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Payment and ehealth

  

2001 Report to Congress on Telemedicine, Office for Advancement of TeleHealth, (Last visited: March 17, 2003)

***Overview bulletTable 1: HCFA Telemedicine Reimbursement Requirements Under the Medicare, Medicaid, and SCHIP Benefits and Improvement Protection Act of 2000

***Medicare Reimbursement: The First Two Years

***Legislation

***Other Payment Coverage bulletBox 1: Medicaid State Coverage  Overview

One of the greatest stumbling blocks to the expansion of the telehealth industry has been lack of reimbursement for telemedicine and telehealth services. Advances in telemedicine technology have made it easy to deliver health care services over a distance but few public or private payers will pay telemedicine costs. Until recently, Medicare has not had an explicit policy to pay for telemedicine services. Historically, Medicare reimbursed some services that did not traditionally require face-to-face contact between a patient and practitioner. For example, it covered EKG or EEG interpretation, teleradiology and telepathology in most of the nation, depending on individual Medicare carrier policies.

However, the Balanced Budget Act of 1997 (BBA) brought about a significant change in Medicare telemedicine reimbursement policy. As of Jan. 1, 1999, Congress required the Health Care Financing Administration (HCFA) to pay for telemedicine consultation services under the BBA. Some important reimbursement eligibility requirements are outlined in Table 1 below.

TABLE 1: HCFA Telemedicine Reimbursement Requirements Under the Medicare, Medicaid and SCHIP Benefits and Improvement Protection Act of 2000 Scope Eligibility Requirements Geographic Scope Only patients located in Rural Health Professional Shortage Areas (HPSAs), counties in Non-MSAs and in approved Federal demonstration projects are eligible for telemedicine reimbursement. A list of shortage areas can be found at http://www.access.gpo.gov. Eligible CPT Codes Eligible Current Procedural Terminology (CPT) codes include professional consultations, office visits, and office psychiatry services (codes 99241-99275; 99201-99215;90804-90809) and any other additional services specified by the DHHS Secretary. Eligible Presenting Practitioner The new law eliminates the requirement to have a telehealth presenter present a patient at a consultation unless it is medically necessary (as determined by the physician or practitioner at the distant site) Fee-Sharing The new law eliminates the fee sharing requirement between a consultant and referring physician. Eligible Technology3 The new Act provides for reimbursement for store and forward technology in demonstration projects in Alaska and Hawaii but no other setting. HCFA's payment policy was developed to replicate a standard consultation as closely as possible. Under Medicare, a separate payment for a consultation requires a face to face examination of the patient. This requirement is consistent with the American Medical Association's description of a consultation. To that end, Medicare's teleconsultation rule requires a certain level of interaction between the patient and consulting practitioner because it offers the best substitute for a "face-to-face" consultation. Regardless of the technology, the patient must be present during the consultation. Medicare does not currently make separate payment for the review and interpretation of a previous examination, photos or records. Home Health Care The new Act clarifies that home health agencies "may adopt telehealth technology that it believes promotes efficiencies or improves quality of care, however, these technologies will not be specifically recognized or reimbursed under the home health benefit. Telehealth encounters do not meet the definition of a Medicare covered home health visit. But this does not preclude a home health agency from spending prospective payment dollars to furnish services outside of the Medicare home health benefit (i.e., for telehealth services to home health beneficiaries). If a physician intends that telehealth serivces be furnished while a patient is under a home ehalth program of care, this should be recorded in addition to the Medicare covered home health services to be furnished." Medicare Reimbursement-The First Two Years

Over the first two years of the Medicare telemedicine reimbursement rule, many telehealth practitioners have found both the BBA mandates and HCFA's interpretation of the BBA too narrow for most practical purposes. On September 30, 2000, after almost two years of telemedicine reimbursement, Medicare has reimbursed a total of $20,000 for 301 teleconsultation claims.

