Telehealth for providers

 

 

 

 

 

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Technology

Under the COVID-19 emergency, providers can use audio-only communication as well as non-public facing remote communication products to communicate with patients, such as:

  • Apple FaceTime
  • Facebook Messenger video chat
  • Google Hangouts video
  • Skype
  • Telephone

See free and for-fee vendors below.

Billing

Audio only communication is now considered a telehealth visit and is reimbursable under Medicare, CO Medicaid and commercial health plans regulated by the Colorado Division of Insurance. Providers can bill for telehealth visits at the same rate as in-person visits. 

CO Medicaid now also includes chat as a telehealth visit, and is reimbursing at the in-person rate.

For more information, see the Medicare and CO Medicaid resources below.

Determine a modality
  • Depending on whether you’ve used telehealth before, determine a modality (i.e. phone, video, virtual platform) to begin delivering services as quickly as possible. 
  • Set up a team that will help facilitate the expedited implementation of telehealth services and be able to make decisions quickly to ensure launch as soon as possible.
  • Check with your malpractice insurance carrier to ensure your policy covers providing care via telehealth.
Consider internet speeds 

The recommended internet speed for telehealth depends on what method of telehealth you want to provide. Download speeds of at least 25 Mbps accommodate most needs but it depends on how you use the internet:  

  • Telephone and Texting: Not applicable.
  • Email and basic computer programs: 3-4 Mbps is recommended.
  • Skype, Facetime, Zoom or Google Hangouts: 10+ Mbps is recommended. 
  • Large file transfers: 40+ Mbps is recommended.

Google provides an easy way to test your internet connection directly from the Google homepage:

  1. Type “internet speed test” in the Google search bar.
  2. Click the blue button that says Run Speed Test. 

Use wired Ethernet instead of wifi, whenever possible. This creates a more stable internet connection. 

You will also need to consider the internet speeds available generally in your community and in the patient populations you serve. Most video platforms work on a 3G/4G cell phone data connection or on personal home internet plans. However, not everyone may have access to the same level of internet or types of personal technology in the home. 

Vendor selection
  • Check with your existing EHR vendor to see if there is telehealth functionality that can be turned on.
  • Leverage resources available at recognized entities nationally and locally to identify possible telehealth vendors to work
Ensure professional compliance   

Providers should consider the applicable law and policies currently in place before initiating a telehealth session, to include:

  • Standard of care - When providing telemedicine, the standard of care is the same as an in-person setting.
  • Patient location - Health care providers in Colorado generally may conduct virtual visits with patients located in Colorado and other states where the provider is licensed or is a member of a national licensing compact.
  • Documentation - Healthcare providers providing telehealth/telemedicine services are under the same obligation to keep and maintain an adequate medical record as they are if the services are provided in person.

Contact the Department of Regulatory Agencies if you require further guidance.

Make a plan 
  • Consider what information can be collected from patients electronically or over the phone to properly triage and determine if a telehealth visit is appropriate.
  • Set up a space to accommodate telehealth visits. A provider may participate in the telemedicine interaction from any appropriate location including their home. All providers, even those working from home, should follow general guidelines related to privacy and professionalism and see patients from a private, quiet room where they will not be overheard or interrupted by animals or family members in the home. 
  • Ensure proper documentation of visits in the EHR. This will keep the patient’s medical record together, allow for efficient testing, prescribing, ordering and billing for telehealth visits. 

Telehealth should be used when possible. However, if a provider feels that a patient's complaint warrants an in-person visit, the provider must adhere to Executive Order D 2020 009 prohibiting elective and non-emergency procedures. Note that provider discretion is allowed in those circumstances where an injury or illness is at risk of worsening or the patient’s health is at risk of rapid deterioration. 

