TeleHealth Reimbursement – Driving Value-based Outcomes

Fee for Service, Value Based Purchasing, Shared Savings

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 TeleHealth for the purposes of reimbursement if the connection between a provider and patient is on the same campus.

Post-surgical updates to familySupervising residentsCovering the inpatient units from EDAny other situation where walking takes away patient

seeing time

CMS Definition of TeleHealth

WHERE WE ARE NOW WITH MEDICARE

Medicare will cover office visits and consults as well as some

other services that are provided via Telehealth, as long as the

patient's actual location is either in a HPSA or outside of a MSA

(metropolitan statistical area). Medicare will reimburse covered

services as long as: 1) the services are on the Medicare covered service list, 2) the

services are provided by eligible providers, and 3) the services are performed at eligible originating

sites.  

ALGORITHM FOR MEDICARE REIMBURSEMENT

Patient Outside

of A MSA

Services within CPT code

Range

Services Delivered

by Eligible

Practitioner

Patient in Designat

ed Originating Site

SUBSEQUENT HOSPITAL CARESubsequent hospital care services,with the limitation for the patient’s

admitting practitioner of one telehealth visit every 3 days

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!

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.

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.

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

CMMS, MEDICAID AND TELEMEDICINEThe 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.

MEDICAID PROCESS FOR REIMBURSEMENT

Use the same modifier as Medicare if ableFlag all claims as TeleHealth

Do not bill if not a covered serviceInclude in cost report

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

MEDICAID AND HEALTH CARE REFORM

PROVISIONS

(f) Monitoring- A State shall include in the State plan amendment--

(1) a methodology for tracking avoidable hospital readmissions and calculating

savings that result from improved chronic care coordination and management under

this section; and`(2) a proposal for use of health information technology in

providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient

technology to improve coordination and management of care and patient adherence to recommendations made by

their provider).

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)

PROBLEM WITH DUAL ELIGIBLE PATIENTS AND TELEHEALTH

Bill Medicare for approved TeleHealth CPT Code

Medicare denies and automatically sends claim to Medicaid

Medicaid uses a different CPT code for TeleHealth services

Medicaid denies the service based on the fact that Medicare was not billed first

Resubmit the claim to Medicaid!

OTHER GOVERNMENT PAY RELATIONSHIPS

Waivers

HMO/PPO Medicaid Contracts

Medicare Advantage Plans

State Residential FacilitiesDirect contracting with the

StateFederal demonstration

projects

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

APPROACHING HEALTH PLANS

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

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

DO NOT TAKE ‘NO’

FOR AN ANSWER

Your Other Money…..

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

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

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

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.

INCREASE IN OTHER ORGANIZATIONAL SERVICES

Ancillary Services Patient Visits – Practice Productivity Use of other departments: R/D,

Technology, Helpline

SUPPORT OF BUSINESS DEVELOPMENT

Testing of new markets Component of a package of services Relationship builder Grant partner

EXPENSE REDUCTION

Decrease in cost of other services or initiatives:

Mobile ServicesMD and supportive personnelAdvanced and allied practitioners versus MDs

Reduction in white space and no-shows

Reduction in cost of outreach

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 visit15% white space in schedule 37 hours per week productive

time5.6 hours of white space = $164 x 2 visits/hr x 5.5 hours =

$1,836.80

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

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

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 ExampleOutreach 5-11 RVUsOn campus + TeleHealth = 37 RVUs

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

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

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

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

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.

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

SHARED SAVINGS – CALCULATION OF VALUE

Number of

Patients

Average Cost of

Hospitalization

# of Hospitalizatio

ns per Year

Cost Burden Shared Savings Program

Average Cost Of Remote

Monitoring*

1 $17,000 3 $51,000 $25,500 $1,900

100 $17,000 7 $5,100,000

$2,550,000

$190,000

100 + RN

$17,000 7 $5,100,000

$2,550,000

$290,000

1 $22, 000 3 $66,000 $33,000 $1,900

100 $22,000 7 $6,600,000

$3,300,000

$190,000

100 + RN

$22,000 7 $6,600,000

$3,300,000

$290,000*Assumes one kit per patient*Add-in cost of RN for 100 high risk patients = $100-150,000 salary and benefits (regional)

CALCULATIONS

# of Hospitalizations x % Reduction x # of High Risk Patients = Cost Savings

Cost Savings – Cost of Remote Monitoring/Patient = Net Savings

Don’t Take this approach!

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715-389-3694CALL ME!

antoniotti.nina@marshfieldclinic.org