Four major issues may have greatly limited the number of reimbursable telemedicine consultations:

*** Health Professional Shortage Area Limitations. Only patients in Health Professional Shortage Areas (HPSAs) were eligible for reimbursement under the BBA. This restriction greatly narrows the number of people, who might benefit from telemedicine, and disregards the needs of many rural patients, who may have access to a nurse or general practitioner, but not to specialists such as cardiologists, psychologists, dermatologists, etc.

***Fee-sharing requirement. Consulting physicians found fee-sharing problematic because they receive only 75 percent of normal pay for their services. Moreover, HFCA reports consultant payment to the IRS at 100 percent. Other problems with fee-sharing included accounting and fee tracking. Most rural practitioners are not equipped to track split fees. Finally, perhaps the most important ramification of the fee-sharing requirement is that, to be paid, the eligible presenter must either be the referring physician or an employee of the referring physician. In many cases, the presenter is an employee of the local hospital or clinic.

*** Eligible presenters. In many (if not most) places rural clinics are staffed only by registered nurses (RNs), licensed practical nurses (LPNs) or by health technicians, who were all ineligible presenters under the Act. In a survey of 20 telehealth networks representing 4,761 telehealth encounters between Jan. 1, 1999 and June 30, 1999, the University of Missouri found that: bulletLPNs and RNs make up the majority of patient presenters in almost all telehealth networks, but they are not eligible presenters. bullet171 or 3.6% of all encounters involved a patient interaction with either an occupational, physical, speech therapist or clinical psychologist. bulletOnly 7% of referring practitioners or employees of the referring practitioner acted as patient presenters in consultations. This suggests that if all of the reported 4,761 telehealth activities were Medicare, less than 7 percent of all cases would meet HCFA's eligible presenter criteria.

***Eligible Current Procedural Terminology Codes. Only a handful of CPT codes were eligible for HCFA telemedicine reimbursement under BBA. This limitation greatly restricted the types of services for which practitioners could be reimbursed. Many services that telemedicine providers already offer were not included in these codes. Legislation

The House and Senate introduced nine bills with telehealth provisions in the 106th Session to address the BBA's telemedicine reimbursement limitations and to allow more Medicare coverage for telemedicine services. At the end of December 2000, Congress passed the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 ("the Act"), which is effective October 1,2001.

Among other things, Section 223 of the Act, eliminates the presenter and fee-sharing requirements, expands eligible locations to include HPSAs and counties not included in a Metropolitan Statistical Area, expands the number of CPT codes that are eligible for Medicare reimbursement and provides full reimbursement to a specialist for services rendered in a teleconsultation. Section 503 addresses the use of telehealth in the delivery of home health services. (See Appendix 1 for language of the Act and a comparison of the bills)

Historically, one of the key challenges to the passage of any expansion of telemedicine reimbursement has been the lack of data upon which to judge its impact on government expenditures. The Office for the Advancement of Telehealth (OAT) has worked with the Center for Telemedicine Law (CTL) and OAT's grantees to develop a series of cost models that would provide a more accurate estimate of the impact of expanded coverage on third party payers. These "scoring" models have the advantage of being able to use actual telemedicine experience from the field. Preliminary results suggest that many of the modest telemedicine reimbursement expansions introduced in the 106th Congress would have minimal impact on Medicare expenditures. (For example, CTL/OAT estimates of Senate Bill 2505 budgetary impact range from $50 to $100 million over five years as compared to an estimate of over a billion dollars scored for legislation in earlier years.)

Other Payment Coverage Box 1 Medicaid State Coverage

Arkansas, California, Georgia, Iowa, Illinois, Indiana, Kansas, Kentucky, Louisiana, Montana, Nebraska, North Carolina, North Dakota, South Dakota, Oklahoma, Texas, Utah, Virginia, and West Virginia. In addition, Connecticut, Maine and Minnesota are piloting telemedicine programs.