  • Decide how patient consent will be captured ahead of telehealth interactions, and how this will be  documented in the patient’s record. Check to see if your technology vendor can support this electronically. Verbal consent is currently allowable due to the state of emergency. If using verbal consent, document that the patient gave consent.
  • Have a plan for preparing and supporting patients in using telehealth technology based on your practice’s technology and workflow to keep visits moving and avoid disruptions to care.
  • Train supporting staff on how to use telehealth platforms, equipment, and patient workflow for telehealth visits.
  • Make a plan for what to do if things go wrong: if the internet fails or the call drops, if the patient is experiencing a mental health crisis, and if the patient is having a medical emergency. Know your patient’s physical location in case you need to send emergency assistance.
Test the process

Before your first session, practice with staff and do a few test runs. It helps to take turns practicing being a patient. If using video, send them a link (just as you would for a patient) to join a session and test the platform. You’ll be much more confident and prepared for your first telehealth session if you know what to expect. This is also a good time to practice new scripts related to verbal consent, explaining telehealth, or doing verbal screening. 

Encourage patient use of telehealth
  • Promote telehealth on your website, patient portal, and other patient communication lines. Include instructions on how the patient would schedule a telehealth visit.
  • Patients can use their mobile devices (phones), laptops, desktops, and tablets to connect. Ask the patient what technology or equipment is available to them.
  • If clients call to book or reschedule appointments, offer telehealth as an alternative.
  • Put up signs in your waiting room to encourage people to ask about using telehealth.
  • Have your office staff help support proactive patient outreach.
  • You can also direct patients to the Health At Home website for informational videos and resources related to telehealth and COVID-19.

See Prime Health’s Directory page for examples of workflows and protocols

Continue to pursue education & support
  • Safety Net Connect Provides Primary Care Physicians With Free Access to Dedicated eConsult Telehealth Portal in Partnership With America’s Physician Groups, Gaine Healthcare and HubMD.
  • ECHO Colorado is hosting several opportunities focused on telehealth implementation, as well as a COVID-19 specific series.
  • Prime Health offers free, online daily and weekly virtual trainings for implementation of telehealth programs and telehealth town halls. They also provide one-on-one workflow, technology and implementation support and have a telehealth FAQ hotline for answering specific questions. Email telehealth@primehealthco.com. 
  • Colorado Medical Society is hosting several town halls and webinars specific to COVID-19.
  • The National Indian Health Board is hosting several calls, webinars and events specific to COVID-19.

SB20-212: Reimbursement For Telehealth Services

On July 6, 2020, Governor Polis signed bill SB20-212 to prohibit certain acts by health insurance carriers related to telehealth. The act prohibits a health insurance carrier from:

  • Imposing specific requirements or limitations on the HIPAA-compliant technologies used to deliver telehealth services;
  • Requiring a covered person to have a previously established patient-provider relationship with a specific provider in order to receive medically necessary telehealth services from the provider; or
  • Imposing additional certification, location, or training requirements as a condition of reimbursement for telehealth services.

The act specifies that, to the extent the state board of health adopts rules addressing supervision requirements for home care agencies, the rules must allow for supervision in person or by telemedicine or telehealth. 

For the purposes of the Medicaid program, the act:

  • Requires the department of health care policy and financing (state department) to allow home care agencies to supervise services through telemedicine or telehealth;
  • Clarifies the methods of communication that may be used for telemedicine;
  • Requires the state department to reimburse rural health clinics, the federal Indian health service, and federally qualified health centers for telemedicine services provided to Medicaid recipients and to do so at the same rate as the department reimburses those services when provided in person;
  • Requires the state department to post telemedicine utilization data to the state department's website no later than 30 days after the effective date of the act and update the data every other month through state fiscal year 2020-21; and
  • Specifies that health care and mental health care services include speech therapy, physical therapy, occupational therapy, hospice care, home health care, and pediatric behavioral health care.

The act appropriates $5,068,381 to the state department from the care subfund for telemedicine expansion services and prohibits the state department from using the appropriation for the state-share of Medicaid services.

See how the expired Executive Order D 2020 020 differs from SB20-212 by reading the Department of Regulatory Agencies’ FAQ.

HIPAA

The Office for Civil Rights (OCR) will exercise enforcement discretion and will not impose penalties for HIPAA violations against covered health care providers in connection with the good faith provision of telehealth through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. 

