Telemedicine Reimbursement

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Telemedicine Reimbursement For Oregon
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Telemedicine Reimbursement

• Why is it important?

Encourages use of telemedicine services Provides
mechanism to reimburse providers One tool to
ensure sustainability of program
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Telemedicine Reimbursement

• What is happening nationally?

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Telemedicine Reimbursement

• Medicare
• First authorized in BBA of 1997
• -Fee splitting
• -Limited CPT code reimbursement
• -Limited eligible presenters

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Telemedicine Reimbursement

• Medicare
• BIPA of 2000-some improvements
• -Eliminated fee sharing
• -Eliminated need for telepresenter
• -Expanded eligible services
• -Included payment to distant site
• physician only

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Telemedicine Reimbursement

• 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

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Telemedicine Reimbursement

• Medicare
• BIPA of 2000-some improvements
• But
• Still substantial limitations
• -Eligible geographic locations
• -Eligible originating sites
• -Eligible services
• -Eligible providers

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Telemedicine Reimbursement

• Medicare
• Eligible Geographical Locations
• -Must be a primary care Health Professional
  Shortage Area (HPSA)
• -Cannot be a Metropolitan Statistical Area (MSA)

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Telemedicine Reimbursement

• Medicare
• Eligible Geographical Locations
• HPSA Three Criteria
• -Rational area for delivery of primary care
• -lt1 primary care physician per 3,500 people
• -Insufficient capacity of providers

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Telemedicine Reimbursement

• Medicare
• Eligible 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

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Telemedicine Reimbursement

• Medicare

MSA December 2006 Oregon 13460 Bend, OR
18700 Corvallis, OR
21660 Eugene-Springfield, OR
32780 Medford, OR 38900
Portland-Vancouver-Beaverton, 41420 Salem
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Telemedicine Reimbursement

• Medicare
• Eligible 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
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Telemedicine Reimbursement

• Medicare
• Eligible Medical Practitioners

Medicare Includes Physician Nurse
Practioner Physician Assistant Nurse
Midwife Clinical Nurse Specialist Clinical
Psychologist Clinical Social Worker Nutrition
Professional
Recommended Additions Dieticians Genetics
Counselors Physical Therapists Occupational
Therapists Speech Therapists
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Telemedicine Reimbursement

• Medicare
• