Telehealth, Technology and Payment Health Thad Dickson, Xpio
Health HCISSP, CPHIMS, PMP, MCTS Dec 2014
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What is Telemedicine? 2 Health Telemedicine generally refers to
the provision of clinical services from a distance.
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What is Telehealth? 3 Health Telehealth is a collection of
means or methods for enhancing health care, public health, and
health education delivery and support using telecommunications
technologies.
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Does Technology Transform Healthcare? 4 Health Yes but
Innovation is unevenly applied Technology is difficult to deploy
Access and affordability are key issues
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Michael E. Porter and Thomas H. Lee Health HBR 2013 The
Strategy that will fix healthcare Technology Enabled Bending of
Cost Curve Telehealth = Expansion of Services Across Geography
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How Does Telehealth Work? 6 Health Live Videoconferencing
(Synchronous): Live, two-way interaction between a person and a
provider using audiovisual telecommunications technology.
Store-and-Forward (Asynchronous): Transmission of recorded health
history through an electronic communications system to a
practitioner, usually a specialist, who uses the information to
evaluate the case or render a service outside of a real-time or
live interaction.
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How Does Telehealth Work? 7 Health Remote Patient Monitoring
(RPM): Personal health and medical data collection from an
individual in one location via electronic communication
technologies, which is transmitted to a provider in a different
location for use in care and related support. Mobile Health
(mHealth): Health care and public health practice and education
supported by mobile communication devices such as cell phones,
tablet computers, and PDAs. Applications can range from targeted
text messages that promote healthy behavior to wide-scale alerts
about disease outbreaks, to name a few examples.
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Behavioral Health and Telehealth 8 Health Quality care requires
2 main key components: 1.Correct and Current Information 2.At the
right place with the right expertise
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Its around here somewhere 9 Health
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Maybe over here, in the EHR 10 Health
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Accurate and accessible Information Diagnosis Problem List
Notes / Care Plan Risks History Family Hx Medication, allergies
Labs and Images Primary language, culture Your EHR should have this
11 Health But Is it accurate and accessible? Summary of Care
Reports? QA process? Review with patients? Process to change
inaccurate data? Accessible to patients?
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Health Care Coordination - including requirements to coordinate
care across settings and providers to ensure seamless transitions
for patients across the full spectrum of health services including
acute, chronic, and behavioral health needs. Quality Reporting
reporting of encounter data, clinical outcomes data, and quality
data. Two of the core Criteria from the Excellence Act
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Health Stage 2 Meaningful Use Criteria
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Health Disease Applicability
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Health Psychiatry
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Health Methods Source: Thomas Nesbitt, MD, MP UC Davis
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Health Disease Applicability Source: Thomas Nesbitt, MD, MP UC
Davis
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Health Clinical Improvement (1 follow) Source: Thomas Nesbitt,
MD, MP UC Davis
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19 LOWER COSTS BETTER CARE BETTER HEALTH Population &
Community Health Efficiency & Cost Reduction Safety Person /
Caregiver Centered Care Coordination Telehealth Clearly Supports
The Triple Aim Clinical Care
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Health Sounds Great. How much does it cost and how do we get
paid?
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Health Medicare
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Medicare Billing Reimbursement for Medicare telehealth has five
criteria for payment of telehealth services: 1. The patient was
seen from an originating site as defined by CMS. An originating
site is the location of an eligible Medicare beneficiary at the
time the service being furnished via a telecommunications system
occurs. Originating sites authorized by law are: a. Offices of a
Physician or Practitioner b. Hospitals c. Critical Access Hospitals
d. Community Mental Health Centers e. Skilled Nursing Facilities f.
Rural Health Clinics g. Federally Qualified Health Centers h.
Hospital-Based or Critical Access Hospital (CAH)-Based Renal
Dialysis Centers (including satellites) 2. The originating site is
located in any of the following geographic areas: a. Rural Health
Professional Shortage Areas (HPSAs), b. Counties located outside
Metropolitan Statistical Areas (MSA), and c. Effective January 1,
2014, HSPAs located in rural census tracts of metropolitan
statistical areas. 22 Health
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Medicare Billing (cont.) Reimbursement for Medicare telehealth
has five criteria for payment of telehealth services: 3. The
encounter was performed at the distant site as defined by CMS as
the site where the health care provider is located. Eligible
distant site practitioners are as follows: a. Physicians b.
