Virtual Care In Alabama: Greater Access and Lower Cost


Telehealth hit a bump in its road to progress when the Office of Inspector General released the April 2018 Audit reporting errors in telehealth claims. This bump, however, should not create a detour away from a cost-effective healthcare delivery model. In today's Medicare reimbursement structure, appropriate implementation of telehealth may help physicians improve MIPS scores, increase reimbursements and provide Alabama patients with greater access to quality care.

Telehealth are healthcare services delivered through audio-video telecommunicating technology or patient-facing portals rather than the typical in-person encounter. Telehealth may include applications such as live videoconferencing, store-and-forward videoconferencing, remote patient monitoring, mobile health, and virtual check-in. Medicare has expressed a commitment to expanding reimbursement for telehealth services. "CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner," said Administrator Verma. The 2019 Physician Fee Schedule proposes reimbursement for virtual check-ins, evaluation of patient-submitted photos, and telehealth services for prolonged preventive care such as chronic care management. In addition, CMS/OIG Waivers for certain payment programs provide availability for reimbursement of telehealth services in urban centers as well as Health Professional Shortage Areas (HPSA) and for additional services typically paid as if an in-person encounter.

Alabama's large concentration of rural and HPSA designated areas makes telehealth an attractive option for providing rural areas with access to quality primary care and specialty medical treatment and reducing costs. Reimbursement structures are available through federal and private insurers and self-insured plans, licensure barriers are lower, and development of HIPAA compliant technologies has increased significantly.

Alabama was among the first states to adopt the Interstate Medical Licensure Compact ("IMLC") in 2017. IMLC expedites multi-state medical licensure for Providers among participating states (24 states, 1 territory and 31 Medical and Osteopathic Boards as of August 2018), offers Alabama providers opportunity for care delivery outside of Alabama for which they can be reimbursed, and provides access to specialty consultation and care from out-of-state Providers. Physicians must hold an unrestricted license in the Compact state of residency or employment. IMLC defers to each state board for review of the IMLC license application and approval. The Alabama Board of Medical Examiners issued 33 licenses in 2017 and 22 letters of qualification issued to other states. Prior to IMLC, Alabama physicians were limited to providing telehealth services within the state.

Government and private payors, such as BCBS, designate a specific set of services for telehealth that are coded and reimbursed as if provided in an in-person encounter. Most payors have some common features in the conditions for reimbursement: synchronous (realtime face-to-face) communication using a HIPAA compliant technology originating from a payor specified location, such as a physician office, clinic or hospital, in the presence of a licensed provider and with medically necessary care delivered by the remote provider. There are some distinctions that increase opportunities for reimbursement.

Recognizing the value of communication technology-based services using asynchronous and non-face-to-face modalities, such as a phone call or pre-recorded videos, CMS proposes new HCPCS codes to separately reimburse these non-face-to-face services which do not fall into the statutory definition of telehealth services (face-to-face real time encounters). The proposed additional services would: (1) pay clinicians for virtual check-ins which are brief, non-face-to-face assessments via communication technology; (2) pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by a RHC or FQHC practitioner when there is no associated billable visit; (3) pay clinicians for evaluation of patient-submitted photos or recorded video; and (4) expand Medicare-covered telehealth services to include prolonged preventive care.

Prior to its proposed changes in the 2019 Physician Fee Schedule, Medicare acknowledged that telehealth fits squarely into its Innovation programs which focus on reducing costs and implementing the use of technology while improving performance and quality. Certain of the CMS and OIG Waivers for bundled payment and shared saving programs expand opportunities for telehealth by permitting delivery from alternative origination sites, such as home or a dialysis facility, permitting telehealth in previously unavailable geographic areas, such as metropolitan areas, and permitting use of asynchronous technology for teledermatology and teleopthamology.

Successes at organizations that provide services to rural areas has demonstrated the value of telehealth. Intermountain Healthcare in Utah conducted a study assessing the cost, quality and performance of telehealth delivered services as compared to similar care delivered at primary care office, urgent care, and ERs and the outcome was that the quality and performance metrics were substantially the same while telehealth resulted in greatly reduced costs. After a 14 years of providing health care services through telehealth, in 2017 The University of Mississippi Medical Center earned the designation of National Telehealth Center of Excellence after implementing a telehealth platform connecting the health system with more than 200 healthcare sites across Mississippi and more than 500,000 patient visits in 69 of the state's 82 counties.

With barriers reduced and reimbursement options enhanced, implementation of telehealth as an additional method for delivering healthcare to patients in Alabama - and elsewhere - is on the horizon.

Beth Pittman is of counsel with Waller.


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