from: Healthcare DIVE
- The House Energy and Commerce Committee released a “discussion document” seeking feedback on its 21st Century Cures initiative, which is filled with a number of healthcare IT proposals.
- Key provisions include one that would create a process at the US Food and Drug Administration to expedite the review of “breakthrough” medical devices; another that would require that data be shared by those receiving grants from the National Institutes of Health; and a third to advance telemedicine opportunities for Medicare beneficiaries.
- However, while suggestions within the provision for improving Medicare’s telehealth policy are broadly considered to be a step in the right direction, a letter from the American Hospital Association to committee chairman Rep. Fred Upton (R-MI) says they don’t go far enough.
The “Advancing Telehealth Opportunities in Medicare” proposal calls on HHS to draw up a methodology to expand coverage and payment for telehealth services nationally. There are limitations to the provision, however. It will only apply if the Centers for Medicare and Medicaid Services find that those telehealth services “would reduce [or would not result in any increase in] net program spending under this title.”
According to the AHA, the proposal does not address technology limitations within Medicare itself, or how remote monitoring would be funded.
“We also are concerned that the requirement for the Medicare actuary to certify telehealth cost neutrality for specific services would be hard for HHS to operationalize, and would add a time consuming step when technology is advancing at a rapid pace,” the AHA wrote.
Written by Helen Gregg | August 26, 2013
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan of South Carolina have announced the start of telemedicine coverage for beneficiaries.
Reimbursements will initially be limited to allopathic or osteopathic physicians in the specialties of stroke or vascular neurology, maternal-fetal medicine and psychiatry, delivered via two-way, real-time, interactive, secured and HIPAA-compliant electronic audio and video telecommunication systems.
Local practitioners are pleased by the announcement. “It’s a very big step, and it shows that they have a sense of commitment to telehealth,” said James T. McElligott, MD, medical director of telehealth at the Medical University of South Carolina in Charleston, in a report in The State.
“We are very hopeful that other payers in the state will follow suit,” said Meera Narsimhan, MD, vice dean of innovative healthcare technologies at the USC School of Medicine in Columbia, in the report. “Given the shortage of specialty providers and access in rural South Carolina, we need to be creative in the use of innovative technology tools to improve care for the citizens of South Carolina.”
As reported in SearchHealth IT – At the recent ATA 2012 annual meeting in San Jose, C3O Telemedicine organized a panel of experts to discuss optimizing reimbursement with accurate and regulatory compliant billing and coding. Quotes from the article include:
<SAN JOSE, CA — A doctor, a lawyer and a medical coding expert walk in to a room. While that might sound like the beginning of a really bad joke, health care CIOs must hear the punch line: “And they share their best strategies for getting telemedicine reimbursement from both commercial and government payers.”
Hospitals that are building telemedicine into their service lines are struggling to make sense of the labyrinthine system of legally coding and billing for them. Organizations that want bean counters to sign off on their clinicians’ otherwise solid ideas for new telehealth services have to begin by having conversations with those payers and understanding the different policies.
That’s what experts discussed in a session in at the American Telemedicine Association’s 2012 annual meeting, when telemedicine services vendor C30 Telemedicine CEO Herb Rogove took the stage along with his company’s EVP and attorney Patrick Moore, who specializes in legal issues surrounding telemedicine claims and compliance. They were accompanied by Kory Stetina, coding expert and founder of Torch Health Solutions, a consultancy specializing in getting large health systems’ telemedicine services paid.
They shared their experiences with the clinical and IT-minded attendees, and gave them ideas to take home and bring up in planning meetings — presumably, with coding staff in attendance — for telemedicine implementations. Currently, C30 and Torch’s most commonly reimbursed services include critical care consultations, inpatient emergency department consultations and some follow-up visits/services surrounding those consults.
“I think there are a lot of providers that avoid the practice of billing because we have a market that’s underdeveloped, and we have guidelines that are constantly changing — and I think that is to the detriment to the industry’s advancement, not to mention the expansion of the reimbursement policies themselves,” Stetina said in urging attendees to take on the payers and bill for telemedicine reimbursement.