Physician assistants c. Nurse practitioners d. Clinical nurse
specialists e. Registered dietitians or nutrition professionals f.
Nurse midwives g. Clinical psychologists* h. Clinical social
workers* *CPs and CSWs cannot bill for psychiatric diagnostic
interview examinations with medical services or medical evaluation
and management services under Medicare. These practitioners may not
bill or receive payment for Current Procedural Terminology (CPT)
codes 90792, 90833, 90836, and 90838 23 Health
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Medicare Billing (cont.) Reimbursement for Medicare telehealth
has five criteria for payment of telehealth services: 4. The
patient was present and the encounter involved interactive audio
and video telecommunications that provides real-time communication
between the practitioner and the Medicare beneficiary. NOTE: Store
and forward telehealth services are only permitted in federal
demonstration programs currently conducted in Alaska and Hawaii.
California Medicare sites are not eligible for reimbursement for
store and forward telehealth services. 5. Type of Service provided
as specified in the Medicare Eligible Services table* Reference 24
Health
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Medicare Eligible Services 25 Health
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Medi-Cal
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Medi-Cal FFS Dec. 2013 The Telemedicine Act of 1996,
Californias enabling legislation, refers to telemedicine and does
not use the term Telehealth. AB415 was passed in 2013 and replaced
the outdated legal terminology of telemedicine with telehealth".
This guide is true to the legislation and regulations and uses the
terminology telehealth. As written in the Medi-Cal bulletin which
was released September 2013, Medi-Cal defines the originating site
as follows: An originating site is where the patient is located at
the time health care services are provided via a telecommunications
system, or where the asynchronous store and forward service
originates. Medi-Cal defines the distant site as where the health
care provider is located while providing services via a
telecommunication system. 27 Health
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Live Interactive: Covered Service A telemedicine service must
use interactive audio, video or data communication to qualify for
reimbursement. The E&M service must be in real-time or near
real-time (delay in seconds or minutes) to qualify as an
interactive two-way transfer of medical data and information
between the patient and health care provider. The audio-video
telemedicine system used must, at a minimum, have the capability of
meeting the procedural definition of the code provided through
telemedicine. The telecommunication equipment must be of a quality
to adequately complete all necessary components to document the
level of service for the CPT-4 code billed. If a peripheral
diagnostic scope is required to assess the patient, it must provide
adequate resolution or audio quality for decision-making. 28
Health
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Live Interactive: Cont. The health care provider who has the
ultimate responsibility for the care of the patient must be
licensed in the State of California and enrolled as a Medi-Cal
provider. The health care provider at the originating site must
first obtain oral consent from the patient prior to providing
service via telehealth and shall document oral consent in the
patients medical record, including the following: a) A description
of the risks, benefits and consequences of telemedicine b) The
patient retains the right to withdraw at any time c) All existing
confidentiality protections apply d) The patient has access to all
transmitted medical information e) No dissemination of any patient
images or information to other entities without further written
consent All medical information transmitted during the delivery of
health care via telemedicine must become part of the patients
medical record maintained by the licensed health care provider. 29
Health
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Conditions Required for Telehealth Verbal and Written Patient
Consent As of 2013, the patients written consent to telehealth
services is no longer required. Prior to a patient receiving
services via telehealth, the health care provider at the
originating site shall inform the patient, where appropriate, of
the option to utilize a telehealth modality and then obtain oral
consent from the patient. Eligible Originating Sites (Patient Site)
For purposes of reimbursement for covered treatment or services
provided through telehealth, the type of setting where services are
provided for the patient or by the health care provider is not
limited (W&I Code Section 14132.72(e). Eligible Distant Site
Practitioners (Provider Site) No restrictions on types or
locations; however, requires licensure in State of California and
adherence to licensure scope of practice. In addition, the distant
(provider) site is only a billable visit if it meets all the
requirements of the Medi-Cal program. 30 Health
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Billing and Reimbursement Modifiers Only services rendered from
the distant site are billed with modifiers. Claims for
reimbursement should be submitted with the appropriate CPT code or
HCPCS code for the professional services provided and one of the
following Telemedicine modifiers: GT for interactive audio and
video telecommunications system (live interactive) or GQ for Store
and forward applications. Originating Site Fee The originating site
is eligible to receive a facility fee for providing services via
telehealth. For 2014, the site facility fee is $22.94. Sites are
instructed to use HCPCS code Q3014 when submitting facility fee
claims. Sites fee are limited to once per day, same recipient, same
provider. Transmission Fee: Live Interactive Medi-Cal allows
payment of transmission costs associated with live interactive
services. This fee can be paid to originating and distant sites. It
is limited to a maximum of 90 minutes per day, same recipient, and
same provider. One unit of service is equal to one minute of
transmission cost. Sites are instructed to use code T1014:
telehealth transmission, per minute. For 2014 the transmission fee
is $0.24 per minute. Clinical Fees: Live Interactive Reimbursement
to the health professional delivering the clinical service is the
same as the current fee schedule amount for the service provided
without telemedicine. 31 Health
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State Flexibility 32 Health Telehealth is seen as a cost
effective alternative to traditional face to face encounters and as
such, States are encouraged to use the flexibility in the
regulations to determine how best to cover services (as long as it
doesnt exceed upper Federal Limits).
