Vermont Medical Society Third Thursday webinar series

1. Vermont Medical Society Third Thursday webinar series Date: March 21, 2019 Title of Talk: Telehealth in Practice 134 Main Street • P.O. Box 1457 • Montpelier, Vermont 05601-1457 Tel.: 802-223-7898 • 800-640-8767 • Fax: 802-223-1201 www.vtmd.org Webinar Materials Archived at: http://www.vtmd.org/vms-announces-free-webinar-series-schedule-201819

2. CME Disclaimer • In support of improving patient care, this activity has been planned and implemented by the Robert Larner College of Medicine at the University of Vermont and the Vermont Medical Society. The University of Vermont is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.The University of Vermont designates this live activity for a maximum of 1 AMA PRA category 1 credit(s)tm. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Please watch your email for a link from the Vermont Medical Society to claim your CME credit. CME credit must be claimed within 30 days of participating in the event.

3. VMS Third Thursday Webinar SeriesTelehealth in Practice Speakers: Terry Rabinowitz, M.D., Clinical Director, Telemedicine UVMMC Todd Young, Director of Telehealth Services, UVM Health Network Lisa Fearon, J.D., Contracting Counsel, Blue Cross & Blue Shield of Vermont Hillary Hill, BA, Medicaid Policy, Agency of Human Services Planning Committee Members: Jessa Barnard, ESQ, Stephanie Winters, Deputy Executive Director & Dr. Carl Dobson, M.D., Southwestern Vermont Medical Center Purpose Statement/Goal of This Activity: Our speakers will provide an update on the latest research and applications of telehealth services as well as answer your practical questions about billing and payment policies Learning Objectives: Demonstrate awareness of how telehealth services will function. Disclosures: Is there anything to Disclose? Yes No: Did this activity receive any commercial support? Yes No In support of improving patient care, this activity has been planned and implemented by the Robert Larner College of Medicine at the University of Vermont and the Vermont Medical Society. The University of Vermont is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The University of Vermont designates this live activity for a maximum of 1 AMA PRA category 1 credit(s)tm. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

4. Telehealth:Clinical Considerations & ApplicationsTerry Rabinowitz, MD, DDSProfessor of Psychiatry and Family Medicine Larner College of Medicine at the University of VermontMedical Director, Telemental HealthDirector Emeritus of TelemedicineUniversity of Vermont Medical Center

5. Background

6. Some Important Things I’ve Learned

7. Acceptance & Support Provider • Proper training before initial telemedicine encounters • Identify and collaborate with support personnel • Understand the equipment and its limitations • Troubleshoot • Develop “telepresence” • Do some practice telemedicine encounters • Request constructive criticism • Adjust your approach accordingly • Make sure you have the appropriate backing to do this! • Partners, Chair, CEO, etc. • License • Insurance

8. Acceptance & Support Patient • Confirm that patient is okay with telemedicine • Make sure patient knows what is going to take place and who will be present • On both sides • Make sure support staff are available for entire telemedicine encounter • They should be “pre-trained” in telemedicine • Critical that there is a designated TM expert available if there are problems with equipment • Need to position patient and help if vision/hearing problems • Privacy issues should be addressed • Will vary depending on several factors • Nature of consultation • Age/ability of patient • Know when confidentiality can be/should be breached • May be different in the state where patient is vs. where you are

9. Applications

10. Most important thing to keep in mind is that almost anything we do in medicine face-to-face can be done via telemedicine • I’m not saying we should do everything by telemedicine, I’m just saying it’s possible

11. Some Cool Approaches • Store and forward/ asynchronous modalities • Some natural fits include dermatology, pathology, wound care, psychiatry/psychology • Can use with translator • I’ll explain • Any other ideas? • Use for vulnerable or underserved populations • Agoraphobia • Homebound • Palliative/ hospice care • LGBTQ • PTSD/ trauma survivors • Elders • ASD, schizophrenia • Inner city • Incarcerated • “Travelers”

12. Questions?

13. Telehealth Operational ConsiderationsTodd YoungNetwork Director of Telehealth Services at UVM Health Network

14. Types of Telemedicine

15. Why Telemedicine? Providers Hospitals Patients • Create access for patients • Convenience for patients • Provide better outcomes for patients • Create access for providers • Convenience for providers • Create competitive services • Expand service offerings for communities • Create competitive services for patients

16. Who can perform Telemedicine? Physicians Advanced Practitioners Registered Nurses Nutritionists Social Workers and Counselors Psychologists

17. Where can Telemedicine be performed? Schools Clinics and Medical Offices Hospitals and Nursing Facilities Homes Hotel Rooms Libraries

18. Things to address in your planning

19. Take an Agile Approach Plan Develop Pilot Adjust Scale Manage

20. Workflow Design

21. Technology For video visits pick a HIPAA compliant cloud based video conference platform. • HIPAA compliant and secure • Works on PC’s, tablets, and mobile devices • Easy to use • As low as $14.99/mo/provider

22. Resources to help Northeast Telehealth Resource Center is a free resource to assist in developing telemedicine programs. www.netrc.org ATA is the largest membership organization supporting telemedicine. www.americantelemed.org Network with your local health systems and partners.

