TeleHealth Reimbursement – Driving Value-based Outcomes

1. TeleHealth Reimbursement – Driving Value-based Outcomes

2. Fee for Service, Value Based Purchasing, Shared Savings Medicare Medicaid Everybody Else!

3. Medicare Reimbursement

4. Two-way live interactive video and audio between the provider and patient. The patient must be present – if not required to be present – is not considered TeleHealth. It is not TeleHealthfor the purposes of reimbursement if the connection between a provider and patient is on the same campus. Post-surgical updates to family Supervising residents Covering the inpatient units from ED Any other situation where walking takes away patient seeing time CMS Definition of TeleHealth

5. Where We are Now with Medicare

6. Algorithm for Medicare Reimbursement YES! Bill Medicare!

7. Subsequent Hospital Care Subsequent hospital care services, with the limitation for the patient’s admitting practitioner of one telehealth visit every 3 days

8. Process for Reimbursement • Develop a specific appointment type for TeleHealth/Telemedicine • Use standardized modifier on all claims (GT) • Electronics comment “Services provided by TeleHealth” • Bill the facility fee when appropriate Q3014 – 1500 form- need an appointment – billed under supervision physician • Do not include other procedures, test, services provided in-person in conjunction with the TH visit (peak flow, walking pulse ox, debridement) • Watch your reimbursement!

9. Federally qualified health centers (FQHC) • Patient is physically present at the FQHC • Specialist is a provider not physically present at the FQHC • FQHC and specialist have agreement to provide services, but FQHC does not • compensate the specialist • Medical reason for a provider to be present with patient at the FQHC site • Patient ‘virtually’ enters specialist site via telemedicine • specialist is the provider site and can bill fee-for-service rate. • FQHC provided a medically necessary service, thus also a provider site, and can bill PPS for a face-to-face visit.

10. Cost Reporting • Medicare hospital cost report Form CMS 2552-96 • The Refinement Act (BBRA) of 1999, requiring hospitals to report information on the uncompensated care they provide. • Provides Secretary of Health and Human Services with the data necessary to develop a Medicare disproportionate share hospital payment methodology that takes into account the cost of providing care to uninsured and underinsured patients as recommended by the Medicare • Payment Advisory Commission.

11. Facility Fees • Q3014 HCPCs code • Billed by the site with the PATIENT • Can be the same organization providing the consulting services • Billed on UB form (technical component) • Site of service is where the patient is • Billing entity is the facility linked to an on-site MD

12. CMMS, Medicaid and Telemedicine The Centers for Medicare & Medicaid Services (CMS) has not formally defined telemedicine for the Medicaid program, and Medicaid law does not recognize telemedicine as a distinct service. Nevertheless, Medicaid reimbursement for services furnished through telemedicine applications is available, at the state's option, as a cost-effective alternative to the more traditional ways of providing medical care (e.g., face-to-face consultations or examinations). Many states are allowing reimbursement for services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs.

13. Medicaid Process for Reimbursement

14. Medicaid State/HMO/PPOContracting for Services • Agreement between single entity and the health care provider • No restrictions unless agreed upon by the parties • Payment usually at a predetermined contract rate – look at your standard and customary rates • Contract for typical services

15. Medicaid and Health Care Reform Provisions

16. Health Care Reform… Medicaid “health home” option for chronic care (section 2703) Medicare “accountable care organizations” demonstration (section 3022) Medicare “independence at home” demonstration (section 3024) Center for Medicare and Medicaid Innovation (section 3021)

17. Problem with Dual Eligible Patients and TeleHealth

18. Other Government Pay Relationships

19. Private Payers... Just Bill 'em!

20. Approaching Health Plans Tell Them Who You Are – Centers of Excellent, Leaders in X National Overview of TeleHealth Demonstration of How It Works VISUALS!!!!! Testimonial by Enrollees of Health Plan who Have Used TeleHealth Video Clips of Visits Share Internal Data – Volume, Performance, Outcomes Outline Program Description – Services, Quality Improvement, Sites Specific Health Plan Data Outline the Program Request

21. Proposals • Pay for Everything the Same as In-Person • Do Not Accept the Medicare Approach • If you get a NO – • Consider suggesting a one year pilot • Suggest a Two Year Population Specific Program

22. Proposals • Pay for Everything the Same as In-Person • Do Not Accept the Medicare Approach • If you get a NO – • Consider suggesting a one year pilot • Suggest a Two Year Population Specific Program • BEG

