Telehealth and Challenges in Reimbursement

Telehealth and Challenges in Reimbursement

By Lynn Gibson, Chief Technology Officer/VP, CHRISTUS Health

Lynn Gibson, Chief Technology Officer/VP, CHRISTUS Health

To borrow from the opening lines of the 70’s TV show “Six Million Dollar Man”—we have the technology, we have the capability—well that is almost where we are with telehealth today but we are still fighting one big issue.  How do we get paid?

There are different variations of a telehealth service. You could be providing the service to new patients, existing patients, or a combination of both. You could be contracting to have specialty services provided to you by either in state or out of state physician groups. Those physicians might be independent in state doctors already credentialed or practioners out of state. There is also the use of physician extenders such as Nurse Practioners or Physician Assistants. You could be offering only to rural area locations, online through your consumer portal, through contracted targeted locations in urban areas, or some combination of all. So, you might be thinking, so what is the point. Dependent your State(s) regulatory processes, you may not always be eligible to bill for all or some of those services because of who is served when and how by whom. Your insurance contracts may or may not include telehealth in your reimbursement fee schedule. Your medical staff credentialing process may or may not provide for support of out of state providers. These are just a simple beginning to the complexity of the ability to bill for the services.

There are a number of changing parameters regarding reimbursement for telehealth services.  Only recently has the Federal Government really weighed in on helping with both physicians and providers being able to charge for technology-driven services. The early assistance was focused on providing to rural or underserved markets, but the evolving technology and demands of the US consumer market, the Federal Government is granting more support. However, many states are slow in being as supportive. This impacts insurance companies’ willingness to change their contracts with providers. It is only in the past few years that insurance companies are starting to understand the benefits, both clinically and economically of providing the services through technology. This has come partially as states begin to adopt legislation requiring them to cover such payments.

" “Early is on-time, on-time is late, and late is unacceptable!” Will your organization be early or just in time for the telemedicine world of tomorrow? "

Many states vary on reimbursement and execution requirements.  For example, some states support reimbursement only with existing patient to physician relationships. Others will support a range from video reimbursement with first time encounters to a “store and forward” video engagement. Some will require a special licensing of the physician before telehealth services can be offered. Slightly more than half of the states have established a special informed consent policy that must be abided. The variations can be a challenge to large providers who operate in multiple states.

For a more direct comparison, the State of Louisiana recently passed the Louisiana Telehealth Act this past June which prohibits payers from requiring an in-person visit as a condition of payment.  It is one of nine states that requires special licensure by the physician to provide telemedicine services.  It is also one of 26 states that has specific requirements for an informed consent for telemedicine.

Although many states have already passed legislation covering payment requirements by insurers, several states have pending legislation to insure coverage. The pending legislation varies from state to state as to what it may address or require. This makes preparation more challenging to meet the demand for such services. Many of States have specifically addressed the payment through their Medicaid program to insure the under insure have access.

Much of this would be the domain of the revenue cycle teams to follow and adopt as appropriate. So, what would this mean to the information technology department of a provider? IT departments are at the center of process flows to insure the different components connect; provide the ability to capture the correct data and pass the information as needed. The IT department must insure the application environment is ready to meet the requirements of the telemedicine program.  It cannot rely on a telemedicine platform by itself. The different supporting applications and interfaces must be ready as well. 

The following are some suggested questions to start the thought process. Can your telemedicine tools connect with Medical Staff Office’s credentialing programs; can your telemedicine tools properly interface with the Revenue Cycle systems; does your EHR accept the documentation to meet the state compliance requirements for the telemedicine program; does your consumer facing website for telemedicine maintain the proper tracking tools and meet the state informed consent requirements? Are you providing the services and then billing the patients or are you contracting for these services and passing the bill to the patient? What services are setup to be billed and how will they be identified and captured? Do you have systems compliant with both state and federal laws? These few questions are just a sample of the questions to begin the thought process which IT must insure exists within the healthcare provider application environment.  If you are involved with a large organization that happens to be multi-state, the level of complexity is potentially exponentially more complex.

Telemedicine is the future of healthcare. The disruptive nature of this new approach will not only transform the processes of the provider world, it will represent a significant change in focus for many Information Technology providers. Providers must be ready to bill for the services when and where they are provided as soon as they are allowed.  An old phrase used in different environments is: “Early is on-time, on-time is late, and late is unacceptable!” Will your organization be early or just in time for the telemedicine world of tomorrow?

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