Sources: CTL "Medicaid Telemedicine and Telehealth Update", July 2000, Health Care Finance Administration http://www.hcfa.gov/medicaid/telemed.htm

In addition to Medicare payments for telemedicine, 20 state Medicaid programs as shown in Box 1 and several state Blue Cross/Blue Shield plans, as well as some other private insurers, pay for select telemedicine services. Several states have recently passed laws that prohibit insurers from discriminating between regular medical and telemedicine services' reimbursement. These states include California, Texas and Louisiana.

Some private insurers also provide limited telemedicine coverage in certain states. For example, Blue Cross-Blue Shield in Montana and North Dakota provides some telemedicine coverage and Blue Cross of California is going a step further by developing a statewide telemedicine network. In July 1999, the Managed Risk Medical Insurance Board awarded $1.8 million to Blue Cross California to expand telemedicine capabilities throughout California. Blue Cross planned to use the funds to expand services at 17 existing clinics to serve medically underserved populations and to provide equipment and support to 22 new telemedicine sites in 18 counties.

 Next Steps

***OAT will collaborate with HCFA, state Medicaid programs, private third party payers and other relevant organizations to create a forum in which the experiences of third party payers with telemedicine can be shared.

***OAT will continue to refine its telemedicine scoring models for a broad range of telemedicine applications.

 

Footnotes

3Medicare has historically reimbursed some telemedicine services that did not traditionally require face-to-face contact between a patient and practitioner. For example, Medicare covered EKG or EEG interpretation, teleradiology, and telepathology in most areas of the nation, in accordance with individual Medicare carrier policies.


Comparison of Legislative Bills Relating to Telemedicine Reimbursement Comparison of Legislative Bills Relating to Telemedicine Reimbursement

2001 Report to Congress on Telemedicine, Office for Advancement of TeleHealth, (Last visited: March 17, 2003)

Feature S. 2505 H.R. 5291 Ways and Means H.R. 4577 Title Telehealth Improvement and Modernization Act of 2000 Revision of Medicare Reimbursement for Telehealth Services Section 324: Expansion of Medicare Payment for Telehealth Services Revision of Medicare Reimbursement for Telehealth Services Reimbursement Secretary shall pay to a physician or practitioner at a distant site that provides an item or service the amount equal to that if it had been provided without telehealth. Not later than April 1, 2001 HHS shall pay for telemedicine services that would be made under part B, Title XVIII of SSA. Same as Senate. Secretary shall pay to a physician or practitioner at a distant site that furnishes a telehealth service to an eligible telehealth individual and amount equal to that if it had been provided without use of a telecommunications system. Facility Fee An amount equal to:1) for 2000 and 2001, $20; and2) for a subsequent year, the facility fee will be increased by the percentage increase in the MEI Same as Senate except facility fee begins April 1,2001 and runs through 2002 at $20. Same as Senate except facility fee for July 1, 2001 through December 2001 and for 2002 is $20. Balanced billing explicitly prohibited. An amount equal to:1) for 7/1/01 through 2002, $20; and 2) for a subsequent year, the facility fee will be the same as 1) or increased by the percentage increase in the MEI Site Eligible for Facility Fee Tier 1:On or before January 1, 2002:1) the office of a physician or practitioner;2) a critical access hospital;3) a rural health clinic; and4) a Federally qualified health center.Tier 2On or before January 1, 2003: 1) a hospital;2) a skilled nursing facility;3) a comprehensive outpatient rehabilitation facility;4) an ambulatory surgical center;5) an Indian Health Service facility; and 6) a community mental health center. Tier 1 Same sites as Senate except coverage begins on or after April 1, 2001.Tier 2 On or before January 1, 2002:1) a hospital;2) a skilled nursing facility;3) a comprehensive outpatient rehabilitation facility;4) a renal dialysis facility;5) an ambulatory surgical center;6) a hospital or skilled nursing facility of the Indian Health Services; and7) a community mental health center Includes only those sites listed below and only if the site is located in a HPSA that is located in all or part of a rural area:1) The office of a physician or practitioner;2) A rural health clinic;3) A Federally Qualified Health Center; and4) A critical access hospital Originating Site:1) An area designated as a rural health professional shortage area2) In a county that is not in a MSA3) A Federal telemedicine demonstration project. Sites: 1) The office of a physician or practitioner;2) A critical access hospital;3) A rural health clinic;4) A Federally Qualified Health Center; and5) A hospital Telepresenter Telepresenter not required Same as Senate except, "unless it is medically necessary as determined by the physician or practitioner at the distant site". Except for certain psychiatric services, an individual shall be presented by a physician or practitioner or an RN. Telepresenter not required, unless it is medically necessary (as determined by the physician or practitioner at the distant site). Geographical Area Covered Applies to eligible Telehealth Beneficiaries residing in:1) a HPSA; 2) a county not included in a Metropolitan Statistical Area; and 3) an inner-city area that is medically underserved. Same as the Senate except: An inner city that is considered medically underserved effective January 1, 2002, and a facility which participates in a Federal telemedicine demonstration project. Same as Sites Eligible for Facility Fee. Only if the site is located in a HPSA that is located in all or part of a rural area:1) The office of a physician or practitioner; 2) A rural health clinic;3) A Federally Qualified Health Center; and4) A critical access hospital Originating Sites including:1) An area designated as a rural health professional shortage area2) In a county that is not in a MSA3) A Federal telemedicine demonstration project. Codes Covered

