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TeleHealth Reimbursement – Driving Value-based Outcomes
Fee for Service, Value Based Purchasing, Shared Savings
Two-way live interactive video and audio between the provider and patient.
The patient must be present – if not required to be present – is not considered TeleHealth.
It is not TeleHealth for the purposes of reimbursement if the connection between a provider and patient is on the same campus.
Post-surgical updates to familySupervising residentsCovering the inpatient units from EDAny other situation where walking takes away patient
seeing time
CMS Definition of TeleHealth
WHERE WE ARE NOW WITH MEDICARE
Medicare will cover office visits and consults as well as some
other services that are provided via Telehealth, as long as the
patient's actual location is either in a HPSA or outside of a MSA
(metropolitan statistical area). Medicare will reimburse covered
services as long as: 1) the services are on the Medicare covered service list, 2) the
services are provided by eligible providers, and 3) the services are performed at eligible originating
sites.
ALGORITHM FOR MEDICARE REIMBURSEMENT
Patient Outside
of A MSA
Services within CPT code
Range
Services Delivered
by Eligible
Practitioner
Patient in Designat
ed Originating Site
SUBSEQUENT HOSPITAL CARESubsequent hospital care services,with the limitation for the patient’s
admitting practitioner of one telehealth visit every 3 days
PROCESS FOR REIMBURSEMENT Develop a specific appointment
type for TeleHealth/Telemedicine Use standardized modifier on all
claims (GT) Electronics comment “Services
provided by TeleHealth” Bill the facility fee when
appropriate Q3014 – 1500 form- need an appointment – billed under supervision physician
Do not include other procedures, test, services provided in-person in conjunction with the TH visit (peak flow, walking pulse ox, debridement)
Watch your reimbursement!
FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) Patient is physically present at the FQHC Specialist is a provider not physically present at the
FQHC FQHC and specialist have agreement to provide
services, but FQHC does not compensate the specialist Medical reason for a provider to be present with
patient at the FQHC site Patient ‘virtually’ enters specialist site via
telemedicine specialist is the provider site and can bill fee-for-
service rate. FQHC provided a medically necessary service, thus
also a provider site, and can bill PPS for a face-to-face visit.
COST REPORTING Medicare hospital cost report Form CMS
2552-96
The Refinement Act (BBRA) of 1999, requiring hospitals to report information on the uncompensated care they provide.
Provides Secretary of Health and Human Services with the data necessary to develop a Medicare disproportionate share hospital payment methodology that takes into account the cost of providing care to uninsured and underinsured patients as recommended by the Medicare
Payment Advisory Commission.
FACILITY FEES
Q3014 HCPCs code Billed by the site with the PATIENT Can be the same organization providing
the consulting services Billed on UB form (technical component) Site of service is where the patient is Billing entity is the facility linked to an
on-site MD
CMMS, MEDICAID AND TELEMEDICINEThe Centers for Medicare & Medicaid Services
(CMS) has not formally defined telemedicine for the Medicaid program, and Medicaid law does not recognize telemedicine as a distinct service. Nevertheless, Medicaid reimbursement for services furnished through telemedicine applications is available, at the state's option, as a cost-effective alternative to the more traditional ways of providing medical care (e.g., face-to-face consultations or examinations).
Many states are allowing reimbursement for services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs.
MEDICAID PROCESS FOR REIMBURSEMENT
Use the same modifier as Medicare if ableFlag all claims as TeleHealth
Do not bill if not a covered serviceInclude in cost report
MEDICAID STATE/HMO/PPOCONTRACTING FOR SERVICES
Agreement between single entity and the health care provider
No restrictions unless agreed upon by the parties
Payment usually at a predetermined contract rate – look at your standard and customary rates
Contract for typical services
MEDICAID AND HEALTH CARE REFORM
PROVISIONS
(f) Monitoring- A State shall include in the State plan amendment--
(1) a methodology for tracking avoidable hospital readmissions and calculating
savings that result from improved chronic care coordination and management under
this section; and`(2) a proposal for use of health information technology in
providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient
technology to improve coordination and management of care and patient adherence to recommendations made by
their provider).
HEALTH CARE REFORM…
Medicaid “health home” option for chronic care (section 2703)
Medicare “accountable care organizations” demonstration (section 3022)
Medicare “independence at home” demonstration (section 3024)
Center for Medicare and Medicaid Innovation (section 3021)
PROBLEM WITH DUAL ELIGIBLE PATIENTS AND TELEHEALTH
Bill Medicare for approved TeleHealth CPT Code
Medicare denies and automatically sends claim to Medicaid
Medicaid uses a different CPT code for TeleHealth services
Medicaid denies the service based on the fact that Medicare was not billed first
Resubmit the claim to Medicaid!
OTHER GOVERNMENT PAY RELATIONSHIPS
Waivers
HMO/PPO Medicaid Contracts
Medicare Advantage Plans
State Residential FacilitiesDirect contracting with the
StateFederal demonstration
projects
Tell Them Who You Are – Centers of Excellent, Leaders in X
National Overview of TeleHealth Demonstration of How It Works VISUALS!!!!! Testimonial by Enrollees of Health
Plan who Have Used TeleHealth Video Clips of Visits Share Internal Data – Volume,
Performance, Outcomes Outline Program Description –
Services, Quality Improvement, Sites
Specific Health Plan Data Outline the Program Request
APPROACHING HEALTH PLANS
PROPOSALS
Pay for Everything the Same as In-Person
Do Not Accept the Medicare Approach
If you get a NO –Consider suggesting a one year pilot
Suggest a Two Year Population Specific Program
PROPOSALS
Pay for Everything the Same as In-Person
Do Not Accept the Medicare Approach
If you get a NO –Consider suggesting a one year pilot
Suggest a Two Year Population Specific Program
BEG
DO NOT TAKE ‘NO’
FOR AN ANSWER
Your Other Money…..
