2%=

28. RUSH Act
• Reducing Unnecessary Senior Hospitalizations (RUSH) Act of
2018
• If passed, enables Medicare to reimburse qualified SNFs for using
telemedicine to reduce rehospitalizations
• Would create a “SNF-based Provision of Preventive Acute Care
and Hospitalization Reduction Program,” which would qualify SNFs
to receive telemedicine equipment and reimbursement
“… allowing [SNF] medical professionals … to provide needed
emergency care through telehealth … will offer Medicare
recipients with better access to care at a lower cost to
taxpayers.” - Joint Press Release

29. Michigan Medicaid
• Permitted when travel by the patient is prohibitive or causes an “imminent
health risk” (50-mile rule no longer applies)
• Store-and-forward services are not reimbursable
• Only specific services included
• Patients must be located at one of the facilities listed in the Medicaid
manual
• Both sites and all providers must be enrolled in Medicaid for
reimbursement
• The originating site can only bill Medicaid for medically necessary
services
• Like Medicare, specific coding modifiers are required
Medicaid Manual, Section 17

30. Michigan Insurance Code
• Interactive video or audio required, but not necessarily
face-to-face contact
• Another healthcare professional must be physically
present and able to interact with the patient
• Insurers have discretion for which telemedicine services
they will reimburse and for how much
• Noted trend in increased list of telehealth services
available for reimbursement

31. Legal FAQs
??
?
?

32. Provider Licensure
• Provider must be licensed in the state where patient is
located
• For Michigan insurance reimbursement:
Telemedicine services must be provided by a health
care professional who is licensed, registered, or
otherwise authorized to engage in his or her health
care profession in the state where the patient is
located. MCL 500.3476; 550.1401k
• Would the provider be licensed to provide the
service in person?

34. HIPAA
Updating Notice of Privacy Practices
Entering into Business Associate Agreements
Providing HIPAA training and education
Incorporating telemedicine-specific risks into compliance program and risk assessment
Determining what should be maintained as part of the medical record
Sharing data and management responsibility with other providers
Transmission security
Using web-based platforms

35. Controlled Substances
Ryan
Haight Act
MCL
333.16285

36. Informed
Consent

37. Contracting For
Success

38. Rebecca Miller
umsphrem@med.umich.edu
(734) 232-1545
Andrea Lee
alee2@honigman.com
(313) 465-7294