Payment will be made for professional consultations, office visits, office psychiatry services, including any service identified as of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215, 90804-90815, and 90862, and any additional item or service specified by the Secretary.

Additionally: Directs Secretary to identify appropriately covered services and to report back 2 years within enactment of the legislation.

Same as Senate except for coding: Codes covered include 99241-99275, 99201-99215, 90804-90809 and 90862.

Additionally: Directs Secretary to identify appropriately covered services and to report back within 2 years of enactment of the legislation.

Same as Senate, except for coding: Codes covered include 99241-99275, 99201-99215, 90804-90809 and 90862.

Also, directs the Comptroller General to conduct a study similar to that called for in Senate bill and requires a report in 3 years.

telehealth service means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes codes 99241-99275, 99201-99215, 90804-90809, and 90862, and as subsequently modified by the Secretary.

Additionally, requires the Secretary to establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes) as appropriate

Eligible Telehealth Providers Expands upon physician only provision in BBA by adding: 1) a practitioner described in section 1842(b)(18)(C) of the Social Security Act; and 2) physical, occupational or speech therapist. Same as Senate except it does not include physical, occupational or speech therapists Refers to physicians and practitioners but does not define them. A physician, (as defined in section 1861 ( r) or a practitioner as described in section 1824 (b)(18)( C) Home Health

Nothing in this section or in section 1895 of the Social Security Act (42 U.S.C. 1395fff) shall be construed as preventing a home health agency furnishing a home health unit of service for which payment is made under the prospective payment system established in such section for such units of service from furnishing the service via a telecommunications system.

LIMITATION- Nothing in this section shall require the Secretary to consider a home health service provided in the manner described in paragraph (1) to be a home health visit for purposes of--`(A) determining the amount of payment to be made under such prospective payment system; or`(B) any requirement relating to the certification of a physician required under section 1814(a)(2)(C) of such Act (42 U.S.C. 1395f(a)(2)(C)).

