Translating Medicaid Policy into Practice in Kansas

1. Translating Medicaid Policy into Practice in Kansas Norbert Belz, MHSA, RHIA Project Director, Telehealth Resource Center Center for Telemedicine & Telehealth

2.  Over 16,000 consultation since 1991 Over 40 specialties and more than 50 sites KUCTT serves as a liaison among Kansas telemedicine sites, 3rd party payors and the clinical departments: Averaging 2500 consults per year Specialty and sub-specialty consultations Interactive Patient Present Continuing and community education Federal, State and Local fundingKUCTT serves as a liaison among Kansas telemedicine sites, 3rd party payors and the clinical departments: Averaging 2500 consults per year Specialty and sub-specialty consultations Interactive Patient Present Continuing and community education Federal, State and Local funding

3. Overview KUCTT Medicaid talk 2 years ago More states securing funding from Medicaid Medicaid says use it or lose it Sustainability through 3rd party payment ATA white paper �Medical Assistance and Telehealth: An Evolving Partnership� Pediatrics in Kansas: 50% of consults�were reimbursed� (75% Medicaid / 25% Other Private) 43% were uninsured* 7% had coverage that does not cover telemed Medicaid says use it or lose it Telemedicine sites look towards 3rd party payment systems for sustainability KUCTT talk 2 years ago about the receiving the Medicaid policy ? still implementing More and more states secure funding from Medicaid (and other 3rd party payors) ATA white paper, �Medical Assistance and Telehealth: An Evolving Partnership� Pediatrics in Kansas: Roughly 50% of the consults�were reimbursed� Medicaid made up 40% 43% were uninsured 17% had coverage that does not cover telemedMedicaid says use it or lose it Telemedicine sites look towards 3rd party payment systems for sustainability KUCTT talk 2 years ago about the receiving the Medicaid policy ? still implementing More and more states secure funding from Medicaid (and other 3rd party payors) ATA white paper, �Medical Assistance and Telehealth: An Evolving Partnership� Pediatrics in Kansas: Roughly 50% of the consults�were reimbursed� Medicaid made up 40% 43% were uninsured 17% had coverage that does not cover telemed

4. Objectives Describe Kansas� experience Provide guidance for other states Summarize the role of third-party reimbursement in Kansas� planning for long-term sustainability of telemedicine services Describe Kansas� experience translating Medicaid policy into practice Provide guidance for other states developing and implementing such a policy Summarize the role of third-party reimbursement in Kansas� planning for long-term sustainability of telemedicine services Describe Kansas� experience translating Medicaid policy into practice Provide guidance for other states developing and implementing such a policy Summarize the role of third-party reimbursement in Kansas� planning for long-term sustainability of telemedicine services

5. Kansas Medicaid Healthwave 19 � Medicaid: Requires referrals, denials from other 3rd party payors, proper documentation, preauthorization, and all other criteria set forth by Medicaid Patient receive new cards monthly Healthwave 21 � SCHIP: Same requirements at Healthwave 19 (Mental Health)-through contractual agreements, requires the patient to utilize the Mental Health Consortium. Passed August 2004 Implementing ? 2+ year process Healthwave 19 � Medicaid: Requires referrals (difficult when most patients don�t know their�s), denials from other 3rd party payors, proper documentation, preauthorization, and all other criteria set forth by KMAP Patient receive new cards monthly Healthwave 21 � SCHIP: (Mental Health)-through contractual agreements, requires the patient to utilize the Mental Health Consortium. Passed August 2004 Implementing ? 2+ year process Healthwave 19 � Medicaid: Requires referrals (difficult when most patients don�t know their�s), denials from other 3rd party payors, proper documentation, preauthorization, and all other criteria set forth by KMAP Patient receive new cards monthly Healthwave 21 � SCHIP: (Mental Health)-through contractual agreements, requires the patient to utilize the Mental Health Consortium.

