Telehealth in Missouri’s HospitalsAn Update

Ben HarveyAssociate Director

Missouri Telehealth Network

Disclaimer: I am not a lawyer.

The time is now for telehealth

Here is what a Hospital needs to know

https://www.americanwell.com/service-lines/urgent-care/

https://mhealthintelligence.com/news/kaiser-ceo-telehealth-outpaced-in-person-visits-last-year

https://mhealthintelligence.com/news/kaiser-ceo-telehealth-outpaced-in-person-visits-last-year

700,000 Veterans receive telehealth services (2016)

VA Video Connect

VA physicians can use telehealth no matter where that veteran is located (state licensing laws need not apply)

https://newtmobile.com/

Real Numbers

Rapid expansion of telehealth services to Medicare beneficiaries

(78% increase in 2 years).

Medicare Payment Advisory Commission (MedPAC) 2018 Report

The global telemedicine market, valued at $18.2 billion in 2016, will be double that by 2022

What about Missouri?

20132011 20122010

2014 2015

MO HealthNet Telehealth Encounters by County

(Medicaid)

Major Change

Before we discuss what is affected, let’s go back in time….

RSMo 191.1145, 191.1146 and 208.670-677 (2016), created via Senate Bill 579 (2016) set new direction for telehealth in Missouri

• Expanded the definition of “who” and “where” (191.1145-46)

• Required MO HealthNet to “promulgate new rules governing the practice of telehealth” (208.670)

• Required coverage for services not previously covered by MO HealthNet (208.670)

HB 1617- TAFP and Signed

• Went into effect, Aug. 28, 2018

• Removes conflict between 2 areas of law (Rescinds RSMo 208.671-5, refines RSMo 191.1145, 208.670, and 208.677)

• Directs MO HealthNet’s administration of telehealth services

Key Language:The department of social services shall reimburse providers for services provided through telehealth if such providers can ensure services are rendered meeting the standard of care that would otherwise be expected should such services be provided in person. The department shall not restrict the originating site through rule or payment so long as the provider can ensure services are rendered meeting the standard of care that would otherwise be expected should such services be provided in person. Payment for services rendered via telehealth shall not depend on any minimum distance requirement between the originating and distant site. Reimbursement for telehealth services shall be made in the same way as reimbursement for in-person contact; however, consideration shall also be made for reimbursement to the originating site. Reimbursement for asynchronous store-and-forward may be capped at the reimbursement rate had the service been provided in person.

MedicaidWho can provide telehealth???

Anybody!.......as long as they are a licensed health care provider.

RSMo 191.1145 (2). Any licensed health care provider shall be authorized to provide telehealth services if such services are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person.

RSMo 376.1350- Healthcare Provider = (19) "Health care professional", a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services consistent with state law

MedicaidWhere can telehealth occur?

Anywhere!…..so long as it does not alter the scope of practice of a health care provider or fail to meet the standard of care

No mileage/geographic restrictions!

RSMo 191.1145 (3) “Distant site”, a site at which a health care provider is located while providing health care services by means of telemedicine;

and

RSMo 191.1145 (5) “Originating site”, a site at which a patient is located at the time health care services are provided to him or her by means of telemedicine.

Medicaid

Store and ForwardMO HealthNet allows “asynchronous store-and-forward transfer”. This means that a patient’s health records can be saved at one point, then sent from an originating site to a health care provider at a distant site. The main point being the patient may not be at the site when the files are sent and reviewed.

ReimbursementReimbursement to the health care provider delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Must use POS “02” code for distant site, and POS “03” and GT modifier when services are provided on school grounds.

SchoolsMust get consent from parent/guardian to provide telehealth services. Parent/guardian may authorize services via telehealth for a whole school year (RSMo 208.677).

Can RHCs be distant sites?

YES!

But wait!

No changes, just clarification

Medicare

Patients must be in a rural area.

Unless you are doing home dialysis.