Same as the Senate, except the language "via a telecommunication system" is excluded. Section 504 states:Nothing in this section shall be construed as preventing a home health agency furnishing a home health unit of service for which payment is made under the PPS established by this section for such units of service from furnishing services via a telecommunication system if such services:1. Do not substitute for home health services ordered as part of a plan of care certified by a physician; and2. Are not considered to be a home health visit for purposes of eligibility or payment under this title. Nothing in this section shall be construed as preventing a home health agency furnishing a home health unit of service for which payment is made under the prospective payment system established by this section for such units of service from furnishing services via a telecommunications system if such services - (A) do not substitute for in-person home health services ordered as part of a plan of care certified by a physician; and (B) are not considered a home health visit for purposes of eligibility or payment under this title. Store and Forward Re: Section 4206(a)(1) of the BBA, in the case of any Federal telemedicine demonstration program in Alaska or Hawaii, the term "telecommunications system" includes store-and-forward technologies that provide for the asynchronous transmission of health care information in a single or multimedia format(s). Same as Senate No provision. In the case of any Federal telemedicine demonstration program conducted in in Alaska or Hawaii, the term "telecommunications system" includes store-and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats. Fee Sharing and Payment of Presenter Fee sharing provisions in BBA '97 are eliminated. Same as Senate Nothing prohibits the physician or practitioner from sharing a portion of the fee that he or she receives from Medicare for an eligible teleheath service with a physician or practitioner who serves as a telepresenter at the originating site;Payment for an RN who serves as a telepresenter shall be made by the distant site physician or practitioner or the originating site facility that is the RNs employer;The provisions of section 1877 shall apply to payments that a physician or practitioner at a distant site makes to a referring physician or practitioner who does not serve as a telepresenter at the originating site. Fee sharing provisions in BBA '97 are eliminated.


 

 

The Medicare, Medicaid, and SCHIP Benefits Improvements and Beneficiary Protection Act of 2000, Section 223 The Medicare, Medicaid, and SCHIP Benefits Improvements and Beneficiary Protection Act of 2000, Section 223

The following was taken from http://thomas.loc.gov/cgi-bin/bdquery/z?d106:HR04577:|TOM:/bss/d106query.html|

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114 STAT. 2763A487 PUBLIC LAW 106554APPENDIX F SEC. 223. REVISION OF MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES.

(a) TIME LIMIT FOR BBA PROVISION.Section 4206(a) of BBA (42 U.S.C. 1395l note) is amended by striking Not later than January 1, 1999 and inserting For services furnished on and after January 1, 1999, and before October 1, 2001.

(b) EXPANSION OF MEDICARE PAYMENT FOR TELEHEALTH SERVICES. Section 1834 (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(m) PAYMENT FOR TELEHEALTH SERVICES.

(1) IN GENERAL.The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary. For purposes of the preceding sentence, in the case of any Federal telemedicine demonstration program conducted in Alaska or Hawaii, the term telecommunications system includes store-and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats.

``(2) Payment amount.--

``(A) Distant site.--The Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this title had such service been furnished without the use of a telecommunications system.

``(B) Facility fee for originating site.--With respect to a telehealth service, subject to section 1833(a)(1)(U), there shall be paid to the originating site a facility fee equal to--

``(i) for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and

``(ii) for a subsequent year, the facility fee specified in clause (i) or this clause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

``(C) Telepresenter not required.--Nothing in this subsection shall be construed as requiring an eligible telehealth individual to be presented by a physician or practitioner at the originating site for the furnishing of a service via a telecommunications system, unless it is medically necessary (as determined by the physician or practitioner at the distant site).

``(3) Limitation on beneficiary charges.--

``(A) Physician and practitioner.--The provisions of section 1848(g) and subparagraphs (A) and (B) of section 1842(b)(18) shall apply to a physician or practitioner receiving payment under this subsection in the same manner as they apply to physicians or practitioners under such sections.

``(B) Originating site.--The provisions of section 1842(b)(18) shall apply to originating sites receiving a facility fee in the same manner as they apply to practitioners under such section.

``(4) Definitions.--For purposes of this subsection:

``(A) Distant site.--The term `distant site' means the site at which the physician or practitioner is located at the time the service is provided via a telecommunications system.

``(B) Eligible telehealth individual.--The term `eligible telehealth individual' means an individual enrolled under this part who receives a telehealth service furnished at an originating site.

