Telemedicine: Expanding Access to Medicaid Services


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2011 Virginia Telehealth Summit presentation

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Telemedicine: Expanding Access to Medicaid Services

  1. 1. Telemedicine: Expanding Access to Medicaid Services Presentation to: Virginia Telehealth Summit Gregg M. Pane, MD, MPA, Director April 5, 2011Va. Department of Medical Assistance Services Wintergreen, Virginia
  2. 2. Federal Guidance on Medicaid and Telemedicine Centers for Medicare and Medicaid Services issued guidance in 2001 on Medicaid and telemedicine. Among the items discussed: – No formal definition exists for telemedicine under the Medicaid program – Federal Medicaid law does not recognize telemedicine as a distinct service – Medicaid reimbursement for services furnished through telemedicine is available at the state’s option as a cost- effective alternative to the more traditional ways of 2 providing care
  3. 3. Federal Guidance on Medicaid and Telemedicine (Cont) Advises that states should consider factors such as the quality of the equipment, type of services to be provided and location of providers (such as remote rural sites) when deciding on the scope of telemedicine coverage Medicaid reimbursement must satisfy Federal requirements of efficiency, economy, and quality of care 3
  4. 4. 35 States Provide Medicaid Reimbursement for Telemedicine States With Medicaid ReimbursementSource: Telehealth Alliance of Oregon, 2008 4
  5. 5. States’ Telemedicine Policies Vary Widely; But Commonalities Exist Medical and psychological consultations/treatments are most prevalent services Fee-for-service reimbursement is generally provided to both the originating site (where the Medicaid recipient is located) and remote site where the physician or other provider is located Primarily physicians but also other providers are eligible for reimbursement, depending on the state Coding/billing inconsistencies across the states makes it difficult to track telemedicine utilization and impact 5
  6. 6. Virginia Medicaid’sInterests in Telemedicine Coverage Improved patient access to medical services Improved patient compliance with treatment Medical services rendered at an earlier stage of disease, improving long-term patient outcomes Reduction in service expenditures such as hospitalizations and transportation Allows for an opportunity to work proactively with physicians and other providers; has potential to be a “win-win” situation 6
  7. 7. Virginia Medicaid at a Glance  Approximately 62 percent of recipients are currently enrolled in a managed care plan (MCO). Five MCOs are under contract to DMAS serving various parts of Virginia 7
  8. 8. Virginia Medicaid at a Glance Among the services covered by DMAS are: ‒ Inpatient and Outpatient hospital ‒Dental care for persons under age services 21 ‒ Physician and nurse midwife ‒Prescription drugs services ‒Occupational therapy and other ‒ Laboratories and x-ray services rehabilitation services ‒ Transportation-emergency and ‒Hospice non-emergency ‒Some mental health services ‒ Nursing facility services ‒Some substance abuse services ‒ Home health ‒Federal waiver programs for ‒ Early and Periodic Screening, recipients with AIDS, Alzheimers, Diagnosis and Treatment program Developmental Disabilities, for children Intellectual Disabilities and others conditions 8
  9. 9. Virginia Medicaid Telemedicine Coverage, Early Years Virginia Medicaid started with a telemedicine pilot project in 1995. Services covered were: – Some consultations – One psychotherapy service – A few clinical services in cardiology and colposcopy Used Virginia defined billing codes Only physicians recognized as providers Reimbursed providers at originating and remote site, using the existing fee schedule 9
  10. 10. Virginia Medicaid Telemedicine Coverage, Early Years Pilot project was limited to three Virginia localities; one was for psychiatric care and the other two were for medical consultations Virginia Medicaid was one of the first states with telemedicine coverage 10
  11. 11. Virginia Medicaid Telemedicine Coverage Expansion, 2003 Virginia Medicaid expanded telemedicine coverage July 1, 2003 to be statewide. Governor Mark Warner announced the coverage in July 2003 at a community health event in southwest Virginia Additional services covered – Evaluation and management, office visits – Range of individual psychotherapies – Full range of consultations – Select clinical services such as in cardiology and obstetrics 11
  12. 12. Virginia Medicaid Telemedicine Coverage Expansion, 2003 Providers recognized by DMAS for telemedicine: – Physicians – Nurse practitioners – Nurse midwives – Clinical nurse specialists – Clinical psychologists – Clinical social workers – Licensed professional counselors 12
  13. 13. Virginia Medicaid Current Telemedicine Coverage Originating sites (where the recipient is located) were expanded in October 2009 to include:‒Certified Outpatient – Rural Health CentersRehabilitation Facilities –Program for All-Inclusive Care‒ Community Services Boards for the Elderly‒ Dialysis Centers – Plus physicians and other providers on previous page‒ Federally Qualified HealthCenters‒ Health Department Clinics‒ Hospitals‒ Nursing Homes 13
  14. 14. Virginia Medicaid Current Telemedicine Coverage Under fee-for-service, billing telemedicine to DMAS involves: – Originating site bills a telemedicine code for presenting patient – Remote practitioner bills for services such as consultation – Reimbursement is according to Virginia Medicaid fee schedule – A procedure modifier for telemedicine is to be entered on the claim form 14 – No telemedicine equipment costs recognized in reimbursement
  15. 15. Virginia Medicaid Current Telemedicine Coverage Providers of telemedicine services are expected to fully comply with service documentation and other coverage and billing requirements described in the Virginia Medicaid provider manuals Providers can only bill for a service using telemedicine, which DMAS already covers for the providers when delivered conventionally Virginia Medicaid telemedicine coverage is similar to Medicare coverage but is not tied to rural area definitions for the originating site 15
