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Telehealth Telehealth ReimbursementReimbursement
KHA Webinar KHA Webinar –– 6/2/20156/2/2015
Rob Sprang MBARob Sprang MBARob Sprang, MBARob Sprang, MBADirector, Kentucky TeleCareDirector, Kentucky TeleCare
Why Telehealth?Why Telehealth?Why Telehealth?Why Telehealth?
Get the right careGet the right careGet the right careGet the right careTo the right peopleTo the right peopleTo the right peopleTo the right people
At the right timeAt the right timeggIn the right placeIn the right place
For the right costFor the right cost
Telehealth in KYTelehealth in KY•• 19951995 –– Telehealth launched at UKTelehealth launched at UK•• 1995 1995 –– Telehealth launched at UK Telehealth launched at UK
•• 1998 1998 –– First Medicare reimbursement legislation First Medicare reimbursement legislation –– Mandated Mandated 75% of fee to the consultant and 25% to the referring provider75% of fee to the consultant and 25% to the referring provider75% of fee to the consultant and 25% to the referring provider75% of fee to the consultant and 25% to the referring provider
•• 2001 2001 –– New Medicare reimbursement legislation New Medicare reimbursement legislation –– 100% of fee 100% of fee t th lt tt th lt t i t l $25 f ilit f t ti t iti t l $25 f ilit f t ti t itto the consultant to the consultant –– approximately $25 facility fee to patient site approximately $25 facility fee to patient site –– Limited to Rural/HPSA Limited to Rural/HPSA –– Limited consult codes/providersLimited consult codes/providers
•• 2000 2000 -- Passage of KY Passage of KY telehealthtelehealth legislation legislation –– Mandated Mandated reimbursement from Medicaid and Commercial Health reimbursement from Medicaid and Commercial Health InsuranceInsurance –– Medicaid limited to 4 visits/beneficiary/year andMedicaid limited to 4 visits/beneficiary/year andInsurance Insurance Medicaid limited to 4 visits/beneficiary/year and Medicaid limited to 4 visits/beneficiary/year and other very strict limitations other very strict limitations –– No facility fee No facility fee –– Membership in Membership in Kentucky Kentucky TeleHealthTeleHealth Network and technology standardNetwork and technology standard
•• Today Today –– Revised Medicaid regulations twice Revised Medicaid regulations twice –– Currently Currently working on another revision to substantially reduce limitationsworking on another revision to substantially reduce limitations
Site DefinitionsSite DefinitionsSite DefinitionsSite Definitions
Originating site = PatientOriginating site = Patientg gg g
Distant site = ConsultantDistant site = Consultant
Commercial Health Insurance Commercial Health Insurance andand telehealthtelehealth reimbursementreimbursementand and telehealthtelehealth reimbursementreimbursement
Equity between Equity between telehealthtelehealth and traditional and traditional q yq yclinical encounterclinical encounter
GT Modifier for the appropriate CPT orGT Modifier for the appropriate CPT or GT Modifier for the appropriate CPT or GT Modifier for the appropriate CPT or HCPCS codeHCPCS codeF ili f h i i i iF ili f h i i i i HCPCSHCPCS Facility fee at the originating site Facility fee at the originating site –– HCPCS HCPCS code Q3014code Q3014
Medicare Medicare telehealthtelehealth reimbursementreimbursementR l i f i i i iR l i f i i i i Rural requirement for originating siteRural requirement for originating site
Approved originating site facilityApproved originating site facilityApproved originating site facilityApproved originating site facility
Approved distant site practitioner typeApproved distant site practitioner type
Approved clinical service (CPT/HCPCS code list)Approved clinical service (CPT/HCPCS code list)
I t ti di AND id t l i tiI t ti di AND id t l i ti Interactive audio AND video telecommunication Interactive audio AND video telecommunication --patient must be present during the encounterpatient must be present during the encounter
GT Modifier for the appropriate CPT/HCPCS codeGT Modifier for the appropriate CPT/HCPCS code
Facility fee at the originating siteFacility fee at the originating site HCPCS codeHCPCS code Facility fee at the originating site Facility fee at the originating site –– HCPCS code HCPCS code Q3014Q3014
KY Medicaid KY Medicaid telehealthtelehealth reimbursementreimbursement No urban/rural distinctionNo urban/rural distinction No urban/rural distinctionNo urban/rural distinction
Must be a member of KTHN network Must be a member of KTHN network –– Letter to the Board of Letter to the Board of Directors includes technical testing for H 323 compatibilityDirectors includes technical testing for H 323 compatibilityDirectors, includes technical testing for H.323 compatibility, Directors, includes technical testing for H.323 compatibility, approved at quarterly board meetingsapproved at quarterly board meetings
Approved distant site practitioner typeApproved distant site practitioner type Approved distant site practitioner typeApproved distant site practitioner type
Approved clinical service Approved clinical service –– not CPT/HCPCS specificnot CPT/HCPCS specific
GT Modifier for the appropriate CPT or HCPCS codeGT Modifier for the appropriate CPT or HCPCS code
Facility fee at the originating site Facility fee at the originating site –– Not permitted by Medicaid Not permitted by Medicaid –– MCO’s will pay if OS is a public health department MCO’s will pay if OS is a public health department ––HCPCS code Q3014HCPCS code Q3014
Current Current regreg differentiates CMHC/nondifferentiates CMHC/non--CMHCCMHC
New New regreg is being drafted is being drafted
Contracts and other opportunitiesContracts and other opportunities
Consider working with those who may beConsider working with those who may beConsider working with those who may be Consider working with those who may be selfself--insured or have the ability to contract insured or have the ability to contract for services such as large employersfor services such as large employersfor services, such as large employers, for services, such as large employers, correctional facilities, ACO’s and others that correctional facilities, ACO’s and others that are exempt from traditional are exempt from traditional payorpayor models.models.