Medicare

No big changes

Who and Where are restricted

Annual Medicare Telehealth Services Guide

Originating sites 42 USC 1395m(m), and Medicare Benefit Policy Manual, R239, Chapter 13, Section 200.Medicare Claims Processing Manual, R4068m Chapter 12

Originating sites are the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in:

• A county outside of a Metropolitan StatisticalArea (MSA) or• A rural Health Professional Shortage Area (HPSA) located in a rural census tract

Telehealth Payment Eligibility Analyzer

https://datawarehouse.hrsa.gov/tools/ analyzers/geo/telehealth.aspx

Originating sites 42 USC 1395m(m), and Medicare Benefit Policy Manual, R239, Chapter 13, Section 200. Medicare Claims Processing Manual, R4068m Chapter 12

• Originating site reimbursement for 2018 is $25.76.

• Use HCPCS code Q3014 for the originating site fee

• A medical professional is not required to present the beneficiary…unless medically necessary.

• The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance.

• The originating site facility fee for telehealth services is not a RHC service. The originating site facility fee must be paid separately from the center or clinic all-inclusive rate.

RHCs are not authorized to be distant sites under Medicare

(e.g. provider at a RHC Site cannot provide services via telehealth to patient at any originating site and receive reimbursement) Medicare Benefit Policy Manual, R239, Chapter 13, Section 200

This includes telehealth services that are furnished by….RHC practitioner who is employed by or under contract with the….RHC, or a….non-RHC practitioner furnishing services through a direct or indirect contract.

Something to keep an eye on

2019 proposed rule Medicare Physician Fee Schedule update(Comment period closed Sept. 10)

Medicare proposes new types of physician payments for the use of “communication technology”.

“These services would not be subject to the limitations on Medicare telehealth services in section 1834(m) of the Act because, as we have explained, we do not consider them to be Medicare telehealth services; instead, they would be paid under the PFS like other physicians' services.”

Essentially, for the following proposed payments, the Medicare telehealth rules do not apply.

1. BRIEF COMMUNICATION TECHNOLOGY-BASED SERVICE, E.G., VIRTUAL CHECK-IN (HCPCS CODE GVCI1)

• Brief check-in services furnished using communication technology that are used to evaluate whether or not an office visit or other service is warranted.

• Provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

• Medication Assisted Therapy (MAT) as an example

2. REMOTE EVALUATION OF PRE-RECORDED PATIENT INFORMATION (HCPCS CODE GRAS1)

• Services may be used to determine whether or not an office visit or other service is warranted.

• Distinct from the brief communication technology-based service described above in that this service involves the practitioner's evaluation of a patient-generated still or video image, and the subsequent communication of the resulting response to the patient

3. INTERPROFESSIONAL INTERNET CONSULTATION (CPT CODES 994X6, 994X0, 99446, 99447, 99448, AND 99449

• Currently, the resource costs associated with seeking or providing such a consultation are considered bundled

• We believe that proposing payment for these interprofessional consultations performed via communications technology such as telephone or internet is consistent with our ongoing efforts to recognize and reflect medical practice trends in primary care and patient-centered care management within the PFS

4. EXPANDING THE USE OF TELEHEALTH FOR INDIVIDUALS WITH STROKE UNDER THE BIPARTISAN BUDGET ACT OF 2018

• The Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished

• Proposing to create a new modifier that would be used to identify acute stroke telehealth services

5. EXPANDING ACCESS TO HOME DIALYSIS THERAPY UNDER THE BIPARTISAN BUDGET ACT OF 2018

• Using telehealth to provide monthly clinical assessments to home dialysis patients.

Regular Updates to telehealth codes (coming in 2019)

HCPCS codes G0513 and G0514 will be added for reimbursement

(Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service) and (Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)

Private Insurers

Two things to keep in mind:

1. If it is a covered service it cannot be denied because it was provided via telehealth

RSMo 376.1900.2- Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2014, shall not deny coverage for a health care service on the basis that the health care service is provided through telehealth if the same service would be covered if provided through face-to-face diagnosis, consultation, or treatment.

