How (and Why) to Build a Telemedicine Practice

Why do you need to build your telemedicine practice? Twenty years ago, telehealth was more concept than reality, popular among visionaries but absent from most doctors’ offices. Today, telehealth is a rapidly growing industry changing the way practitioners and patients interact. The technology and the capabilities change almost daily.

And then there are the coding, billing, and reimbursement implications that providers must understand to jump on the telemedicine bandwagon, notes healthcare management consultant Toni Elhoms in her ProfEdOnDemand webinar “How to Get Paid for Telehealth Services.”

To implement telemedicine services and stay at the leading edge of healthcare, physicians and other medical professionals need a better understanding of the basics—including the compliance and financial elements—of this growing trend in healthcare.

What Is Telehealth?

In the broadest sense, telehealth is any health service provided using telecommunication technology. Smartphone apps, wearable tech, video conferencing, and protected email accounts could all be considered “telehealth.”

While many telehealth technologies, such as video conferencing or real-time vital monitoring, are new phenomena, telehealth as a concept is not. Telehealth, especially teleradiology, dates to the 1960s. Healthcare providers have been using telehealth for over 50 years to deliver care to rural populations.

Telehealth has evolved since its humble beginnings. As consumer technologies advance at a breakneck pace, more people have access to cheaper smartphones, computers and other connected devices. This consumer tech revolution has created an unprecedented opportunity for healthcare providers to care for their patients. These tools can help providers increase the quality and convenience of care for all patients, not just underserved populations.

‘Telehealth’ versus ‘Telemedicine’

Telehealth and telemedicine are often used interchangeably—an approach taken by the American Telemedicine Association (ATA), which notes that it “largely views telemedicine and telehealth to be interchangeable terms, encompassing a wide definition of remote healthcare, although telehealth may not always involve clinical care.”

Centers for Medicare and Medicaid Services (CMS), and many insurers, have more formal definitions. According to Medicaid.gov, telemedicine is a service “permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.” By this definition, telemedicine is a specific subset of telehealth that uses live conferencing between providers and patients.

4 Telehealth Benefits

While the pros and cons to telemedicine will vary by provider and practice, there are some common, cross-specialty considerations:

1. The first obvious advantage is greater convenience and patient satisfaction. Patients don’t like waiting rooms; it’s a fact. And telemedicine can significantly reduce the time spent waiting for care. Plus, you’ll save patients the time they would have spent driving to appointments as well.
2. Similarly, telemedicine can reduce costs for both your practice or facility and the patient. Patients will have to spend less time away from work, and you can maximize your time and efficiency.
3. By using telemedicine, your practice can also immediately extend its access to specialist consult services. This is a great way for small hospitals and practices to outsource certain treatments and provide specialist services without hiring new physicians.
4. Finally, by lowering healthcare-access hurdles, you give patients the chance to interact with their providers more frequently and conveniently—ultimately improving patient outcomes. With telehealth, follow-up and medication management become easier. And providers can check in on patients between visits to ensure they’re following their care plans.

4 Telehealth Disadvantages

Of course, moving to a telecommunications-based service does not come without drawbacks.

1. For one, the very nature of telehealth means you get fewer in-person interactions with patients, and that’s not appropriate or recommended for every condition. Certain conditions require an inpatient visit to properly treat and diagnose them; and, even for those that don’t, interacting with your patient face-to-face has its benefits. Some patients simply respond better to a physician’s presence. It’s easier to misdiagnose and inadequately assess patients when you can’t see them. Verbal instructions and reminders can more easily fall through the cracks too, even if they’re documented in the patient’s records.
2. Reduced continuity of care is a concern for consumer-facing services. Any service that provides on-demand consults with physicians or replaces visits to a patient’s primary care physician jeopardizes continuity and keeps patients from building strong relationships with providers.
3. Like any new technology, telemedicine requires resources—and those aren’t without costs. In addition to the cost of telemedicine technology and equipment, nurses, clinicians and staff will all need training to use any new telemedicine services.
4. Finally, your ability to get paid for providing telemedicine services will rely on evolving reimbursement rules and legislation. Each year, CMS and private insurers update their billing practices. In addition, Medicaid policies vary by state, and many states have specific laws regarding telehealth practice and billing. To learn more about your state’s laws and regulations, check out the ATA State Policy Resource Centeror the tracking of state telehealth policies by the Center for Connected Health Policy (CCHP).

Conditions Amenable to Telemedicine

While telehealth consultation services can be used in almost any specialty, telemedicine has a smaller number of conditions that can be directly diagnosed.

