Building a Telemedicine Program in a Skilled Nursing Facility
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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.
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Building a Telemedicine Program in a Skilled Nursing Facility
- 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
- 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.
- 7. Methods • Synchronous “Real time” communication (e.g., TeleICU) • Asynchronous “Store and forward” (e.g., Teleradiology) • Telemonitoring/Remote Patient Monitoring
- 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.
- 17. Draw up your plan of attack
- 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
- 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
- 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
- 36. Informed Consent
- 38. Rebecca Miller umsphrem@med.umich.edu (734) 232-1545 Andrea Lee alee2@honigman.com (313) 465-7294