``(C) Originating site.--

``(i) In general.--The term `originating site' means only those sites described in clause (ii) at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system and only if such site is located--

``(I) in an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A));

``(II) in a county that is not included in a Metropolitan Statistical Area; or

``(III) from an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

``(ii) Sites described.--The sites referred to in clause (i) are the following sites:

``(I) The office of a physician or practitioner.

``(II) A critical access hospital (as defined in section 1861(mm)(1)).

``(III) A rural health clinic (as defined in section 1861(aa)(s)).

``(IV) A Federally qualified health center (as defined in section 1861(aa)(4)).

``(V) A hospital (as defined in section 1861(e)).

``(D) Physician.--The term `physician' has the meaning given that term in section 1861(r).

``(E) Practitioner.--The term `practitioner' has the meaning given that term in section 1842(b)(18)(C).

``(F) Telehealth service.--

``(i) In general.--The term `telehealth service' means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215, 90804-90809, and 90862 (and as subsequently modified by the secretary)), and any additional service specified by the Secretary.

``(ii) Yearly update.--The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate, to those specified in clause (i) for authorized payment under paragraph (1).''.

(c) Conforming Amendment.--Section 1833(a)(1) (42 U.S.C. 1395l(1)), as amended by section 105(c), is further amended--

(1) by striking ``and (T)'' and inserting ``(T)''; and

(2) by inserting before the semicolon at the end the following: ``, and (U) with respect to facility fees described in section 1834(m)(2)(B), the amounts paid shall be 80 percent of the lesser of the actual charge or the amounts specified in such section''.

(d) Study and Report on Additional Coverage.--

(1) Study.--The Secretary of Health and Human Services shall conduct a study to identify--

(A) settings and sites for the provision of telehealth services that are in addition to those permitted under section 1834(m) of the Social Security Act, as added by subsection (b);

(B) practitioners that may be reimbursed under such section for furnishing telehealth services that are in addition to the practitioners that may be reimbursed for such services under such section; and

(C) geographic areas in which telehealth services may be reimbursed that are in addition to the geographic areas where such services may be reimbursed under such section.

(2) Report.--Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit to Congress a report on the study conducted under paragraph (1) together with such recommendations for legislation that the Secretary determines are appropriate.

(e) Effective Date.--The amendments made by subsections (b) and (c) shall be effective for services furnished on or after October 1, 2001.


 

The Medicare, Medicaid, and SCHIP Benefits Improvements and Beneficiary Protection Act of 2000, Section 504 The Medicare, Medicaid, and SCHIP Benefits Improvements and Beneficiary Protection Act of 2000, Section 504

The following was taken from http://thomas.loc.gov/cgi-bin/bdquery/z?d106:HR04577:|TOM:/bss/d106query.html|

Adobe PDF version of this document

114 STAT. 2763A531 PUBLIC LAW 106554APPENDIX F SEC. 504. USE OF TELEHEALTH IN DELIVERY OF HOME HEALTH SERVICES.

Section 1895 (42 U.S.C. 1395fff ) is amended by adding at the end the following new subsection:

(e) CONSTRUCTION RELATED TO HOME HEALTH SERVICES.

(1) TELECOMMUNICATIONS.Nothing in this section shall be construed as preventing a home health agency furnishing a home health unit of service for which payment is made under the prospective payment system established by this section for such units of service from furnishing services via a telecommunication system if such services

(A) do not substitute for in-person home health services ordered as part of a plan of care certified by a physician pursuant to section 1814(a)(2)(C) or 1835(a)(2)(A); and

(B) are not considered a home health visit for purposes of eligibility or payment under this title.

(2) PHYSICIAN CERTIFICATION.Nothing in this section shall be construed as waiving the requirement for a physician certification under section 1814(a)(2)(C) or 1835(a)(2)(A) of such Act (42 U.S.C. 1395f(a)(2)(C), 1395n(a)(2)(A)) for the payment for home health services, whether or not furnished via a tele-communications system..

 

 

 

 

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