The treatable conditions are limited by the nature of telemedicine and by insurers’ reimbursement policies. While multiple specialties can treat and bill for certain conditions, primary care physicians have the most flexibility.

Here is a list of some of the many conditions primary care physicians can feasibly treat via telemedicine. These conditions can be reliably identified, explained, and treated without a complex physical examination:

• Allergies
• Cold/flu symptoms
• Sinus problems
• Ear infections
• Conjunctivitis
• Skin infections, including rashes, insect bites, and poison ivy
• Bladder and urinary tract infections
• Respiratory infections and bronchitis
• Sprains and strains

Remember: The exact list of billable conditions is determined by your patients’ insurance providers. Check with your insurers for a complete list of billable conditions before using telemedicine.

Specialties Amenable to Telemedicine

Telemedicine and telehealth continue to grow in popularity and are the subjects of recent legislation in New York and Texas, both of which acted to make remote medical services easier to provide. But telemedicine is definitely better suited to some specialties than others—and any consideration to begin offering telemedicine services should include the nature of the provider practice and common conditions be treated.

Obviously, telemedicine is easier to provide when fewer physical exams are required. And images and/or patient communication is key. As a result, the following specialties are particularly suited to offer telemedicine:

• Radiology: Radiologists were some of the first to use telemedicine because they can easily receive, analyze, and provide feedback about image, as well as advise the patient’s primary physician.
• Psychiatry:With a dearth of practicing psychiatrists, particularly in rural communities, psychiatry practices can make excellent use of telemedicine technology. Since services require fewer physical exams and are based on communicating effectively with patients, psychiatry is better suited for telemedicine than many other specialties.
• Dermatology:Like radiologists, dermatologists can use telemedicine to remotely examine and diagnose patients’ images. Because dermatologists often struggle to keep up with patient demand for their services, telemedicine provides a cost-effective opportunity for expanding a practice.

More Telemedicine Opps: PCP Partnerships

Physicians across practice areas are constantly finding new ways to utilize telemedicine, and specialists can also consider teaming up with primary care doctors to offer such services.

In a 2015 survey, Becker’s Health IT & CIO Review compiled 2,000 primary care physicians’ perceptions of video consultations. The top ten specialty video consults they found most valuable to their practice were, in order of importance: dermatology, psychiatry, infectious disease, pain management, neurology, cardiology, rheumatology, gastroenterology, sports medicine, and oncology.

As just one example of telemedicine in action, more than 40 Kaiser Permanente medical groups offer—at the primary care site—instant consultations with specialists, according to Dr. Robert M. Pearl, former leader of the Permanente Medical Group (the largest medical group in the country), and the Mid-Atlantic Permanente Medical Group.

Become Telehealth-Capable

Both patients and doctors are seeing the potential advantages of telehealth—especially the way it can be used in novel ways, such as during disasters, to fight opioid addiction, and in complicated federal payment programs for hip and knee replacement surgeries. But novel or run of the mill, the key to success with any telehealth service is the delivery method.

There are three major steps providers need to take when setting up their practices to add telehealth capabilities. You must choose:

1. a network
2. the type of telehealth services you’ll offer, and
3. the technology you’ll rely on.

Choose from 3 Networks

There are three major types of telehealth networks:

1. Networked programs connect smaller clinics (or service sites) to other smaller clinics, allowing individuals sites to communicate with multiple other sites. This model is popular with rural clinics, which use networked programs to access specialist services from multiple different sites. For a visual, think of these networks like a web with crossing and intersecting connections. Instead of one central hospital at the center, multiple smaller clinics create the network. According to the ATA, there are roughly 200 of these networks, with more than 3,500 service sites in the United States.
2. Point-to-point connections form networks that look like a hub with many spokes. They connect multiple smaller clinics to one large hospital or healthcare facility. This model is often used to provide telemedicine services in large health systems. Smaller affiliate clinics can access specialists from a single location and don’t have to coordinate with other service locations. Point-to-point connections are also useful for cross-practice specialty consults. For example, teleradiology services that receive images from clinics around the country often use this model.
3. Monitoring centers are primarily used for telehealth services. These centers provide patients and clinicians with monitoring technology, allowing patients to record and send health information, which these centers then analyze or forward to a provider. Monitoring centers can track an amazing variety of conditions, from basic vital signs after surgery to usage data for a morphine breakthrough pump. Depending on your practice and your needs, there’s a monitoring center that can help better manage your patients’ care.