6. Kansas Medicaid Medicaid policy in it�s entirety: Started August 2004 Addition of the �GT� Modifier: Medicare: 99214-99275: Consultations* 99201-99215: Office or other outpatient visits* 90804-90809: Individual psychotherapy * 90862: Pharmacologic management* 90801: Psychiatric diagnostic interview examination* (Effective March1, 2003). End stage renal disease related services (HCPCS codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) (Effective January 1, 2005). Individual Medical Nutrition Therapy: HCPCS codes G0270, 97802, and 97803 (Effective January 1, 2006). *Medicaid: 90847GT � Family Thearpy Medicaid policy in it�s entirety: Started August 2004 Addition of the �GT� Modifier: Medicare: 99214-99275: Consultations* 99201-99215: Office or other outpatient visits* 90804-90809: Individual psychotherapy * 90862: Pharmacologic management* 90801: Psychiatric diagnostic interview examination* (Effective March1, 2003). End stage renal disease related services (HCPCS codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) (Effective January 1, 2005). Individual Medical Nutrition Therapy: HCPCS codes G0270, 97802, and 97803 (Effective January 1, 2006). *Medicaid: 90847GT � Family Thearpy

7. Challenges Telemedicine competing with in-person clinics Scheduling / Intake Department Specific: Adaptation / Costs Site Specific: Originating Site Fee Specialty Specific: Mental Health Some challenges not specific to telemedicine:Mental Health carve outs Interdisciplinary teams Some challenges not specific to telemedicine:Mental Health carve outs Interdisciplinary teams

8. Telemedicine In-person

9. Challenges: Scheduling/Intake Set time �No OVERBOOK No-show = downtime for provider Multiple sites Patient doesn�t physically present in the clinic Did consult actually occur? PCP referral needed Preauthorization HIPAA � Health Information (NPP) Means testing for school-based Set time � difficult for OVERBOOK --in-person clinic overbooks schedule to account for cancellations/no-shows Originating Site & Distant Site No-show = downtime for provider Patient doesn�t physically present in the clinic - Changes in patient demographics, insurance & copay (Changes with insurance ? Medicaid in Kansas get new card monthly) -Co-pay collection complicated Did consult actually occur? Complete intake packet needed to schedule...patients that weren�t filling out the packets were more likely to cxl/ns. The provider manual also states (Kansas Medical Assistance Program; General Third Party Payment 3-2;3-3;3-4 It is important that providers maintain adequate records of third party recovery efforts for a period of time not less than five years. These records, like all other Kansas Medical Assistance Program records, are subject to audit by Health and Human Services, SRS, or their representatives. Providers should gather insurance information each time the ID card is presented by the consumer. If other insurance is identified by name and/or type of coverage, proof of payment or denial, or a letter of explanation of benefits from that company, must be attached to the claim. No other documentation is acceptable. For electronic claim filing, please refer to your electronic claim filing manual for filing instructions. When a service is not covered by a consumer�s primary insurance plan, a Blanket Denial letter maybe requested from the insurance carrier. The provider will need to request from the insurance carrier a letter, on company letterhead, stating that the service/HCPCS code is not covered by the insurance plan covering the Medicaid beneficiary. Providers can retain this statement on file to be used as proof of denial for one year. The �non-covered� status must be reconfirmed and a new letter obtained at the end of one year. Set time � difficult for OVERBOOK --in-person clinic overbooks schedule to account for cancellations/no-shows Originating Site & Distant Site No-show = downtime for provider Patient doesn�t physically present in the clinic - Changes in patient demographics, insurance & copay (Changes with insurance ? Medicaid in Kansas get new card monthly) -Co-pay collection complicated Did consult actually occur? Complete intake packet needed to schedule...patients that weren�t filling out the packets were more likely to cxl/ns. The provider manual also states (Kansas Medical Assistance Program; General Third Party Payment 3-2;3-3;3-4 It is important that providers maintain adequate records of third party recovery efforts for a period of time not less than five years. These records, like all other Kansas Medical Assistance Program records, are subject to audit by Health and Human Services, SRS, or their representatives. Providers should gather insurance information each time the ID card is presented by the consumer. If other insurance is identified by name and/or type of coverage, proof of payment or denial, or a letter of explanation of benefits from that company, must be attached to the claim. No other documentation is acceptable. For electronic claim filing, please refer to your electronic claim filing manual for filing instructions. When a service is not covered by a consumer�s primary insurance plan, a Blanket Denial letter maybe requested from the insurance carrier. The provider will need to request from the insurance carrier a letter, on company letterhead, stating that the service/HCPCS code is not covered by the insurance plan covering the Medicaid beneficiary. Providers can retain this statement on file to be used as proof of denial for one year. The �non-covered� status must be reconfirmed and a new letter obtained at the end of one year.

