Telemedicine Reimbursement For Oregon. Why is it important? Telemedicine Reimbursement Encourages...

Telemedicine ReimbursementFor Oregon

Why is it important?

Telemedicine ReimbursementTelemedicine Reimbursement

Encourages use of telemedicine services

Provides mechanism to reimburse providers

One tool to ensure sustainability of program

What is happening nationally?



Medicare

•First authorized in BBA of 1997

-Fee splitting-Limited CPT code reimbursement-Limited eligible presenters


Medicare

•BIPA of 2000-some improvements

-Eliminated fee sharing

-Eliminated need for “telepresenter”

-Expanded eligible services

-Included payment to distant site

physician only

Medicare

•BIPA of 2000-some improvements

-Expanded definition of originating site

-Expanded eligible geographical regions

-Allowed originating site facility fee

-Permitted use of store and forward


Medicare

•BIPA of 2000-some improvementsBut

Still substantial limitations:-Eligible geographic locations-Eligible originating sites-Eligible services-Eligible providers


Medicare

Eligible Geographical Locations

-Must be a primary care Health Professional Shortage Area (HPSA)

-Cannot be a Metropolitan Statistical Area (MSA)


Medicare

Eligible Geographical Locations

HPSA: Three Criteria

-Rational area for delivery of primary care

-<1 primary care physician per 3,500 people

-Insufficient capacity of providers


MedicareEligible Geographical Locations

MSA: County or contiguous counties with:

-One city with population of 50,000 or more

-Census Bureau-defined urbanized area of at least 50,000 and metropolitan population of at least 100,000


MSA December 2006Oregon

13460 Bend, OR 18700 Corvallis, OR 21660 Eugene-Springfield, OR 32780 Medford, OR 38900 Portland-Vancouver-Beaverton, 41420 Salem

Medicare


MedicareEligible Originating Sites:

Medicare includes:

Office of a Physician

Hospital

Critical Access Hospital

Rural Health Clinic

Federally Qualified Health Center

Additions Needed:

Skilled Nursing Facilities

Community Mental Health Centers

County Mental Health Departments

Public Health Departments

Indian Health Service Sites


Medicare

Eligible Medical Practitioners


Medicare Includes:PhysicianNurse PractionerPhysician AssistantNurse MidwifeClinical Nurse SpecialistClinical PsychologistClinical Social WorkerNutrition Professional

Recommended

Additions:Dieticians

Genetics Counselors

Physical Therapists

Occupational Therapists

Speech Therapists

Medicare

Eligible Services


CoveredBIPA

- Consultations

- Office or other outpatient visits

- Individual psychotherapy

- Pharmacologic management

Medicare

Eligible Services


Covered

Added since BIPA

- ESRD services, 2-3, or 4 or more visits per month

- Individual nutritional therapy

Medicare

Eligible Services


Requested but not yet approved

- Nursing facility care

- Speech language pathology

- Audiology

- - Physical therapy services.

Medicaid


•State administered program, Federal Match

•Each state sets its Medicaid telemedicine reimbursement policy

Medicaid


Alabama, Alaska, Arizona, Arkansas, California,Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia,Wisconsin, Wyoming.

35 States Reimburse for Telemedicine

Medicaid


Reimbursement models vary among states:

-Internal agency decision-Legislative initiatives-Regulatory initiatives-Other: SCHIP, Waivers

Medicaid


Per 2004 Survey (Institute for Child Health Studies, U of Florida):

27 States have been reimbursed for telemedicine:-Medical consultations or treatments-22 states-Psychological consultations or treatment-12 states-Home health-2 states-Case management-2 states- Patient education (diabetes)-1 state

Private Payers

-Less published information on private payer

reimbursement

-Progress is being made…..


• States with government mandated legislation

- California, Louisiana, Texas, Oklahoma,

Kentucky

• All prohibit payers from excluding services

solely because they are delivered telemedically


Private Payers

Private Payers


•Growing number of states enacting legislation:- Example: Kansas HB 2065: Private insurers should cover medical care

provided via telemedicine as they do for in-person

Coverage should include:-Office visits or consultations-Individual psychotherapy-Pharmacological management-Emergency services

If passed, effective in 2008

Private Payers


•2005 Survey:American (Telemedicine Association and AMD Telemedicine)

- Phone survey of 72 programs as offering potentially billable services

- 38 receiving reimbursement from private payers

-Payers reimbursing in at least 25 states

-Many are following lead of Blue Cross/Blue Shield

www.amdtelemedicine.com/private_payer

Private Payers


•2005 Survey (American Telemedicine Association and AMD Telemedicine)

- 3 programs receive reimbursement for store and forward

- 7 programs receive reimbursement for facility fees

- Over 100 private payers currently reimburse for telemedicine services

What is happening in Oregon



Oregon

•Oregon’s Landscape

•HJR4

•What’s Next

Oregon’s Landscape

Oregon


Oregon HJR4 passed in 2003 legislative session

Three major goals:– Quality health care should be available to all

Oregonians– To assure best access possible, Telehealth

should be an appropriate tool for delivery of service

– To reduce healthcare costs, Telehealth should be an appropriate tool for delivery of service

HJR4: Key Points: Providers reimbursed for in-person services

should receive same reimbursement for services delivered via telemedicine

Any service reimbursed on an in-person basis should be reimbursed if delivered via telemedicine