Choose from 3 Telehealth Service Types

Telehealth services are defined by the systems they use and how they connect practitioners to patients. Here are the three primary types of telehealth services:

1. ‘Store and forward’ (or asynchronous telemedicine) is any telehealth service where a clinician records patient data and sends (or forwards) it to another clinician. Since providers are not communicating in real time, it’s deemed asynchronous. Store and forward technologies provide a convenient mechanism for physicians to collaborate on their own schedule. Ophthalmology, radiology and dermatology practices are frequent users of store and forward technology.
2. Remote patient monitoring (RPM) services use remote monitoring centers to record information from patients and forward the results to clinicians. These services are great for managing complex, chronic conditions like diabetes and depression.
3. Real-time telemedicine (or synchronous telemedicine), as the name suggests, connects patients and clinicians through live video conferencing software. Medicare-approved telemedicine relies on real time telemedicine technologies. In addition to the reimbursement benefits, real time telemedicine is a great way to manage post-op care, track medication adherence, and supplement traditional primary care.

Choose from 3 Common Technologies

Once you’ve found a telehealth solution that fits your needs, you need three things: technology, training, and software—and the compliance protocols to go along with using them. There are three common types of telehealth technologies to choose from:

1. Live video conferencing requires more than a Skype connection. To safely use and bill for telemedicine, you need a video conferencing system certified by the Health Insurance Portability and Accountability Act (HIPAA). Many companies provide either apps or standalone cameras and computers to facilitate video conferencing.
2. Specialized email systems are often used to store and forward telehealth services, providing a safe, encrypted and HIPAA-certified way for clinicians to share patient information.
3. RPM systems have endless uses and almost as many companies willing to provide them. If you have something you want to monitor, there’s likely a service ready to help. For information on patient monitoring systems, check out this helpful resource from CCHP.
   

Build your Telemedicine Practice – Startup Best Practices: Find Funding & Get Consent

Once you’ve started your delivery of telemedicine, here are six tips and best practices to help you get the most from your telemedicine program.

1. Look for grants. Especially if you practice in an underserved community, the Health Resources & Services Administration (HRSA)and other agencies and nonprofits provide grants to help you integrate telehealth. There are also rural health associationsin many states that can provide additional support.
2. Create an internal implementation committee. For any new program to be successful, you need buy-in from every member of your team. Creating a committee with representatives from each department in your practice will ensure a smoother telehealth rollout. Building an internal committee, especially for larger practices, lessens the need for outside support and consultants.
3. Make a space for telemedicine. This step is crucial for anyone using live video-conferencing. Make sure you have a dedicated space to host video calls that’s clean, neat and professional. A welcoming space is key, even though your patients aren’t physically present. They will be able to see the space you’re in, after all!
4. Make a plan for which services you’ll provide. Before you ever offer telehealth to a patient, you should know exactly what you can and cannot provide. This removes ambiguity for you and your patients while also streamlining reimbursement. Start small and scale up. When beginning, only offer a few services. This way, your staff and patients aren’t overwhelmed, allowing you to troubleshoot any problems that might arise. As everyone becomes more comfortable, you can add more procedures and services to your repertoire.
5. Set measurable goals. Sit down with your team and decide on a timeline and list of goals for your telehealth program. Decide how many patients you hope to reach, how you’ll reach them, and how you’ll measure success. Schedule progress check-ins throughout the process.
6. Get informed consent from every patient. Some state laws require specific informed consent before using telehealth. Even if your state doesn’t, it’s a good practice and provides an opportunity for your patients to ask questions about the program. Getting informed consent for telehealth also provides an extra layer of protection for your practice and helps your patients better understand their care.

Regularly Update Your Regs & Rules Knowledge

Navigating regulations is nothing new to physicians and other providers, but adding telemedicine capabilities to your practice will add a few new compliance concerns. From CMS and Medicaid requirements to HIPAA privacy concerns and various state regulations, you will need to devote resources to properly planning and training on telemedicine rules. And be sure you make that ongoing training because the rules keep changing.