REIMBURSEMENT
Typically payment for clinical services
Set or negotiated fees Medicare, Medicaid, County, Private
Payers, Self-Funded Payers, Patients, Families
Endowments, Charity Purchasing Groups – Under, Non-
insured State Budget Line Item
PAYMENT FOR SERVICES
Organization bills professional fees Bills and collects independent of third
party Typically for specific service rendered: software, maintenance, single specialty
Direct Bill to organization for patient care
Cash, credit card payments Usually contractually based
State Budget Line Item
Store-and-forward services Occupational Medicine School Clinics Dermatology Self – Insured Employers Workers Compensation Carriers Insurance Plans Primary Care Services Specialty Care Services Diabetes Services
CONTRACTUAL FEES
All types of business arrangements and TeleHealth organizations – clinical, network, vendor
Typically outlines services to be delivered
May be based on RFPs Outlines detailed arrangement Schedule of Fees Provide off-site services: billing,
coding, network management Don’t forget to go after contracts:
State, Feds, DOD, etc.
INCREASE IN OTHER ORGANIZATIONAL SERVICES
Ancillary Services Patient Visits – Practice Productivity Use of other departments: R/D,
Technology, Helpline
SUPPORT OF BUSINESS DEVELOPMENT
Testing of new markets Component of a package of services Relationship builder Grant partner
EXPENSE REDUCTION
Decrease in cost of other services or initiatives:
Mobile ServicesMD and supportive personnelAdvanced and allied practitioners versus MDs
Reduction in white space and no-shows
Reduction in cost of outreach
REDUCTION IN WHITE SPACE (NO SHOWS, CANCELLATIONS, NO APPT)
Look at average revenue per visit Identify lost time in schedule Calculations:
$164 for Level III Office visit15% white space in schedule 37 hours per week productive
time5.6 hours of white space = $164 x 2 visits/hr x 5.5 hours =
$1,836.80
HEART FAILURE CLINIC NP Clinic uses TeleHealth to enroll
health plan patients with Congestive Heart Failure Primary diagnosis
Entered into standardized program that includes regular NP visits, education, and coaching
Use of TeleHealth to get all patients enrolled at low cost to organization and without additional staff.
Savings to the health plan led to a $216 per month per member payment (+ prof component
DIABETES OUTCOMES
HgA1c levels Blood Pressure Foot Exams Appropriate hyperglycemic therapy How many Endocrinologists are
there in your service area? Tele-Endocrinology
Patients have better HgA1c control, blood pressure control, meet annual foot and eye exam requirements, when seen via TeleHealth Better patient compliance No loss to follow-up Fewer cancellations and no show
OUTREACH
Average number of RVUs per day on campus
Average number of RVUs per day on outreach
Interventionalists going to sites without procedure resources (Cardiology, Ortho)
Cardiology ExampleOutreach 5-11 RVUsOn campus + TeleHealth = 37 RVUs
CMS MEANINGFUL USE METRICS
health outcomes clinical processes patient safety efficient use of health
care resources care coordination patient engagements population and public
health adherence to clinical guidelines
The 6 NQS domains are:1. Patient and Family Engagement2. Patient Safety3. Care Coordination4. Population/Public Health5. Efficient Use of Healthcare Resources6. Clinical Process/Effectiveness
PRIMARY CARE MEDICAL HOME
Identifying patients at highest risk for hospitalization, based on specific criteria, and put those patients on remote monitoring, safety measures, and in-home video. Value? = Bonus and incentive payments
MEDICAL HOME Care Coordination Model Transitional Care Model Extends the care team into the home Objectives of reduced hospitalizations
and avoidance of rehospitalization within 31 days
Keeping people healthier and happier
TRANSITIONAL CARE MODEL
Following a patient from discharge from acute care admission for 60 days to prevent re-admission. Use remote monitoring and care coordination staffwith
interactive video consultations as a tool.
CONTRACTING FOR SHARED SAVINGS – ECONOMIC ANALYSIS Average cost of hospitalizations -
$17-22,000 Average hospitalizations per year
for high risk patients 3-15 Shared savings contracts – 50% Based on 100 high risk patients
SHARED SAVINGS – CALCULATION OF VALUE
Number of
Patients
Average Cost of
Hospitalization
# of Hospitalizatio
ns per Year
Cost Burden Shared Savings Program
Average Cost Of Remote
Monitoring*
1 $17,000 3 $51,000 $25,500 $1,900
100 $17,000 7 $5,100,000
$2,550,000
$190,000
100 + RN
$17,000 7 $5,100,000
$2,550,000
$290,000
1 $22, 000 3 $66,000 $33,000 $1,900
100 $22,000 7 $6,600,000
$3,300,000
$190,000
100 + RN
$22,000 7 $6,600,000
$3,300,000
$290,000*Assumes one kit per patient*Add-in cost of RN for 100 high risk patients = $100-150,000 salary and benefits (regional)
CALCULATIONS
# of Hospitalizations x % Reduction x # of High Risk Patients = Cost Savings
Cost Savings – Cost of Remote Monitoring/Patient = Net Savings
Don’t Take this approach!