Two things to keep in mind:

2. Telehealth services must be paid on the same basis as in-person visits

RSMo 376.1900.4- A health carrier shall not be required to reimburse a telehealth provider or a consulting provider for site origination fees or costs for the provision of telehealth services; however, subject to correct coding, a health carrier shall reimburse a health care provider for the diagnosis, consultation, or treatment of an insured or enrollee when the health care service is delivered through telehealth on the same basis that the health carrier covers the service when it is delivered in person.

Non-reimbursementConsiderations

Ryan Haight Act

Haight Act

Providers must have at least one in-person visit with a patient before prescribing controlled substances……..unless you use telemedicine.

21 USC 829 (e)- (1) No controlled substance that is a prescription drug as determined under the Federal Food, Drug, and Cosmetic Act [21 U.S.C. 301 et seq.] may be delivered, distributed, or dispensed by means of the Internet without a valid prescription

(2)(A)- The term "valid prescription" means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by-

(2)(A)(i)- a practitioner who has conducted at least 1 in-person medical evaluation of the patient

(3)(A)- Nothing in this subsection shall apply to-

the delivery, distribution, or dispensing of a controlled substance by a practitioner engaged in the practice of telemedicine;

Haight Act- What is “the practice of telemedicine”?

To circumvent the in-person requirement, patient must be in a DEA registered clinic/hospital or be in the presence of a DEA registered provider.

21 USC 802 (54)- The term "practice of telemedicine" means…the practice of medicine…which practice

(A) Is being conducted-(i) while the patient is being treated by, and physically located in, a hospital or clinic registered under section 823(f) of this title; and(ii) by a practitioner-

(I) acting in the usual course of professional practice;(II) acting in accordance with applicable State law; and(III) registered under section 823(f) of this title in the State in which the patient is located,

(B) is being conducted while the patient is being treated by, and in the physical presence of, a practitioner (i) acting in the usual course of professional practice;(ii) acting in accordance with applicable State law; and(iii) registered under section 823(f) of this title in the State in which the patient is located

Haight Act

There is a notable (thought currently not possible) exception…..we will talk about it later.

21 USC 823(f)-

The Attorney General shall register practitioners (including pharmacies, as distinguished from pharmacists) to dispense, or conduct research with, controlled substances in schedule II, III, IV, or V and shall modify the registrations of pharmacies so registered to authorize them to dispense controlled substances by means of the Internet, if the applicant is authorized to dispense, or conduct research with respect to, controlled substances under the laws of the State in which he practices. The Attorney General may deny an application for such registration or such modification of registration if the Attorney General determines that the issuance of such registration or modification would be inconsistent with the public interest. In determining the public interest, the following factors shall be considered:

(1) The recommendation of the appropriate State licensing board or professional disciplinary authority.

(2) The applicant's experience in dispensing, or conducting research with respect to controlled substances.

(3) The applicant's conviction record under Federal or State laws relating to the manufacture, distribution, or dispensing of controlled substances.

(4) Compliance with applicable State, Federal, or local laws relating to controlled substances.

(5) Such other conduct which may threaten the public health and safety.

Haight Act

Example:• Physician located in Springfield,

Nurse Practitioner and patient located in Monett Clinic, 40 miles to the west (both physician and NP are DEA registered)

• Physician utilizes live, interactive telemedicine to see patient in Monett, while Nurse Practitioner is physically present with the patient

• Physician can prescribe controlled substances without an in-person visit (e.g. buprenorphine)

Haight Act

In order to avoid sanctions, if you use telehealth to prescribe controlled substances without an in-person visit, you

• MUST be a DEA registered practitioner

• MUST have a DEA registered practitioner physically present with the patient or the clinic the patient is located in must have a DEA registration

• MUST act in the usual course of professional practice

Telehealth for Collaborative Practice

Telehealth for Collaborative Practice

RSMo 335.175.1- An advanced practice registered nurse (APRN) providing nursing services under a collaborative practice arrangement under section 334.104 may provide such services outside the geographic proximity requirements of section 334.104 if the collaborating physician and advanced practice registered nurse utilize telehealth in the care of the patient and if the services are provided in a rural area of need.