10. Suggestions: Scheduling/Intake Act as the intermediary Revised process ? ? ? ? ? Completed intake sent in advance Digital fax/email intake Forms on-line New vs. Follow-up forms Virtual Registration (VR) Encounter Database - monitoring Cancellation list Add on one patient Systems in physician clinic (ALS) Site training for HIPAA KUCTT Patient Database � monitors cancel and now show rates (focus on high rates) Follow up from and update Medicaid card sent at visit Working with Virtual Registration *in-progess* KUCTT Patient Database � monitors cancel and now show rates (focus on high rates) Follow up from and update Medicaid card sent at visit Working with Virtual Registration *in-progess*

11. Challenges: Departmental Volume drives need, experience and resources allocated 2500 total telemed vs. 20,000 Internal med Medicaid is Payor of LAST resort Potential for Fraud & Abuse Place of Service Codes Billing practices across specialties History of grant funding Volume drives need, experience and resources allocated (Telemed volume is low in comparison to in-person clinic) 2500 consult vs. _____ Internal med Need to bill everyone, wait for rejection and then submit to Medicaid. For companies the repeatively decline payment, and blanket denial letter can be sought. Medicaid is Payor of LAST resort - Blanket denial requirement problematic Potential for Fraud & Abuse (See below) Place of Service (11 vs. 22) Billing practices need to be consistent across specialties complicated for multiple projects Under this statute, no intent is needed and only a minimal amount of evidence that the accused knew or should have known of the fraudulent activities is necessary. In some cases, doctors and healthcare facilities can face criminal charges, an excess of millions in fines, suspension of license, termination of reimbursement for Medicaid and Medicare services or imprisonment. In the fiscal year 2002, there were 1147 convictions of Medicaid fraud, totaling $288,315,524 in recoveries.2 The same report gave examples from every area where potential abuse occurred, including, but not limited to; clinics, hospital, specialists, providers, laboratories and pharmacies. Volume drives need, experience and resources allocated (Telemed volume is low in comparison to in-person clinic) 2500 consult vs. _____ Internal med Need to bill everyone, wait for rejection and then submit to Medicaid. For companies the repeatively decline payment, and blanket denial letter can be sought. Medicaid is Payor of LAST resort - Blanket denial requirement problematic Potential for Fraud & Abuse (See below) Place of Service (11 vs. 22) Billing practices need to be consistent across specialties complicated for multiple projects Under this statute, no intent is needed and only a minimal amount of evidence that the accused knew or should have known of the fraudulent activities is necessary. In some cases, doctors and healthcare facilities can face criminal charges, an excess of millions in fines, suspension of license, termination of reimbursement for Medicaid and Medicare services or imprisonment. In the fiscal year 2002, there were 1147 convictions of Medicaid fraud, totaling $288,315,524 in recoveries.2 The same report gave examples from every area where potential abuse occurred, including, but not limited to; clinics, hospital, specialists, providers, laboratories and pharmacies.

12. Challenges: Departmental Manual process? Increased complexity? Increased administrative burden ? INCREASED COST + Standard reimbursement = DECREASED PROFITS Manual process ? Increased complexity ?increased administrative burden = INCREASED COST Covering increased overhead & costs ? minimal reimbursement = DECREASED PROFITS Manual process � when billing, the departments have to monitor those with co-pay in order to mail them a bill Manual process ? Increased complexity ?increased administrative burden = INCREASED COST Covering increased overhead & costs ? minimal reimbursement = DECREASED PROFITS Manual process � when billing, the departments have to monitor those with co-pay in order to mail them a bill

13. Suggestions: Departmental Education � Evaluation Protocols similar to in-person clinic Protocols similar to outreach Implement protocols simultaneously Defer to departments for billing concerns Place of service �11� (physician office) Focus on specialties that make sense (outreach, customer svs, etc.) Education � Evaluation (continual monitoring) Develop protocols that are as similar to the in-person clinic Implement protocols for groups of population (Pediatrics) Defer to departments for billing concerns (how are they typically addressed) Focus on specialties that make sense for telemedicine (outreach, customer svs, etc.) Consider protocols similar to outreach Interdisciplinary clinics don�t make sense from a billing perspective Co-pays responsibility of department ? they get the reimbursement Education � Evaluation (continual monitoring) Develop protocols that are as similar to the in-person clinic Implement protocols for groups of population (Pediatrics) Defer to departments for billing concerns (how are they typically addressed) Focus on specialties that make sense for telemedicine (outreach, customer svs, etc.) Consider protocols similar to outreach Interdisciplinary clinics don�t make sense from a billing perspective Co-pays responsibility of department ? they get the reimbursement