With exception of “store-and-forward”, reimbursable services should include clinician to patient services (not clinician to clinician)

Oregon


HJR4: Key Points: Informed consent document specific to

telemedicine should be signed by patient prior to services

Patient should have the right to choose telemedicine or in-person services when both are available

Payers should consider reimbursing transmissions costs

Oregon


Recommended contract language: Matches existing Medicare language, with the

following exceptions:Originating sites are not specific to

geographic locationsEligible originating sites:

Medicare includes:

Office of a Physician

Hospital

Critical Access Hospital

Rural Health Clinic

Federally Qualified Health Center

Additions:

Skilled Nursing Facilities

Community Mental Health Centers

County Mental Health Departments

Public Health Departments

Indian Health Service Sites

Oregon


Recommended Contract Language: Matches existing Medicare language, with the

following exceptions:Payment is permitted for asynchronous

“store and forward” technologyEligible Medical Practitioners:

Medicare Includes:PhysicianNurse PractionerPhysician AssistantNurse MidwifeClinical Nurse SpecialistClinical PsychologistClinical Social Worker

Recommended Additions:DieticiansGenetics CounselorsPhysical TherapistsOccupational TherapistsSpeech Therapists

Oregon


Telemedicine Reimbursement Criteria Medicare

Oregon Medicaid (Fee For Service)

Oregon Medicaid (Managed Care) See sheet 2 (Not Yet Developed)

Regence Blue Cross

Providence Health Services Lifewise Comments

Geographic Locations HPSA: Health Professional

HPSA (Eligible) Y Y ? Y Y Y Shortage Area

MSA (Not Eligible) N Y ? N N Y MSA: Metropolitan

Any Originating Location N Y ? N N Y Statistical Area

Covered Org Sites ? Y

Physician Office Y ? Y Y

Hospital Y ? Y Y

Critical Access Hosp Y ? Y Y

Rural Health Clinic Y Language not ? Y Y See coment

Federally Qualified Health Center Y specific ? Y Y Below

Skilled Nursing Facility See Comment ? Y Y

Comm Mental Health Centers Below ? Y Y

County Mental Health Dept ? Y Y

Public Health Dept ? Y YIndian Health Svc Site ? Y Y

Covered Providers Y Y

Physician Y ? Y Y

Nurse Practioner Y ? Y Y

Physician Assistant Y ? Y Y

Nurse Midwife Y ? Y Y

Clinical Nurse Specialist Y Language not ? Y Y

Clinical Psychologist (Excludes CPT Codes 90805,90807 and 90809) Y specific ? Y Y See CommentClinical Social Worker (Excludes CPT Codes 90805,90807 and 90809) Y See Comment ? Y Y Below

Dieticians N Below ? N N

Genetics Counselor N ? N N

Physical Therapist N ? N N

Occupational Therapist N ? N NSpeech Therapist N ? N N

Covered ServicesConsultations (CPT codes 99241-99275) Y Language not ? Y YOffice or other outpatient visits (CPT codes 99201-99215) Y specific ? Y Y See CommentIndividual psychotherapy (CPT codes 90804-90809) Y See Comment ? Y Y BelowPharmacologic Management (CPT code 90862) Y Below ? Y Y

Telemedicine Reimbursement Criteria By Payer

Telemedicine Reimbursement Criteria Medicare

Oregon Medicaid (Fee For Service)

Oregon Medicaid (Managed Care) See sheet 2 (Not Yet Developed)

Regence Blue Cross

Providence Health Services Lifewise Comments

Other

Facility Fee Y Y ? Y Y ?

Interactive Video Required Y Y ? Y Y ?

Patient Must be Present Y Y ? Y Y ?

Physician to Physician Consult N N ? N N ?

Patient to Physician e-mail consult N N ? N Y ?Asychnchronous Store and Forward * N ? * * ? *Allowed only in the case

of Federally funded demonstration projects in Hawaii and Alaska

Comments Medicare currently reimburses.

Reimburse for sites, care providers, and services as if patient is see in person. Fee for Service Medicaid will begin reimbursing in April,05

. Negotiation with OMAP Managed Care Plans will begin soon.Will suggest same language as Medicaid fee for service.

Target date for Implementation of reimbursement rules is July, 05.

Providence currently reimburses.

Lifewise currently reimburses, but does not have specific contract language for telemedicine reimbursement, reimburse the same as if patient seen in person

Telemedicine Reimbursement Criteria By Payer

Oregon


Convene workgroup to draft telemedicine reimbursementbill for 2009 legislative session.

-Who should be at the table?-What is our strategy?

What’s Next?


Convene workgroup to draft telemedicine reimbursementbill for 2009 legislative session.

-What should language contain?Eligibel Services?Eligible Originating Sites?Eligible Providers?“Should” vs. “Will”?

What’s Next?

Contact Us

Catherine S. BritainCSBritain ConsultingSecretary, Telehealth Alliance of OregonEmail: csbritain@ gmail.com

Kim HoffmanOutreach Coordinator, ITG, OHSUSenior Manager, HERONTelehealth Coordinator, ITG, OHSU1515 SW 5th Avenue, 9th FloorPortland, Or 97201Mail Code: MSB 9th FloorOffice (503) 494-6089Email: [email protected]

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