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Bandwidth - KUCTT 33 Health At a higher bandwidth, more video
data can be transferred, resulting in a better image. KUCTT
transmits most of its clinical consults at 384 Kbps using H.323
Internet Protocol. HD videoconferencing can be done at these lower
speeds, but true HD can only be obtained at 1Mbps of bandwidth or
higher. Even at a bandwidth lower than1Mbps, HD systems provide
better image quality than standard definition systems at the same
speed.
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Small County Telehealth Pilot 34 Health Key considerations are:
Return on Investment low cost / low bandwidth solutions Home based
options Patient suitability considerations HIPAA (privacy
protection) EHR and patient portal integration (patient
access)
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References and Resources 1.Telemedicine Resource Guide prepared
by the California Telehealth Resource Center September 2014
2.Medi-Cal Telemedicine Guidelines:
http://files.medi-cal.ca.gov/pubsdoco/DocFrame.asp?wURL=publications%2Fmasters-
mtp%2Fpart2%2Fmednetele_m01o03.doc 3.HRSA has developed a tool that
will help providers determine geographic eligibility for Medicare
telehealth services. This tool, the Medicare Telehealth Payment
Eligibility Analyzer, is available at:
http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx.
35 Health
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Key Goals of MITA 36 Health
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Key Goals of MITA 37 Health
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Key Goals of BH-MITA The key goal of the BH-MITA project is to
promote integration, interoperability, and coordination with
Medicaid in particular to improve overall health, data supported
analysis, and decision making. 38 Health
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39 LOWER COSTS BETTER CARE BETTER HEALTH Population &
Community Health Efficiency & Cost Reduction Safety Person /
Caregiver Centered Care Coordination Telehealth Clearly Supports
The Triple Aim Clinical Care
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MITA for Behavioral Health The BH-MITA and Medicaid MITA
visions have some similarities, but arose from different
objectives. BH-MITA was conceived not only to confirm the
extensibility of the MITA Framework approach and strengthen the
relationship with Medicaid as an important funding and service
partner, but also to advance the BH-MITA framework and focus more
on system capabilities that support interoperability and PHRs/EHRs,
and less on State agency operational details. Therefore, the
BH-MITA vision includes the notion of interoperability and
interconnectedness across all partners and processes, and focuses
on integrating technology and automation into all aspects of the
recovery-oriented systems of care delivery continuum. 40
Health
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BH-MITA Vision Interactive, consumer-centered and controlled
data and systems Standardized, streamlined, interoperable and
automated processes that eliminate complexity and redundancy and
facilitate timely and appropriate care Real-time, fully automated
reporting and exchange mechanisms Elimination of administrative and
programmatic barriers to care A seamless and transparent
integration of treatment programs and recovery support services
across not just health related entities, but across other sectors
as well, such as the courts system, housing and employment
services, correctional institutions and probation offices, the
child welfare system, social services and disability, and any other
systems and services that impact individual health and wellness. 41
Health
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HITA / MITA / BH MITA Crosswalk 42 Health
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Short Term Proposal / Pilot CPT code episodic reporting 837 and
835 file data used to support determination of CPE Align Pilot
county EHR system (s) with requirement Adjust billing and claim
process Test files generated and sent to State Review outcome and
determine next steps 43 Health
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Creates criteria for Certified Community Behavioral Health
Clinics Provides $25,000,000 that will be available to states as
planning grants Stipulates that eight (8) states will be selected
to participate Requires participating states to develop a
Prospective Payment System
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Health TIMELINE September 1, 2015: Deadline for the Secretary
of Health and Human Services to publish criteria January 1, 2016:
Deadline for the Secretary to award planning September 1, 2017:
Deadline for the Secretary to select the States that will
participate in the demonstration program.