14. Challenges: Site Specific Originating Site Fee: Limited by statute to specific sites Diagnosis requirement Billing everyone�s insurance Limited $$$$ Problem with design Ex: CPT 99243 Outpt Consultation Lvl 3: Place of Svs Payment Facility Fee 11 $114.56 N/A 22 $88.88 $??? Ex: CPT 99243 Outpt Consultation Lvl 3: Place of Svs Payment Facility Fee 11 $114.56 N/A 22 $88.88 $???

15. Suggestions: Site Education: site/provider/patient Monthly site visits (increases in utilization) Contracts Record of Consult

16. Challenges: Specialty Specific - Mental Health Patient doesn�t physically present in the office Healthwave 21 (SCHIP) requirements Need for PCP referral when it�s a school Carve-outs: may not cover telemedicine Mental health excluded from many plans Restricted number of visits Patient doesn�t physically present in the office ? difficult to communicate Carve-outs: may not cover telemedicine Healthwave 21 (SCHIP) requirements Need for PCP referral when it�s a school visit creates an additional visit with PCP Mental health excluded from many plans Restricted number of visits Some elements are unique to telemedicine such as use of the GT modifier for specified telemedicine codes. Other concerns mirror face-to-face challenges, particularly related to coverage for telemental health services within carve outs. For Mental Health consider using same guidelines as the in-person clinic as most problems are similar Patient doesn�t physically present in the office ? difficult to communicate Carve-outs: may not cover telemedicine Healthwave 21 (SCHIP) requirements Need for PCP referral when it�s a school visit creates an additional visit with PCP Mental health excluded from many plans Restricted number of visits Some elements are unique to telemedicine such as use of the GT modifier for specified telemedicine codes. Other concerns mirror face-to-face challenges, particularly related to coverage for telemental health services within carve outs. For Mental Health consider using same guidelines as the in-person clinic as most problems are similar

17. Suggestions: Specialty Some elements are unique to telemedicine such as use of the GT modifier ? Need to work case-by-case with the departments Other concerns mirror face-to-face challenges, particularly related to coverage for telemental health services within carve outs ? Defer to in-person clinic practices Examples:Working with Community Mental Health Center Requiring information in advance to allow time for department to check pcp referral and preauthorization (carve-out) Examples:Working with Community Mental Health Center Requiring information in advance to allow time for department to check pcp referral and preauthorization (carve-out)

18. Now What? Continue securing grant support Continue monitoring reimbursement Work with physicians and hospitals to increase efficiency in billing & streamline process Adoption of patient tracking system Integration into EHR Policy � HB 2065 HB 2065Rep. Tom Sloan introduced HB 2065 on January 12, 2007. On January 31, the House Insurance and Financial Institutions Committee held a hearing at which KUMC Assistant Vice Chancellor for External Affairs Dave Cook testified in favor of HB 2065 Would require Kansas insurance companies to pay for telemedicine services the same way they pay for face-to-face services. Not for consultations in the form of emails, phone calls, or faxes. The committee has not yet voted on the legislation and the impact study is scheduled for the summer HB 2065Rep. Tom Sloan introduced HB 2065 on January 12, 2007. On January 31, the House Insurance and Financial Institutions Committee held a hearing at which KUMC Assistant Vice Chancellor for External Affairs Dave Cook testified in favor of HB 2065 Would require Kansas insurance companies to pay for telemedicine services the same way they pay for face-to-face services. Not for consultations in the form of emails, phone calls, or faxes. The committee has not yet voted on the legislation and the impact study is scheduled for the summer

19. OAT funded Telehealth Resource Center (TRC) Partners include Marquette General Health System (Michigan), Kansas University Medical Center, Michigan State University and Purdue Telehealth/HIT resources for business planning, clinical protocols, operations, research, strategic planning, technology and other telemedicine topics Online toolkits and Resource Request System www.midwesttrc.org

20. More Information KU Center for Telemedicine & Telehealth www2.kumc.edu/telemedicine/ nbelz@kumc.edu (913) 588-2226