While the speakers were careful not to offer advice on specific services — lest they incur liabilities or misrepresent reimbursement customs in one U.S. region as a national trend — they did offer plenty of general advice for organizations that want to bill for telemedicine services.
The tips that were offered include:
- Create a coding crosswalk for the services you as a provider typically provide via telemedicine, starting with CPT codes in the left-hand column, with columns representing each payer you deal with, as well as additional codes a payer requests when claims wend their way through the claims-processing department. Since each payer may use slightly different codes to define a particular telemedicine service, this reference will save time on successive claims and also create a “history” document that helps establish precedents for future claims.
- Proactively furnish documentation about the care provided, which helps prove your telemedicine services are exactly the same as those provided in-person and therefore should be reimbursed the same.
- While the federal Centers for Medicare and Medicaid Services (CMS) typically lead reimbursement trends — commercial payers follow their lead — remember that the reverse is true in telemedicine. If CMS rejects a claim, that doesn’t necessarily mean that commercial payers will, too. Stetina said that more than 130 private plans nationally reimburse for telemedicine services, and many states have laws either in effect or soon to go into effect that require coverage of telemedicine services.
- CMS introduced “G codes” a few years ago to begin ground work for reimbursing telemedicine services. They updated guidance on using “G codes” last year. Billing and coding departments who check the site regularly for more policy updates can take advantage of changes that further open reimbursement policies.
- Understand your liabilities. Billing CMS for telemedicine services is more of a legal risk depending on how densely populated your area is. That dictates what Office of Management and Budget statistical category you’re in, such as “metropolitan statistical area” (MSA), “micropolitan,” and so on — and CMS telemedicine reimbursement policies vary from region to region depending on population density — typically with more rural areas getting more favorable reimbursements. But it still can be done in the city, Moore said, as long as providers mitigate risks by following CMS rules and proactively repaying CMS when they demand it for perceived erroneous payments.
- ATA members can use the association’s “reimbursement central” area of the website to keep abreast of the latest changes in laws and telemedicine reimbursement policies among payers.
- Before submitting claims to a payer, request information on its telehealth coverage, coding guidelines and fee schedules to understand its present thinking regarding telemedicine reimbursement. Then, call the payer’s claims department — preferably a supervisor, or the supervisor’s supervisor, who will invariably understand your question much better than a front-line service rep — to glean tips for documenting care and submitting claims that are most likely to be paid.
Such payer consultations could be a double-edged sword, Moore said, because it might draw scrutiny on a provider, and possibly increase odds of claim denials. “If the payer tells you a claim is not covered, then you have to be extra careful if you go ahead and submit the claim so the payer doesn’t come back to you with an allegation that you misrepresented that you have a right to payment for that service,” he concluded.>
According to FierceHealth IT, the National Rural Health Association (NRHA) met this week in Washington, DC and made significant recommendations regarding telehealth reimbursement:
- Reimbursement for services provided through telehealth should be made based upon medical effectiveness and utilization and not based upon or limited to particular delivery platforms or locations.
- The Medicare law should be expanded to allow anything currently covered by Medicare to be reimbursed when provided through telehealth by appropriately licensed or credentialed providers otherwise eligible for Medicare reimbursement.
- A telemedicine payment methodology should be provided so that a professional fee is paid to all providers necessary to that particular encounter, including a technical fee to the facilities to cover costs associated with the technology at rates to be determined by the HHS Secretary.
- A separate Medicare billing code for telehealth consultations should be implemented to assist in monitoring the use of telehealth.
- A federal policy should be adopted to allow telemedicine providers to receive deemed status and to allow for healthcare facilities receiving telehealth services to perform credentialing by proxy. If a provider is already credentialed at a Medicare participating facility, that credential would be sufficient for providing telemedicine services at another facility.