23. Do not Take ‘NO’ for an answer

24. Your Other Money…..

25. Reimbursement • Typically payment for clinical services • Set or negotiated fees • Medicare, Medicaid, County, Private Payers, Self-Funded Payers, Patients, Families • Endowments, Charity • Purchasing Groups – Under, Non-insured • State Budget Line Item

26. Payment for Services • Organization bills professional fees • Bills and collects independent of third party • Typically for specific service rendered: software, maintenance, single specialty • Direct Bill to organization for patient care • Cash, credit card payments • Usually contractually based • State Budget Line Item

27. Store-and-forward services • Occupational Medicine • School Clinics • Dermatology • Self – Insured Employers • Workers Compensation Carriers • Insurance Plans • Primary Care Services • Specialty Care Services • Diabetes Services CONTRACTING

28. Contractual Fees • All types of business arrangements and TeleHealth organizations – clinical, network, vendor • Typically outlines services to be delivered • May be based on RFPs • Outlines detailed arrangement • Schedule of Fees • Provide off-site services: billing, coding, network management • Don’t forget to go after contracts: State, Feds, DOD, etc.

29. Increase in Other Organizational Services • Ancillary Services • Patient Visits – Practice Productivity • Use of other departments: R/D, Technology, Helpline

30. Support of Business Development • Testing of new markets • Component of a package of services • Relationship builder • Grant partner

31. Expense Reduction Decrease in cost of other services or initiatives: • Mobile Services • MD and supportive personnel • Advanced and allied practitioners versus MDs • Reduction in white space and no-shows • Reduction in cost of outreach

32. Reduction in White Space (no Shows, Cancellations, no appt) • Look at average revenue per visit • Identify lost time in schedule • Calculations: $164 for Level III Office visit 15% white space in schedule 37 hours per week productive time 5.6 hours of white space = $164 x 2 visits/hr x 5.5 hours = $1,836.80

33. Heart Failure Clinic • NP Clinic uses TeleHealth to enroll health plan patients with Congestive Heart Failure Primary diagnosis • Entered into standardized program that includes regular NP visits, education, and coaching • Use of TeleHealth to get all patients enrolled at low cost to organization and without additional staff. • Savings to the health plan led to a $216 per month per member payment (+ prof component

34. Diabetes Outcomes • HgA1c levels • Blood Pressure • Foot Exams • Appropriate hyperglycemic therapy • How many Endocrinologists are there in your service area? • Tele-Endocrinology • Patients have better HgA1c control, blood pressure control, meet annual foot and eye exam requirements, when seen via TeleHealth • Better patient compliance • No loss to follow-up • Fewer cancellations and no show

35. Outreach • Average number of RVUs per day on campus • Average number of RVUs per day on outreach • Interventionalists going to sites without procedure resources (Cardiology, Ortho) • Cardiology Example • Outreach 5-11 RVUs • On campus + TeleHealth = 37 RVUs

37. The 6 NQS domains are:1. Patient and Family Engagement2. Patient Safety3. Care Coordination4. Population/Public Health5. Efficient Use of Healthcare Resources6. Clinical Process/Effectiveness CMS Meaningful use metrics • health outcomes • clinical processes • patient safety • efficient use of health care resources • care coordination • patient engagements • population and public health • adherence to clinical guidelines

38. Primary Care Medical Home Identifying patients at highest risk for hospitalization, based on specific criteria, and put those patients on remote monitoring, safety measures, and in-home video. Value? = Bonus and incentive payments

39. Medical Home • Care Coordination Model • Transitional Care Model • Extends the care team into the home • Objectives of reduced hospitalizations and avoidance of rehospitalization within 31 days • Keeping people healthier and happier

40. Transitional Care Model Following a patient from discharge from acute care admission for 60 days to prevent re-admission. Use remote monitoring and care coordination staffwith interactive video consultations as a tool.

41. Contracting for shared savings – Economic Analysis • Average cost of hospitalizations - $17-22,000 • Average hospitalizations per year for high risk patients 3-15 • Shared savings contracts – 50% • Based on 100 high risk patients

42. Shared Savings – calculation of Value *Assumes one kit per patient *Add-in cost of RN for 100 high risk patients = $100-150,000 salary and benefits (regional)

43. Calculations # of Hospitalizations x % Reduction x # of High Risk Patients = Cost Savings Cost Savings – Cost of Remote Monitoring/Patient = Net Savings

44. PLEASE Don't Overthink Telemedicine - treat it the same as in-person care and go from there.....

45. Don’t Take this approach!

46. 715-389-3694 CALL ME! antoniotti.nina@marshfieldclinic.org