  16. 16. Virginia Medicaid Current Telemedicine Coverage Coverage was expanded in January 2011 to include diabetic retinopathy screening. This is the first “store and forward” telemedicine coverage for DMAS – For diabetics, digital images of the retina are captured by community health centers and transmitted to ophthalmologists – Ophthalmologists perform an evaluation of the image and report results 16
  17. 17. DMAS Telemedicine Billing Experience Telemedicine “billing” has been low for Virginia Medicaid with about 3300 claims and encounters for FY2010. Other Medicaid programs have reported low billing as well The predominant service is psychiatric consults, especially pharmacologic management Possible explanations as to why telemedicine is not appearing in data include: – Providers not using telemedicine billing modifier on claims form – Telemedicine as part of the larger bundle of services rendered to patients with particular diagnoses – Contracts for services with hospitals/clinics do not break out telemedicine 17
  18. 18. Telemedicine, Virginia Medicaid Managed Care Organizations Under the contract with DMAS, MCOs are to cover telemedicine at least to the extent the select services are covered for the fee-for-service population 18
  19. 19. Recent Virginia Legislation on Telemedicine Virginia Senate Bill 675 Was Signed Into Law by Governor McDonnell on April 5, 2010 – Mandates health insurance coverage for telemedicine in the commercial plans – The legislation significantly expands the availability of telemedicine coverage in the Commonwealth 19
  20. 20. Recent National Legislation with Reference to Medicaid and Telemedicine Section 3011 of the American Recovery and Reinvestment Act of 2009 directs the Secretary of Health and Human Services to invest in infrastructure necessary to allow for and promote electronic exchange and use of health information for individuals, consistent with the strategic plan developed by the National Coordinator for Health Information Technology The Centers for Medicare and Medicaid Services is listed as one of the participating agencies Infrastructure and tools for the promotion of telemedicine are included at 3011(a)(4) 20
  21. 21. Recent National Legislation with Reference to Medicaid and Telemedicine National Health Reform (2010) – A change under Medicare, which also applies to Medicaid, allows physicians to use telehealth to certify the need for home health services and durable medical equipment also applies to Medicaid – A “health home” option is available to states for serving persons with chronic conditions. The state is to include a proposal for the use of health information technology in providing health home services and improving service delivery and coordination across the care continuum 21
  22. 22. Future Possibilities for Virginia Medicaid Telemedicine Coverage Adding home health services to the telemedicine coverage. DMAS currently covers home health services when delivered conventionally The Medicaid recipient’s home serves as the telemedicine originating site with an electronic connection to the home health agency office Medicaid recipient’s condition is monitored via telemedicine by the home health agency 22
  23. 23. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Telemedicine applications for Medicaid recipients at home include: – Post-operative care – High risk pregnancies – Asthma – Diabetes – Congestive Heart Failure  Use of telemedicine for home health patients depends on the diagnosis, medical need, permission of the patient, and patient’s ability to use the equipment  Home health providers are interested in telemedicine because care is delivered more efficiently. The home health nurse can serve more patients in a day than when the care is delivered conventionally 23
  24. 24. Future Possibilities for VirginiaMedicaid Telemedicine Coverage (Cont.) Studies have documented savings particularly due to fewer hospitalizations and shorter hospital lengths of stay. Medicaid transportation is reduced The telemedicine visit is not intended to substitute for needed physical visits to the home by the nurse DMAS issue of relatively few recipients have more than a small number of home health visits, making telemedicine for home care less viable 24
  25. 25. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Expanding DMAS telemedicine “store and forward” coverage  Store and forward involves electronic medical information, such as video, still images, and MRIs, which is stored and transmitted for review by a physician or other practitioner at a later time. – The patient is not present when the physician conducts the evaluation of the image but findings are reported back to the 25 patient’s primary care provider
  26. 26. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.) Store and forward applications under consideration include: – Screening for retinopathy of prematurity – Dermatology Store and forward can be inexpensive for the originating and remote sites because the electronic medical information, such as a digital picture, simply needs to be captured and transmitted to the physician or other practitioner 26
  27. 27. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.) Adding “telepractice” to the DMAS telemedicine coverage, which is the delivery of speech therapy services using telemedicine. DMAS currently covers speech therapy in the schools and other settings Current pilot project involves a speech therapist at James Madison University performing telepractice with elementary school children in Wise County. These sites are approximately 280 miles apart Pilot made possible by a grant from the Virginia Department of Education to James Madison University DMAS in discussion with CMS due to the reimbursement method required for school services 27
  28. 28. Questions? DMAS Website DMAS telemedicine coverage description (“Provider Memo”, September 30, 2009) at b/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf Contact DMAS staff Jeff Nelson- 804-371-8857 or 28