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The Telemedicine OpportunityPresented By: Marybeth McCall, MD
1962 Episode of the The Jetsons
Presentation Objectives
Identify telemedicine utilization projections
Describe New York’s Telemedicine Mandate
Identify potential use cases of telemedicine for members and provider teams
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Are Your PatientsDriving Telemedicine Consumerism?
Why Use Telemedicine?
Members want to get their health care online
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1Advisory Board “Telemedicine and Concierge Care: Trends in Consumerism and Non-Traditional Primary Care Delivery, 2014
3 of 4 patients want their doctor to offer online services1
US Telehealth Utilization Projections
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Employers need it
Towers Watson predicts telemedicine could save U.S. employers $6 billion2
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$6b
2Towers Watson, Current Telemedicine Technology Could Mean Big Savings, August 11, 2014
$$$ 6 billion
Rapid Adoption
Alaska Hawaii
FLTX
CT
NMAZ
CO
UT
NV
CA
OR
WA
ID
MTND
WYSD
OHNE
KS
OK
MN
IA
MO
AR
LA
MS ALGA
TN
KY
IL IN
MIWI
SC
NC
VA
ME
PA
NY
WV
NH
MA
MDDC
DE
NJ
VT
RI
This map is not a legal opinion. It represents MDLIVE's understanding of state telemedicine regulations and the applicability to MDLIVE's program. Please seek the advice of counsel for a legal opinion as to specific state regulations. MDLIVE reserves the right to revise this document at anytime in its sole discretion
Full Services – Video + Phone
Services Temporarily Suspended
Services Limited to Phone
Arkansas: Services temporarily suspended in Arkansas due to differing interpretations between respective state medical boards and MDLIVE over state regulations that govern telemedicine. MDLIVE is engaged in dialogue with Arkansas board and hopes to return comprehensive telemedicine in Arkansas as soon as possible.
Services Limited to Video
2015 08 10
Rapid Adoption
NY Telemedicine Mandate Overview
General Information
New York state “quasi” mandate
Effective for policies issued, renewed or modified on or after 01/01/2016
Applies to municipal cooperative health benefit plans (Article 47 Plans); fully insured individual, small group and large group policies, Essential Plan and Child Health Plus products
Expands coverage under Medicaid products
Does not change any existing requirements for Medicare products
Does not apply to self-funded (other than Article 47 Plans)
Commercial Line of Business
Requirement: Telemedicine services may not be excluded from coverage if the services provided are otherwise covered under the policy
Definition: Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider
Generally no restrictions on type of provider
No limitations on places that services may be performed
Medicaid Line of BusinessRequirement: Must provide coverage for telemedicine as defined below Definition: Telemedicine includes:
Telemedicine virtual visits Store and forward technologies Remote patient monitoring
Telemedicine providers are limited to:o A licensed physician, physician assistant, nurse practitioner, dentist, podiatrist,
optometrist, psychologist, social worker, speech language pathologist or audiologist, midwife
o Certified diabetes educator, asthma educator, or genetic counselor o Hospital, home care services agency, hospiceo Licensed registered professional nurse only when the nurse is receiving patient
specific health information or medical data at a distant site by means of remote patient monitoring
Medicaid Line of Business (Cont’d)Distant site: A site at which a telemedicine provider is located while delivering
health care services by telemedicine
Originating site*: A site at which a patient is located at the time health care services are
delivered to him/her by means of telemedicine
* Originating sites are limited to NY-licensed hospitals, hospice, facilities for the mentally disabled, private physicians offices located in New York. When a patient is receiving services by means of remote patient monitoring, the patient’s home located within New York or other temporary location located within or outside of New York.