New Models to ConsiderNew Models to Consider Consider Remote Patient Monitoring Continuity ofConsider Remote Patient Monitoring Continuity of Consider Remote Patient Monitoring, Continuity of Consider Remote Patient Monitoring, Continuity of
Care and Chronic Disease Management Care and Chronic Disease Management opportunitiesopportunitiesopportunitiesopportunities Chronic Disease Management (CPT 99490) $42.60/moChronic Disease Management (CPT 99490) $42.60/mo Remote Patient Monitoring of Chronic Condition (CPT Remote Patient Monitoring of Chronic Condition (CPT g (g (
99091) $56.92/mo99091) $56.92/mo Can be combined for $99.52/moCan be combined for $99.52/mo
ff Focus on readmission penalties and other financial Focus on readmission penalties and other financial benefitsbenefits
“Di“Di C ”C ” l h l hl h l h i fi f “Direct“Direct--toto--Consumer” Consumer” telehealthtelehealth services for acute services for acute primary care primary care –– High opportunities High opportunities –– High risk of legal High risk of legal and regulatory actionand regulatory actionand regulatory actionand regulatory action
Other legal/regulatory considerationsOther legal/regulatory considerationsS i dS i d KTHN h fKTHN h f Security and consent Security and consent –– KTHN has a consent form KTHN has a consent form and policy and policy –– Nothing is 100% secure Nothing is 100% secure –– Be Be transparent about the risks with the patienttransparent about the risks with the patienttransparent about the risks with the patienttransparent about the risks with the patient
Kentucky Board of Medical Licensure has an opinion Kentucky Board of Medical Licensure has an opinion onon telehealthtelehealthon on telehealthtelehealth
Other provider licensure boards have regulations or Other provider licensure boards have regulations or are considering regulations regardingare considering regulations regarding telehealthtelehealthare considering regulations regarding are considering regulations regarding telehealthtelehealth
Interstate licensure/Malpractice insuranceInterstate licensure/Malpractice insurance JC/CMS have approved the concept of “delegated JC/CMS have approved the concept of “delegated
credentialing and privileging” to permit a healthcare credentialing and privileging” to permit a healthcare f ilit t d l t th t t th id ’ “h ”f ilit t d l t th t t th id ’ “h ”facility to delegate that to the provider’s “home” facility to delegate that to the provider’s “home” practice site practice site
Legal/Regulatory issuesLegal/Regulatory issues•• ReimbursementReimbursement
•• MedicaidMedicaid•• MedicareMedicare•• Private InsurancePrivate Insurance
N ti it f d d R t P ti tN ti it f d d R t P ti t•• New continuity of care codes and Remote Patient New continuity of care codes and Remote Patient Monitoring for homeMonitoring for home--based carebased care
P i il i /C d ti liP i il i /C d ti li•• Privileging/CredentialingPrivileging/Credentialing
•• Interstate LicensureInterstate Licensure
•• Emergent issues with new “DirectEmergent issues with new “Direct--toto--Consumer” Consumer” telehealthtelehealth initiatives initiatives
•• Patient/Provider relationshipPatient/Provider relationship•• What is appropriate care?What is appropriate care?
ResourcesResources•• Medicare fact sheet onMedicare fact sheet on telehealthtelehealth reimbursementreimbursement http://http://www.cms.gov/Outreachwww.cms.gov/Outreach--Medicare fact sheet on Medicare fact sheet on telehealthtelehealth reimbursement reimbursement http://http://www.cms.gov/Outreachwww.cms.gov/Outreach
andand--Education/MedicareEducation/Medicare--LearningLearning--NetworkNetwork--MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdfMLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
•• Rural eligibilityRural eligibilityRural eligibility Rural eligibility http://http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspxdatawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx
•• Medicaid regulations on Medicaid regulations on telehealthtelehealth reimbursement reimbursement http://http://www.lrc.ky.gov/kar/907/003/170.htmwww.lrc.ky.gov/kar/907/003/170.htmttp //ttp // c y go / a /90 /003/ 0 tc y go / a /90 /003/ 0 t
•• KY Medical Licensure Board opinion on KY Medical Licensure Board opinion on telehealthtelehealthhttp://http://kbml.ky.gov/board/Documents/Board%20Opinion%20regarding%20The%20Ukbml.ky.gov/board/Documents/Board%20Opinion%20regarding%20The%20Use%20of%20Telemedicine%20Technologies%20in%20the%20Practice%20of%20se%20of%20Telemedicine%20Technologies%20in%20the%20Practice%20of%20% % % g % % % % %% % % g % % % % %Medicine.pdfMedicine.pdf
•• KTHN Consent and policy KTHN Consent and policy –– Sent to Elizabeth Cobb at KHASent to Elizabeth Cobb at KHA
D l t d d ti li / i il iD l t d d ti li / i il i b f d tb f d t•• Delegated credentialing/privileging Delegated credentialing/privileging –– resources can resources can be found at be found at http://ctel.org/expertise/credentialinghttp://ctel.org/expertise/credentialing--andand--privilegingprivileging//
•• KTHN network schedule KTHN network schedule –– www.kytelehealth.netwww.kytelehealth.net
•• Kentucky Kentucky TeleHealthTeleHealth Network Board of Director’s contactsNetwork Board of Director’s contactsDonna Veno Donna Veno -- Administrator Administrator –– KTHN Board information and membership 502KTHN Board information and membership 502--564564--6478x2421 6478x2421 [email protected]@ky.govRob Sprang Rob Sprang –– Board Chair Board Chair –– 859859--218218--5105 5105 –– [email protected]@uky.edu