For years the debate as to whether CMS(Medicare) should reimburse physicians for tele-ICU care has been receiving a resounding NO! Their decision is based on their belief that tele-ICU’s cannot be equated with on-site care. While most agree that there is no argument that onsite care is paramount, what is left is whether NO ICU care, especially for hospitals that have no intensivists, is better than Tele-ICU care. Our bias is that tele-ICU care means immediate care for acutely ill patients who without such care have a high risk for death. In addition, tele-ICU care certainly adds that extra expertise to help insure guidelines are followed and up to date evidence-based care is delivered to the 5 bed ICU equal to the care that one gets in the 32 bed ICU located in a large academic or tertiary care hospital.
McCambridge et al in the October issue of Chest believe that based on 13 studies showing improved patient survival and decreased length of stay for patients receiving tele-ICU should be the basis for providing reimbursement. This means not for just monitoring patients, but actively diagnosing and treating critically ill patients. The long and arduous task to convince those physicians who oppose this is based on finances – sharing that pie that fails to get larger. Realistically, the CMS data accumulated by the American College of Chest Physicians and the National Association for Medical Direction of Respiratory Care at eight existing tele-ICU programs revealed critical care charges amounted to 0.04% of the total Medicare charges for all physician services.
The counterpoint by Dr. S. Hoffman from The Ohio State University feels there should not be reimbursement because of uncertain benefit, the hospital is already reimbursing physicians, it serves as a disincentive for onsite care, and it de-values face-to-face care. In response to this is that there are several scientifically based good outcome studies, hospitals could enhance their already narrow financial margins if CMS paid, and the tele-ICU service is an extension which complements an onsite service that is the core value of having an intensivist program. A major barrier such as reimbursement only slows the growth and prevents hospitals that either cannot afford onsite intensivists nor can justify coverage for a few ICU beds. The question we all must weigh is that all patients no matter what their geographic location or financial background should ever be denied access to board certified intensivists? The past thirty years has shown the value of an intensivist team, so why limit our patient’s access to these needed specialists? Science and common sense we hope will ultimately prevail.
Proposals affecting telehealth: CMS is proposing to add smoking cessation counseling to the list of telehealth services. In addition, CMS is proposing to change the way additional services are added to the telehealth list by focusing on the clinical benefit, rather than on whether the telehealth service is equivalent to a corresponding in-person service. The proposed change would likely improve access to care by expanding the list of services eligible to be delivered via telehealth. If adopted, this would affect the evaluation of services discussed in the CY 2013 proposed rule.
According to ATA, this may mean tele-ICU and tele-stroke may be reimbursed based upon the key words “clinical benefit”. It most likely won’t come to discussion until preparation for the release of fiscal year 2013 codes.
For those who practice telemedicine in California, there may be some uplifting news. According to the California Telemedicine and eHealth Center, CTEC, “on March 31, 2011 Assembly Member Dan Logue’s bill, AB 415, was amended to allow for coverage of telemedicine visits by Medi-Cal for any service otherwise covered by Medi-Cal. The billing rates and services covered would remain consistent with those applicable at in person visits. It is the intent of the Legislature to recognize the practice of telehealth as legitimate means by which may receive health care services from a healthcare provider without person-to-person contact with the provider”.
CTEC’s website can be viewed for more information and also check our Resource Page for further information.
I in recent chat with Dr. JIm Mathers (posted on the American Telemedicine HUB), past president of the American College of Chest Physicians and advocate of telemedicine “the Category III code will expire in 1.5 years. The AMA has not responded to my request for information. As far as I can tell from talking to VISICU no one has been using the code. The only way to keep it on the books is for one of the professional organizations with a seat on the CPT advisory panel to submit a request for it to be moved to a Category I code or be renewed as a Category III Code. With no member pressure, the ATS, ACCP and SCCM leadership have repeatedly stated their opposition to the establishment of a Category I code so I think that is a dead issue. While they might support continuation of a Category III code it is unlikely to be successful with little or any current use of that Code.”