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Health Care Coordination - including requirements to coordinate
care across settings and providers to ensure seamless transitions
for patients across the full spectrum of health services including
acute, chronic, and behavioral health needs. Quality Reporting
reporting of encounter data, clinical outcomes data, and quality
data. Two of the core Criteria from the Excellence Act
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Health Stage 2 Meaningful Use Criteria
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PDF Stage 1 & 2 Comparison Health
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Pre-Cursor Acquire Certified EHR (2014) (AIU) Health
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Stage 1 Wax On (Implement EHR and collect data for 90 days)
Health
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Clinical Dashboard - MU
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Health Clinical Dashboard Sample - MU
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Health What is the meaningful use reporting period in 2014? A
full calendar year for everyone who has already earned the first
incentive payment, i.e., who has reported for 90 days in 2011,
2012, or 2013. Any 90-day period for physicians in their first year
of meaningful use; a calendar quarter for everyone else. It depends
on whether the physician is reporting for Stage 1 or Stage 2. Pop
Quiz
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Stage 1.5 More Wax On (Meaningfully Use EHR but now like you
really mean it - 365 days or 90 in 2014) Health
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Stage 2 Care Coordination Focus Health
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Data Sharing and Portal Implications Health
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URL for Last Pass Checker
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The focus should be on value for patients, not just lowering
costs. Value is driven by provider experience, scale and learning
at the medical condition level. Free flow of information that is,
information on results and prices needed for value-based
competition must be widely available. Innovation in healthcare such
as enhancing the patients experience, redefining the business
around medical conditions, growing by developing its delivery value
chain etc. that increase the value must be strongly rewarded.
Health Value Focused = Excellence
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Michael E. Porter and Thomas H. Lee Health HBR 2013 The
Strategy that will fix healthcare Technology Enabled Bending of
Cost Curve
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Health
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What does Meaningful Use Mean to our Organization? Health
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Meaningful Use Implementation Driver Clinical Process and
Quality Improvement Data Collection and Outcomes Analysis Patient
Engagement Strategy Foundation of Excellence and Economic and
Strategic Planning Tool Workflow Re- Design Tool Catalyst for
Innovation
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Get to Know a Virus (before it gets to know you) Health
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The Heartbleed Bug is a vulnerability in the OpenSSL
cryptographic software library. This weakness allows stealing the
information protected, under normal conditions, by the SSL/TLS
encryption used to secure the Internet. SSL/TLS provides
communication security and privacy over the Internet for
applications such as web, email, instant messaging (IM) and some
virtual private networks (VPNs). CVE-2014-0160
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Health If you are a service provider you have signed your
certificates with a Certificate Authority (CA). You need to check
your CA how compromised keys can be revoked and new certificate
reissued for the new keys. Some CAs do this for free, some may take
a fee. What is Leaked?
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Health If you are a service provider you have signed your
certificates with a Certificate Authority (CA). You need to check
how your CA compromised keys can be revoked and new certificates
reissued for the new keys. Some CAs do this for free, some may take
a fee. VeriSign is a common CA. What do I do now? Revocation and
Reissue
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Thad Dickson, BIO Health Thad Dickson is principal and CEO of
Xpio Health. Mr. Dickson has helped behavioral healthcare
organizations and hospitals receive close to $22 Million dollars in
Meaningful Use incentives and established compliance programs that
will qualify nearly 300 Eligible Professionals for federal and
state incentives over the next 6 years. Thad is a frequent speaker
on topics related to technology and behavioral health, a member of
the National Council and NAMI as well as HIMSS and ISC2 and holds a
HCISSP, CPHIMS, PMI, and multiple Microsoft network and product
technical certifications. Thad is formerly a behavioral healthcare
counselor and has a BA with an emphasis on Psychology from The
Evergreen State College.
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Contact Information Health Thad Dickson HCISPP, CPHIMS, PMP
Xpio Health [email protected] (800) 287-1456 (253) 651-7482 -
direct
