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Medicare Evaluating Payments for Telehealth

Virtual Health

Telehealth is undoubtedly the wave of the future when it comes to delivering healthcare. In fact, there are many examples of health systems turning to telehealth to connect patients with providers. Although there are many burdens to full telehealth implementation, one major barrier has been payment. Fortunately, Medicare in its recently proposed rule has outlined some opportunities for payment in a push towards a more virtual health environment.

Virtual Check-Ins

CMS has proposed three different types of visits or services that may be payable in 2019. The first service is a Virtual Check-In. This service would be billable when a health care professional has a brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit. CMS stated that if the encounter originates from an E/M service provided within the previous 7 days or within the next 24 hours, it would not be a billable service but bundled into that visit. Finally, if it does lead to an in-person visit, it would not be billable.

The Virtual Check-In provides significant opportunity for organizations to focus more on the customer. Historically, the health care provider was incentivized to have the patient physically come into a visit, even if it was for a checkup and/or education. This type of visit allows the provider to receive payment but also for the patient to reduce their payment while still receiving the same service. It is important to remember that medical necessity it still required even when billing under this future code. Above all, this type of service represents a significant opportunity for both patients and providers.

Remote Evaluation of Pre-Recorded Patient Information

Another proposed billable service includes when a provider uses recorded video and/or images captured by a patient in order to evaluate a patient’s condition. Specifically, CMS is proposing to create specific coding that describes the remote professional evaluation of patient-transmitted information conducted via pre-recorded “store and forward” video or image technology.

Much like the service above, there are restrictions. If the remote evaluation results in an office visit, it would not be payable. In addition, if it originates from a visit within the previous 7 days or leads to a visit within 24 hours, it would not be payable. This is a unique code in that it could have a huge impact on the way skin disease is addressed. This could significantly change both revenue and access when it comes to dermatological care and many other specialties that could rely on remote evaluation.

Interprofessional Internet Consultation

“As part of this shift in medical practice, and with the proliferation of team-based approaches to care that are often facilitated by electronic medical record technology, we [CMS] believe that making separate payment for interprofessional consultations undertaken for the benefit of treating a patient will contribute to payment accuracy for primary care and care management services.” In other words, CMS is now interested in paying for true consultation for the benefit of the patient.

CMS outlined some general concerns though. First, CMS does not intend to pay for a consultation in which it solely benefits the provider. For example, a physician talking with another physician on general education would not benefit a specific patient and therefore would not payable. Second, CMS wants to ensure patients provide consent to this consultation. This is interesting simply because HIPAA already contains exceptions for treatment purposes. However, it would result in potential payment from a patient. Finally, CMS is seeking comment as to how to assess these services being reasonable and necessary.

Future of Industry and Telehealth

You can read more about these proposed changes here, but it is important to remember where the industry might be going with these types of changes. First, organizations should start focusing on specialties in which a virtual check-in is both a revenue generator but also beneficial to the patient. For example, if you have a family nurse practitioner treating a patient for diabetes, the patient might not physically have to come in except for every 2 months. However, perhaps a virtual check-in could be performed between in-person visits but also lengthening the time to perhaps 2.5 months for when a patient comes in.

Second, organizations across the country should start developing plans for the evaluation of patient via image or store and forward technology. This area provides a great opportunity for both traditional health systems and non-traditional delivery of care. Finally, although CMS is proposing payment for consultations, organizations should begin their own focus groups with providers to understand when this might be beneficial. As with any of these proposals, there needs to be a clear process and strategy for developing these opportunities for your organizations and patients.