Establishing Telehealth Services at Your Practice

Physician's Practice®: Happy Holidays everyone! As you recline into your various festivities, feasts, and celebrations, business should be far from your mind.

Healthcare does not take such breaks.

If you are one of the lucky few who have downtime at this point in this hectic year,

The offices at MJH Life Sciences are closed for the holidays, but we still wanted to bring you our conversation with Elizabeth Woodcock, founder and principal Woodcock and Associates [and an adjunct faculty at the Rollins School of Public Health at Emroy University in Atlanta, Georgia].

A little fun fact about this special guest: she was actually the 'director of knowledge management' at Physician's Practice from 2003-2004. Our contemporary Pearls writers are a direct result of her work—she originally christened our newsletter 'Pearls', and that title has lived on though migrated to our regular expert contributors.

Earlier this year, Elizabeth joined me to answer some questions about telemedicine. Then, the concept was fresh as most practices were attempting to understand and implement these strategies while simultaneously trying treat through these platforms.

We began by discussing whether or not it is too late for practices to begin setting up those services.

Elizabeth Woodcock: A great question of the day. And the answer is actually: Absolutely not. In fact, I've worked with physicians who have been up and running literally within hours. Now I know I mean, a decade maybe even a year ago, the technology interface was not particularly user friendly. And, you know, there weren’t great features; but now there are and prices are actually ranging from totally free to monthly subscriptions that are starting at $20 to several hundred dollars. And you know, it's interesting, after we spent a few years kind of all getting EHR systems—which were very, very expensive, this one is a fraction of that cost.

Physician's Practice®: Good, good. Even for you listening to this podcast right now—whenever 'right now' might be—it is not to late to begin setting up these services.

The next question is: how do you get started quickly?

Elizabeth Woodcock: Well, I like to go to the horse's mouth. So I would say talk to colleagues, look at listservs that have been very active or like specialty societies, particularly if you're in a specialty and you really want you know, you have some nuances that might dictate specific product for your specialty; your state medical societies; you can do an internet search, but I actually find the best thing to do is to ask colleagues.

Now I will say, Drew, though that the easiest part, maybe the platform actually, the more difficult part is the workflow, like who will answer the phone? How are you going to explain all this to patients? They're used to seeing you in person? What is you know, what is the meaning of all this? Are you going to see new patients? Are you just going to see established patients where you still see in person visits? Are you moving everything to telemedicine? And then what is your scheduling template going to look like? And then Oh, the By the way, how are you going to register patients collect consents, insurance cards, etc.

Now, I don't mean this in any manner to be a comprehensive list, but I think it pays to sit down and just kind of think about like, what, what is my workflow in the office? And then what should it look like when my patients aren't standing there in person. And quite often, of course, my team, my staff isn't standing there in person. And if I may, a couple of like best practices that I've heard from physicians is to definitely sign up every patient on our portal, because this avoids that telephone tag afterwards. Especially since you aren't seeing the patient in person. A lot of the portals now have electronic signatures, you can upload insurance cards, so that can kind of take care of that.

And then the other best practice I've heard is, okay, so there's going to be no shows, right? You have this telemedicine, the patient may not be able to get their video to work. So, another great best practice is to have your MA or your nurse actually initiate the visit. And maybe they can perform like the clinical intake or rooming you know, ask the patient about medications if they have a home blood pressure monitor or ask for their BP, etc. but this really kills two birds with one stone because now instead of sitting there trying to figure out, is the patient going to show up? Do they have the right technology? You are ready know that when you're seeing the patient, the patient is going to be ready for you. So definitely, it was thought I would mention those two best practices from a workflow perspective.

So, when some I think the platform is actually one of the easiest decisions. What really is something you need to work through is the workflow.

Physician's Practice®: So you've chosen your telemedicine platform, you've planned out your workflow strategies—what's next?

Before you jump right into telemedicine, consider whether or not you can actually be reimbursed for these services.

Elizabeth Woodcock: Well, definitely, we can get reimbursed. And so I kind of like think about this as what's going on at the federal government level and they've kind of issued a well who can practice telemedicine and who can't. But what's interesting, like reimbursement for medicine in general, this is a web of complexity because there's what's going on at the federal level, and then each individual payer almost has different policies about who can perform what services remotely and what those services actually entail.

What's interesting Drew, this actually may be a good time to bring up the fact that telemedicine is actually only one of a series of digital services that can actually be provided today. So, telemedicine has a specific definition: two-way, interactive audio visual. Sometimes you'll see the government add the term real time as well. But actually, there are lots of other services that can be rendered and paid that are not technically telemedicine.

You see, historically, telemedicine was only allowed for patients who were in a health care professional shortage area. That is, there weren't enough doctors available. So they were able to or they were able to see physicians who could bill, you know, from the cities, if you will, for those patients, but obviously, it was pretty restricted. So now we have services that are telemedicine and they kind of blew up, I say they—the federal government said less than a patient could be anywhere.