23. Blue Cross & Blue Shield of VermontTelemedicine Policies & Procedures Lisa Fearon March 2018

24. BCBSVT Covers: • Medically Necessary, clinically appropriate telemedicine consultations performed by a network provider • Consultations, including second opinions • Initial or follow-up inpatient consultations • Office or other outpatient visits • Follow-up visits after a skilled nursing facility or hospital stay • Psychology and psychiatric examinations intended to provide a diagnosis • Prescription drug management (applies only if member has prescription drug coverage) • Nutritional counseling visits • End-stage renal disease services • Medical genetic and genetic counseling services (subject to applicable prior approval requirements) • Neuro-cognitive testing • Intervention and behavior change counseling to quit tobacco or smoking cessation or substance use disorder or alcohol use disorder treatment • Education and training services for managing an illness • Transitional care management services

25. BCBSVT does not reimburse: • Services rendered via audio-only phone, email, fax, or other non-HIPAA-compliant means • Services provided by store and forward means (asynchronous, patient not present) • A “hosting” or “facility” fee for the originating site • Exception: treatment of substance use disorder where the provider at the distant site and facility at the originating site are not owned by the same entity

26. BCBSVT requires: • POS 02 (telehealth) • Modifier -95 for CPT codes • Modifier -GT for HCPCS codes • Use of HIPAA-compliant software (not Skype or FaceTime) • Services must be covered by the member’s benefits • Services must be delivered through the use of live interactive audio and video (synchronous) • Distant site provider obtains patient’s prior consent

27. Location Considerations • If the patient is in VT, provider must be licensed here. • If the patient is outside VT, the provider must comply with any state/local requirements that apply for that state or jurisdiction. • For claims filing purposes, services are rendered where the provider is located.

28. BCBSVT’s Telehealth Vendor – American Well (AmWell) • BCBSVT contracts with American Well to provide a nationwide network of providers delivering services via telemedicine to BCBSVT members. • AmWell services: • “sick visits” (cough, sore throat, vomiting, fever, bronchitis, sinus infection, stuffy head, allergies, pharyngitis, respiratory infections, flu, cold, pinkeye, rashes, UTIs) • Nutritional counseling • Breastfeeding support • Mental health and substance use disorder • Option to enroll with AmWell (or other telehealth vendors) directly

29. I’m contracted with BCBSVT and my office is in VT. What should I know if I want to offer services via telemedicine? • BCBSVT payment policy requirements apply, no reimbursement differential, no special contract • Confirm member benefits (other Blue Plan members) • Provider location matters • Provider’s normal office location/NPI determines where the claim should be filed • If provider is using a VT-based NPI, file the claim to BCBSVT (even if provider was temporarily outside of VT at the time of service (e.g., on vacation)) • Patient location (at the time of service) matters

30. I’m contracted with BCBSVT and my office is in a county contiguous to VT. What should I know if I want to offer services via telemedicine? • Claims for services rendered via telemedicine to BCBSVT members should be submitted to BCBSVT, and your BCBSVT contract controls. • Claims for services rendered to non-BCBSVT members should be submitted to your local plan (e.g., Anthem if in NH).

31. Where do I file a claim if I have contracts with two different Blue Plans (not contiguous to each other, like VT and FL)? • Provider location (billing NPI) at the time of service determines where the claim should be filed. • Patient location at the time of services generally determines licensing requirements.

32. I’m contracted with BCBSVT, but I will be moving away from Vermont. How should I submit claims for telemedicine services when I move? • If a provider leaves VT permanently, he/she is no longer eligible to participate with BCBSVT. • Provider may have the option to participate with AmWell to maintain the relationship with BCBSVT members. • Provider may contract with the local Blue plan and provide services via telemedicine pursuant to that plan’s policies and procedures.

33. Telehealth and Vermont Medicaid Hillary Hill Medicaid Policy State of Vermont Department of Vermont Health Access March 21, 2019

34. Telehealth • Telemedicine • Two-way, real-time transmission between beneficiary and provider • Store and Forward (Asynchronous) • Transmission of medical information from one provider to another provider without the beneficiary present • Telemonitoring • Remote monitoring of a beneficiary’s data by a home health agency

35. Timeline of Telemedicine and Vermont Medicaid

36. Coverage Requirements: Services provided must be: Clinically appropriate Medically Necessary For telemedicine: Include any service that a provider would typically provide to a beneficiary in a face-to-face setting Providers are expected to adhere to the same program restrictions, limitations, and coverage that exist for services when not provided through telemedicine Non-Covered Services for telemedicine: Services not covered in a face-to-face setting under Vermont Medicaid Services delivered via audio-only telephone, facsimile, or electronic mail messages

37. Provider Requirements • Complete list provided in the Telehealth administrative rule • Privacy: • Meet or exceed applicable federal and state legal requirements of medical health information privacy, including HIPAA compliance • Appropriate Informed Consent • Platform: • Vermont Medicaid does not have a platform; providers must have their own HIPAA compliant platform • Prior Authorizations: • Same requirements that exist for the service when not provided through telehealth

38. Telemedicine Billing: Must follow correct coding rules and only bill for services within scope of practice that can be done via telemedicine All claims must have Place of Service (POS) 02 Facilities delivering must apply the “GT” modifier Originating site providers may be reimbursed a facility fee Facility fees will not be reimbursed if the provider is employed by the same entity as the originating site

39. What’s Next?

40. Helpful Resources • Health Care Administrative Rule – Telehealth • http://humanservices.vermont.gov/on-line-rules/health-care-administrative-rules-hcar/3.101-telehealth-rule-adopted-rule.pdf • Provider Manuals • Telemedicine: • http://vtmedicaid.com/assets/manuals/GeneralBillingFormsManual.pdf • Telemonitoring • http://vtmedicaid.com/assets/manuals/HH_ACCS_ERC_HBW.pdf • Telehealth Resource Page • http://dvha.vermont.gov/telehealth?portal_status_message=Changes%20saved • Telehealth Brochure • http://dvha.vermont.gov/telehealth-handout-10-12-18-ekc-edits.pdf