Strategies for Navigating the Evolving Telehealth Landscape

In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) and commercial payers have relaxed their rules and requirements for telemedicine. On July 23, 2020, the American Academy of Allergy, Asthma & Immunology (AAAAI) hosted a webinar to discuss the current telemedicine regulations and rules, as well as the latest coding and billing protocols related to telemedicine. The presenters also described the steps that the AAAAI is taking to advocate for the continuation of expanded telemedicine rules and discussed how allergists can become involved in these advocacy efforts.

Telemedicine Billing and Coding Challenges

Sakina Bajowala, MD, Owner and Medical Director, Kaneland Allergy & Asthma Center, North Aurora, IL, discussed telemedicine billing and coding issues, as well as reimbursement challenges, that have arisen during the pandemic. According to Dr Bajowala, telemedicine services were historically very limited because of barriers in coverage and reimbursement. Under CMS rules prior to the COVID-19 pandemic, to qualify for telemedicine services, Medicare beneficiaries were required to reside in underserved or rural areas. Patients were obliged to visit a designated originating site where a telemedicine platform was provided. Thus, patients who lived in urban or suburban locations, and those who were physically incapable of leaving their homes, were unable to receive telehealth services.

In addition, insurance carrier policies have previously prevented many patients and physicians from participating in telehealth services. Prior to the COVID-19 public health emergency, only 1 major carrier had a mechanism in place for submitting telemedicine claims. Many carriers had narrow networks of precontracted telemedicine providers. Reimbursement was significantly lower for telehealth services than for the equivalent in-person services. Payment parity of telemedicine and in-person encounters had only been mandated by a few states, with rules varying widely from state to state and among different carriers.

CMS Regulation of Telemedicine Services

The COVID-19 pandemic has brought about rapid and dramatic changes to the regulation and reimbursement of telemedicine services. With a population sheltering in place but still needing healthcare services, CMS quickly expanded telemedicine availability and reimbursement. Emily Graham, RHIA, CCS-P, Vice President, Regulatory Affairs, Hart Health Strategies, Washington, DC, outlined the changes made by CMS in response to the current public health emergency.

According to Ms Graham, the expansion of Medicare telehealth services through waivers and regulatory revisions allows physicians to provide telehealth services to Medicare beneficiaries, regardless of their physical location. Patients are no longer limited to rural areas and may now receive telehealth services in their homes, thus avoiding travel to an originating site. In addition, Medicare will cover telehealth services for new and established patients and will provide reimbursement that is equal to that of in-person visits. Medicare also now allows for the use of smartphones for the delivery of telehealth services. In addition, the US Department of Health and Human Services (HHS) Office for Civil Rights will use its enforcement discretion to allow the utilization of nonpublic-facing technologies, such as FaceTime and Skype, for the delivery of telehealth services to Medicare beneficiaries.

A new CMS provision allows reimbursement for virtual check-ins for both new and established patients. Medicare also will now allow audio-only telephone evaluation and management visits for new and established patients and will reimburse these at the in-person established patient visit rate. In addition, CMS also revised its direct supervision requirements, to allow physicians to supervise in-office clinical staff using communication technology, when appropriate. This is significant, because in the event that a physician might need to be isolated or quarantined because of illness or exposure to COVID-19, he or she can still supervise the office staff remotely and allow patients to receive treatments, such as in-office infusions.

Many commercial carriers followed the lead of CMS, as did many state-administered plans and TRICARE. A number of payers waived cost-sharing for patients obtaining telemedicine services. Some states waived the requirement for a physician to be licensed in the state where a patient received care, allowing for telemedicine to be practiced across state lines.

Changes to Coding and Billing Guidelines

It is important for physicians and their staff to be aware of current coding and billing guidelines, as well as their expiration dates, as policies are changing rapidly. In addition to keeping abreast of coding and billing changes, medical practices should perform internal audits of their telehealth services. Dr Bajowala emphasized the importance of internal audits, in order to ensure that a practice is following the current rules and regulations regarding telemedicine and is billing appropriately for all eligible provided services.

Changes in billing affect patients as well, and they should be made aware of billing policies. It is vital for physicians and staff to obtain consent from patients prior to providing telemedicine services, particularly as it pertains to billing. For example, although a patient might not have been billed previously for such services as a virtual check-in, under the new telemedicine expansion, this is a billable service and patients must be informed of such.

Telemedicine has allowed physicians to continue to care for their patients during the public health emergency and to keep their practices afloat financially. Although the current expansion of telehealth will not last forever, telemedicine will continue to play a larger role in healthcare than it did prior to the pandemic. Patients will demand the ability to continue to receive telemedicine services from their established physicians, and this will put pressure on CMS and payers to provide these services. Providing telemedicine services after the pandemic, however, will not be without its challenges.

Possible Obstacles for Physicians

Nick Hernandez, MBA, FACHE, Chief Executive Officer and Founder, ABISA Consulting, Valrico, FL, discussed some of the obstacles that physicians may face once the public health emergency has ended. Currently, 16 states have laws in place that address the reimbursement of telehealth services, but only 10 of those states have true payment parity. “Physicians whose practices are outside of these states are really going to have an uphill battle,” he said.

Mr Hernandez explained that state boards can vary widely when it comes to telemedicine licensure requirements. For example, some states offer a limited or special-purpose telemedicine license, whereas other states require a physician to obtain a full state licensure. Therefore, it is critical to understand the scope and application of the telemedicine requirements for a specific state to ensure compliance.

Although CMS has expanded access to telehealth services to allow for practice across state lines, once the emergency declaration ends, geographic location could once again become a barrier for patients seeking telehealth services. State medical boards vary widely in telemedicine licensure requirements. Whereas some states offer limited, special-purpose telemedicine licenses, others require full state medical licensure. Physicians should fully understand the requirements of the states in which they plan to practice. In addition, although such platforms as FaceTime and Skype have been permitted during the telehealth expansion, physicians and practices should prepare now to be equipped to provide secure end-to-end encryption and Health Insurance Portability and Accountability Act (HIPAA) compliance.

The AAAAI has been involved in ongoing advocacy to ensure availability and reimbursement for telemedicine and other virtual healthcare services. According to Ms Graham, at the start of the public health emergency, the AAAAI encouraged CMS and HHS Secretary Alex Azar to expand telehealth coverage during the pandemic. As a result of the paradigm shift that has taken place, the AAAAI is now asking HHS, Congress, and CMS to make access to telehealth and other virtual care services more available, even after the pandemic is over.

Paul V. Williams, MD, FAAAAI, Chair, AAAAI Advocacy Committee, encouraged allergists to become involved in advocacy for issues involving allergy and immunology. He suggested that all physicians participate in the American Medical Association’s Telehealth Impact Physician Survey, which aims to identify barriers and benefits in the practice of telemedicine. In addition, Dr Williams encouraged physicians to contact their governors, state health officials, and state representatives to work toward attaining greater telehealth access and payment parity after the public health emergency waivers expire.

All of the webinar panelists agreed that the COVID-19 pandemic has presented significant barriers to care. Navigating new technologies for healthcare delivery, rapidly evolving policies regarding billing and coding, and practice changes in response to the public health emergency have been challenging for physicians and patients alike. Advocacy efforts to maintain telehealth access and payment parity is important, however, and may generate positive change as a result of the pandemic.

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