If you serve Medicare beneficiaries, you will need to check CMS regulations and requirements relating to telehealth. Although the list is still rather limited, CMS does increase its Medicare-eligible telemedicine treatments each year. For a complete list of currently covered services, check out this CMS guide. Here are a few highlights of what is covered:

• Inpatient and hospital services
• Psychotherapy and behavioral counseling
• Kidney and end-stage renal disease
• Substance abuse counseling
• Behavioral counseling
• Advance care planning
• Primary care and well-visits
• Critical care consultations

Plus: In the July 2018 proposed changes to the Medicare Physician Fee Schedule for Calendar Year 2019, CMS proposed expanding access to care using telecommunications technology by:

• Paying physicians for conducting virtual check-ins
• Paying clinicians for evaluating patient-submitted photos
• Expanding Medicare-covered telehealth services to included prolonged preventative services

Beware: Telemedicine compliance under HIPAA involves more than a secure connection and safe data transfers. Providers must be aware of HIPAA regulations for all telehealth technologies and services. And service platforms must be explicitly HIPAA-compliant, too. Exact regulations for HIPAA compliance are dependent on the specific technology or system. So, before purchasing any new technology, look for a statement about HIPAA compliance. Make sure it meets your practice’s needs before investing. For more information about HIPAA compliance as it relates to telemedicine, read HIPAA Journal’s Guidelines on Telemedicine.

Get Your Terminology Straight

Vocabulary is important to your compliance efforts, too.

Medicare tightly regulates where practitioners can provide services and where patients can receive services. For instance, patients must receive services at an approved “originating site” and practitioners must be located at an approved “distant site.” Here’s what those terms mean:

The originating site is the patient’s location. Originating sites must be outside of a metropolitan statistical area (MSA) or in a rural health professional shortage area (HPSA). Not sure whether your site qualifies? Consult HRSA’s definitions and this Medicare Telehealth Payment Eligibility Analyzer to determine eligibility.

Within those approved originating site areas, patients must also be in one of the following locations when receiving services: the offices of physicians or practitioners, hospitals, critical access hospitals (CAHs), rural health clinics, federally qualified health centers, hospital-based or CAH-based renal dialysis centers (including satellites), skilled nursing facilities, or community mental health centers (CMHCs).

The distant site is the provider’s location. While the location of this site is less prescribed than it is for an originating site, the telemedicine services must be furnished at the site by an eligible provider. Eligible providers are: physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals.

Get Paid for Telemedicine

Telemedicine and telehealth services fall under several regulatory frameworks overseen by CMS. Be sure you check rules and regulations under all of the following:

• Live reimbursement only: Unless you’re practicing at an approved site in Hawaii or Alaska, Medicare will only reimburse for live telemedicine services.
• Double reimbursement: Originating sites that host patients can claim a “facility fee” reimbursement from Medicare. Even if you don’t provide any services, make sure you bill Medicare for your facility fee.
• GT modifier: When billing Medicare, make sure to use the “GT” modifier on all your codes. This signifies that these were telemedicine services.
• Changing Medicare rates: Each year, Medicare updates its rates and its eligible services. Use CMS’s Fee-for-Service Payment Tool or its previously mentioned List of Services to find the current services and rates.

Don’t forget to dig into state rules, too. Since Medicaid is state-run, telehealth policies vary across all 50 states and Washington, D.C. To find out more about Medicaid in your state, check out CCHP’s State Telehealth Laws and Reimbursement Policies Report. Here are just a few highlights from that report:

• 48 states and D.C. reimburse for live video services
• 13 states reimburse for store and forward services
• 22 states cover remote patient monitoring
• 31 cover a facility fee or transmission fee

To find out more about your state’s Medicaid program, visit Medicaid’s Telemedicine website.

Bottom Line: The Future of Telehealth

If history is any indication, telehealth will look radically different in 2030 than it does today. Each year, CMS approves more services for telemedicine. More communities gain access to reliable broadband each day. New technologies emerge. And more and more patients have smartphones and web-enabled devices.

Congress continues to propose—and may enact—laws to promote the use of telemedicine, and states are very active in legislating and regulating it. Vendors of telemedicine technologies are proliferating, and new platforms are born all the time.

That’s why now is the time to educate yourself about: how telemedicine works, the latest Medicare rules and regulations regarding its use, and the special requirements for physicians and practitioners that you might capitalize on.

Much of the guidance for telemedicine or telehealth services comes from the Medicare program—where changes occur almost every year. And the recently enacted 21st Century Cures Act directs CMS to expand telemedicine services. Remote robotic surgery is on the horizon, and Medicare Advantage programs are being given more latitude in what they can include relative to telemedicine. You need all the help you can get to comply with the rules, policies, and procedures—but doing so can be hugely advantageous to both your practice or facility and your patient outcomes.

For an even more comprehensive look at how to make the leap into telehealth, download the free report “Telehealth in a Nutshell.”

(This post first appeared in a ProfEd blog)