  • HHS’ Office of Civil Rights (OCR), which oversees HIPAA enforcement, issued a new bulletin that provides guidance on ongoing (lack of) enforcement actions: 
    • Notice of Enforcement Discretion – OCR will not impose penalties for HIPAA violations on providers who are acting in good faith in the provision of telehealth during COVID-19 emergency. 
      • This does not include health plans that are paying for telehealth services. 
    • There is no expiration date on the Notice, OCR will issue a statement when this order ends.
    • Accepted forms of telehealth (non-public facing): Apple Facetime, Facebook Messenger video, Google Hangouts, Whatsapp video, Zoom, Skype
    • Non-accepted forms of telehealth (public facing): Tik Tok, Facebook Live, Twitch, chat rooms, Slack.
Medicare
  • Medicare will make payment for telehealth services furnished to beneficiaries in all areas of the country in all settings (meaning, the geographic and originating site limitations have been removed, and Medicare beneficiaries can receive services anywhere (their home or any healthcare facility) during the COVID-19 public health emergency.
  • To the extent the 1135 waiver (section 1135(g)(3)) requires that a Medicare patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during the COVID-19 public health emergency.
  • As of March 30th, 2020, CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health. During the pandemic, individuals can use commonly available interactive apps with audio and video capabilities to visit with their clinician.
  • As of March 30th, 2020, CMS will now allow for more than 80 additional services to be furnished via telehealth.
  • Changes in HR 748 added Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to the list of eligible distant providers for this emergency period only.
  • As of April 7th 2020, CMS released a Dear Clinician Letter outlining policies related to accelerated and advanced payments, testing and claims reporting for COVID-19, Medicare telehealth visits, expanded options for telehealth services, workforce flexibilities, and the CMS quality payment program. 

For additional background information on the waivers and rule changes, go to: Additional Background:Sweeping Regulatory Changes to Help US Healthcare System Address COVID-19 Patient Surge.

For CMS billing related questions and resources, contact Colorado’s designated Quality Innovation Network – Quality Improvement Organization, Telligen.

Medicaid 

Throughout the COVID-19 state of emergency, Health First Colorado (Colorado’s Medicaid Program) is temporarily expanding its telemedicine policy to authorize the following: 

  1. Expanding the definition of telemedicine services to include telephone only and live chat modalities. These additional services (and live video visits) will be reimbursed at the normal visit rate.
  2. Authorizing Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services to bill encounters for telemedicine visits.
  3. Adding specified Physical Therapy, Occupational Therapy, and Home Health, Hospice and Pediatric Behavioral Therapy services to the list of eligible interactive audiovisual telemedicine services. 

For additional information and billing instruction, visit the Colorado Department of Health Care Policy & Financing (HCPF) COVID-19 Information for Health First Colorado and CHP+ Providers and Case Managers webpage.

Private carriers

Under direction of Colorado’s Department of Regulatory Agencies, Division of Insurance: 

Visit DORA’s website if you have questions or need to file a complaint with the Division of Insurance.

Behavioral health 

The CARES Act includes the Protecting Jessica Grubb’s Legacy Act, which makes substantial changes to the statute underlying the substance use disorder (SUD) treatment record confidentiality regulations at 42 CFR Part 2 and aligns Part 2 more closely with HIPPA. 

For more information, see the Colorado Department of Human Services’ Office of Behavioral Health COVID-19 Information page

Drug Enforcement Agency 

For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

  1. The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice.
  2. The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.
  3. The practitioner is acting in accordance with applicable Federal and State law.
Remote Patient Monitoring 

The U.S. Food and Drug Administration (FDA) issued a new policy that allows manufacturers of certain FDA-cleared, non-invasive vital sign-measuring devices to expand their use so that health care providers can use them to monitor patients remotely. The devices include those that measure body temperature, respiratory rate, heart rate and blood pressure.

General 
Telemental health
Telehealth and video collaboration
Texting
Remote patient monitoring

The U.S. Food and Drug Administration (FDA) issued a new policy that allows manufacturers of certain FDA-cleared, non-invasive, vital sign-measuring devices to expand their use so that health care providers can use them to monitor patients remotely. The devices include those that measure body temperature, respiratory rate, heart rate and blood pressure.

E-consult 
Payment
  • Novitas Medicare Administrative Contractor (MAC) for Colorado Medicare providers
    • When Medicare publishes new payment guidelines, each MAC is responsible to interpret those for their respective jurisdiction and then set up the codes, denials, audits, etc for payment. Therefore, the Novitas MAC website and helplines will always be the best and most up to date for Medicare reimbursement and billing guides. 
Policy
Regulatory compliance