Medicare Advantage Product
The new law does not apply to Medicare Advantage Products
Coverage is consistent with fee-for-service Medicare requirement:o Must cover specific set of CPT and HCPCS codes via telemedicine
Definition: Telemedicine is the use of an interactive audio and video telecommunications system that permits real-time communication between patient and provider
Medicare Advantage Product (Cont’d)
Providers are limited to: Physicians, nurse practitioners, physician assistants, nurse midwives,
clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers (with some limits); registered dieticians or nutrition professionals
Originating site: The place an individual receiving telemedicine services is located – but
must be located in a rural Health Professional Shortage Area located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or a county outside of a MSA. The site must be a provider office, hospital, critical access hospital (CAH); rural health clinic; federally qualified health center; hospital-based or CAH-based renal dialysis center (including satellites); skilled nursing facility or community mental health center
Distant site: Any site the provider is located
Coding, Documentation and Corporate Medical Policy
What Documentation is Required?The following documentation is required to participate in a telemedicine session:
The patient must give verbal authorization/consent for his/her doctor to use telemedicine, which the doctor then documents and generates a patient’s medical record
The presentation site submits forms to carrier to describe what telemedicine events have been performed
The presentation site (if a facility or office) and specialty location submit claim forms to the carrier for payment of the telemedicine consultation
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Coding
Use of code 99444 online medical evaluation
Or evaluation and management (E/M) code with use of the modifier, may use time-based care and counseling
Modifier-GT for synchronous-GQ for asynchronous
Corporate Medical PolicyCorporate Medical Policy 1.01.49, updated 10/28/15
CPT Codes 99441-99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment (code range)
CPT Code 99444 Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous seven days, using the Internet or similar electronic communications network
Telemedicine Use Cases
Products & Services
SecondOpinion
Life Coach
Price Transparency
In-Office Scheduling
ConnectedDevices
Telemedicine
Triage &Redirection
Medically-Trained Service
Center
SecureMessaging
Health Records
Nurse Advice
SymptomChecker
Behavioral Health
Telemedicine Opportunities
Telemedicine:ConnectingPatients
with Participating Providers
Telemedicine Use Cases
Urgent non life threatening symptom – virtual visits ED and urgent care avoidance / DSRIP Chronic disease management Diabetic control Specialty long distance or shortage consultation Newborns, movement disorders Store and forward images Dermatology/retinal images Home health oversight and consultation Post discharge, prevention of readmission Quick check of home environment and patient status Care management
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Pediatric Cardiology Circa 1995 (via Integrated Services Digital Network Line)
Problem: Distressed newborns transferred to Level 4 nursery right after birth, separated from mother and family (one hour away) 10 times per month
Solution: Obtain pediatric echocardiogram and electrocardiogram; have telemedicine connection for pediatric cardiologist to view baby and decide whether transfer is needed urgently or not
Result: Reduced transfers by 80 percent
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Insulin Pump Management
Problem: Joslin Clinic patients with insulin pumps and long distances for visits
Solution: Pulaski Clinic developed ability to send diabetic monitor information and allow face to face via telemedicine
Result: Diabetic members were able to obtain high-quality visits, despite distance and weather
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Movement Disorder Subspecialty
Problem: Patient with Huntington’s Chorea and Parkinson's Disease has difficulty with transportation
Solution: Movement disorder specialist does video virtual visit with member from home on a scheduled basis and adjusts medication as needed
Result: Member has reduced stress and visits are more productive and comfortable
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Diabetic Retinal Evaluation (DRE)
Problem: HEDIS scores for DRE are low due to documentation in the record
Solution: High-definition cameras are placed in the primary care office and images are transmitted to retinal specialist and the retinal physician interprets the image and returns a report to the primary care physician.
Result: Improved screening for diabetic changes, hopefully, reducing blindness
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Competitive Forces National vendors direct to consumer
Pharmacy-sponsored programso Walgreens
Supermarket moveso Wegmanso Price Chopper
Major Medical Organizationso University of Pittsburgh Medical Center, Mass General,
Cleveland Clinic
Competitive Forces
Questions?
Marybeth K. McCall, MD, MMM, FACP, CPE, CPCChief Medical Officer, Utica Region
Excellus BlueCross BlueShield12 Rhoads DriveUtica, NY 13502
315‐798‐4388 office315‐794‐5038 cell
