telemedicine reimbursement for oregon. why is it important? telemedicine reimbursement encourages...
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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?
Telemedicine ReimbursementTelemedicine Reimbursement
Telemedicine ReimbursementTelemedicine Reimbursement
Medicare
•First authorized in BBA of 1997
-Fee splitting-Limited CPT code reimbursement-Limited eligible presenters
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
Medicare
•BIPA of 2000-some improvementsBut
Still substantial limitations:-Eligible geographic locations-Eligible originating sites-Eligible services-Eligible providers
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Medicare
Eligible Geographical Locations
-Must be a primary care Health Professional Shortage Area (HPSA)
-Cannot be a Metropolitan Statistical Area (MSA)
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
MSA December 2006Oregon
13460 Bend, OR 18700 Corvallis, OR 21660 Eugene-Springfield, OR 32780 Medford, OR 38900 Portland-Vancouver-Beaverton, 41420 Salem
Medicare
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
Medicare
Eligible Medical Practitioners
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
CoveredBIPA
- Consultations
- Office or other outpatient visits
- Individual psychotherapy
- Pharmacologic management
Medicare
Eligible Services
Telemedicine ReimbursementTelemedicine Reimbursement
Covered
Added since BIPA
- ESRD services, 2-3, or 4 or more visits per month
- Individual nutritional therapy
Medicare
Eligible Services
Telemedicine ReimbursementTelemedicine Reimbursement
Requested but not yet approved
- Nursing facility care
- Speech language pathology
- Audiology
- - Physical therapy services.
Medicaid
Telemedicine ReimbursementTelemedicine Reimbursement
•State administered program, Federal Match
•Each state sets its Medicaid telemedicine reimbursement policy
Medicaid
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
Reimbursement models vary among states:
-Internal agency decision-Legislative initiatives-Regulatory initiatives-Other: SCHIP, Waivers
Medicaid
Telemedicine ReimbursementTelemedicine Reimbursement
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…..
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• States with government mandated legislation
- California, Louisiana, Texas, Oklahoma,
Kentucky
• All prohibit payers from excluding services
solely because they are delivered telemedically
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Private Payers
Private Payers
Telemedicine ReimbursementTelemedicine Reimbursement
•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
Telemedicine ReimbursementTelemedicine Reimbursement
•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
Telemedicine ReimbursementTelemedicine Reimbursement
•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
Telemedicine ReimbursementTelemedicine Reimbursement
Telemedicine ReimbursementTelemedicine Reimbursement
Oregon
•Oregon’s Landscape
•HJR4
•What’s Next
Oregon’s Landscape
Oregon
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
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 ReimbursementTelemedicine Reimbursement
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
Telemedicine ReimbursementTelemedicine Reimbursement
Convene workgroup to draft telemedicine reimbursementbill for 2009 legislative session.
-Who should be at the table?-What is our strategy?
What’s Next?
Telemedicine ReimbursementTelemedicine Reimbursement
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]