But in addition to telemedicine, we actually have he visits, remote patient monitoring, and virtual visits. So, I like kind of think about these collectively as digital services. And the key factor in determining these is how they are delivered. So, for example, if you serve as a patient over the portal, you can look at the codes for he visits or virtual visits. But you can't bill telemedicine because it doesn't fit within that two-way interactive audio visual definition. And of course, the other factor is what is delivered what services that is. And that's where I would actually suggest looking at the CPT codes themselves to determine.

In fact, I should mention that the American Medical Association has an amazing fact sheet that kind of goes through the different scenarios and offers you guidance about who can bill for it and what they can bill for. So that's something I would highly recommend to physicians.

Physician's Practice®: Good, you CAN get reimbursed for these services. Now, you need to consider how to set up payments for these services at your practice.

Elizabeth Woodcock: Well, let's take a look at telemedicine first, for Medicare, there's actually more than 200 codes now that can be delivered over telemedicine. So your traditional evaluation management codes like 99213, or even annual wellness visits. And interestingly enough, they are paid at the in-person rates.

So, let's say you got paid $75 for 99213—which was kind of a very close to the national payment rate for Medicare—that's what you'll get from telemedicine. So that's awesome. But for the other digital services, and CMS actually uses the term ‘Communication Base Technology Services’ or CTBS. But from a Medicare perspective, they kind of range for about 12 to $15. And the highest you're going to get is like 50 to $60. So, you know, I'm not going to list off all the particular reimbursement, but you can just tell from my example that is definitely more favorable for you to actually bill for a telemedicine visit.

Now, I'm giving those figures from a Medicare perspective, but each payer has of course, their own fee schedule, and you'd want to look to them to see what what's the most conducive for you and of course, to be compliant to actually render the services appropriately from a coding perspective.

Physician's Practice®: In setting up your services, you might wonder: do certain services performed via telemedicine cost more than others?

Here's what Elizabeth had to say...

Elizabeth Woodcock: Well, interesting that you asked that because just on April 11, the federal government issued a policy. And this was really fascinating to me, because not only are they saying any services that are provided related to COVID-19, or that which a COVID-19 test was ordered, are covered at full cost, like no cost share patient don't have any copayments, etc. But they've dictated to private payers to do the same. So basically, that to me was kind of like, okay, we have the landscape of what's COVID related. And that looks like it's going to be no cost share no copayment, no coinsurance from Medicare, or private payers. But then we kind of trickled down into private payers. So, like me, I'm a COVID, excuse me, a Cigna patient. So, if I call my internist today and had a sinus infection, I still have to pay a copayment. Interestingly enough, if I was an Aetna patient at Aetna has actually decided to waive all copayments. So, it depends

Physician's Practice®: Unfortunately, the 'it depends' aspect of telemedicine service and payer reimbursement does not end there.

Payers may have individual requirements for who can and cannot perform Telehealth services to receive certain payments.

Elizabeth's advice on determining what individuals can perform which services is to go to CMS' website because even at the time we spoke, CMS' regulations were changing by the day.

Elizabeth also offered similar advice regarding licnesure. At the time, physicains were just recently granted the ability to work across state lines; however, Elizabeth says that since licensure is controlled by the states, physicians operating across state lines via telemedicine should keep a watch on the Federation of State Medical Boards' website, where they retain updated information for all 50 states and U.S. territories.

Elizabeth did offer some final advice about the pandemic situation and the rise of new telemedicine services and related regulations...

Elizabeth Woodcock: Well, I mean, I think personally, this is one of those situations. And I'm an optimistic person by nature where we have to kind of think about, okay, this is either like, we’re going down, or we're gonna make some lemonade out of lemons. And I know, that's really a trite analogy at the moment, but I think things are shifting, literally in front of our eyes.

I really think there's two important narratives going on. Number one, we've been complaining—me particularly—about regulations, since I mean, forever. I've been working in healthcare since the early 1990s, I know I've been a big complainer. And basically, it's a blank slate every — HIPAA, privacy, you name the regulation, and I can tell you how it's changed. I mean, we just have this amazing opportunity. And then secondly, our patients are probably never going to go back to the days of calling us waiting months for an appointment, waiting hours in our waiting room. So like, we've got to think about this thing like: okay, the regulations have sort of gone away, what can we do to be innovative here, our patients are going to be thinking about different ways that we are delivering medicine today. I'm afraid we may never be able to go back to the old ways.

So, we can kind of take you know, two paths. And I would encourage us to think about how we can create a path that our patients and our industry can really go down together in a good way.

Physician's Practice®: Thank you again, Elizabeth, for your insights and advice on telemedicine, reimbursements, and regulations.

And thank you all for listening to this episode of Perspectives, brought to you by Physician’s Practice.

We hope you subscribe where you listen to podcasts, rate us, and let us know what topics you would like to hear more about.

For more practice management insights from the top experts in the field, be sure to visit us at physciainspractice.com and sign up for our newsletter.

We’ll see you again in two weeks.