RSMo 354.650- Rural area of need means any rural area of this state which is located in a health professional shortage area.

Note: Nearly every rural part of Missouri is a HPSA

The provisions of this law sunset in August 28, 2019, unless reauthorized by MOGA.

Example:

Collaborating Physician in Cape Girardeau, Nurse Practitioner in Bloomfield, providing telehealth services to patients in Doniphan

Bloomfield is 44 miles from Poplar Bluff, Doniphan is over 100 miles from Poplar Bluff

Without telehealth the NP could not provide services in Doniphan, due to mileage restrictions

If using telehealth, this law allows the NP to exceed the normal mileage restrictions and to provide care in Doniphan under the collaborative practice agreement

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and

Treatment for Patients and Communities Act

(SUPPORT Act)

SUPPORT Act

Medicaid substance use disorder treatment via telehealth.

• Directs CMS to issue guidance to states on options for providing services via telehealth that address substance use disorders under Medicaid.

• And issue a couple of other telehealth reports.

(i.e. CMS must create a nice report for States)

SUPPORT Act

Expanding the use of telehealth services for the treatment of opioid use disorder and other substance use disorders (Medicare).

• Expands telehealth services by eliminating some originating site requirements for services furnished to Medicare beneficiaries for the treatment of substance use disorders and co-occurring mental health disorders, beginning July 1, 2019.

• Allows payment for those services furnished via telehealth at originating sites, including a beneficiary’s home, regardless of geographic location. A separate facility fee would not be provided if the originating site is the beneficiary’s home.

No geographic requirementsPatient’s home is an approved originating site

SUPPORT Act

Section 3232. Regulations relating to special registration for telemedicine.

• Federal law permits the Attorney General to issue a special registration to health care providers to prescribe controlled substances via telemedicine in legitimate emergency situations, such as a lack of access to an in-person specialist.

• Unfortunately, the waiver process has never been implemented through regulation, and some patients do not have the emergency access they need to treatment. This provision directs the Attorney General, with the Secretary of Health and Human Services, to issue final regulations (e.g. who and how) within one year of enactment.

Remember the Haight Act? This will create a loophole.

Interstate Compact for Psychologists

SB 660 (and SB 951, HB 1719, HB1419, HB1629, and HB1896)

“Psychology Interjurisdictional Compact”aka “PSYPACT”

(RSMo 337.100-337.165) (MO, IL, NE, CO, AZ, UT, NV)

Psychology Interjurisdictional Compact

Allows psychologists to provide “telehealth” services without getting an additional state license

RSMo 337.100.2(1)The general purpose is.. Increase public access to professional psychological services by allowing for telepsychological practice across state lines as well as temporary in-person, face-to-face services into a state which the psychologist is not licensed to practice psychology;

Check with the Missouri Committee of Psychologists.

Sorry, but…………Compacts don’t increase access to care (according to available literature)

Steps to Consider with Telehealth Implementation

http://caltrc.org/wp-content/uploads/2014/12/Complete-Program-Developer-Kit-2014.pdf

We have resources available….Our protocols, American Telemedicine Association processes, and processes from our fellow Telehealth

Resource Centers

Two of the best

The Office of the National Coordinator for Health IThttps://www.healthit.gov/sites/default/files/playbook/pdf/telehealth-startup-and-resource-guide.pdf

California TRC Program Development Kithttp://caltrc.org/wp-content/uploads/2014/12/Complete-Program-Developer-Kit-2014.pdf

Wrap-up

Take advantage of telehealth to support/expand the services you provide!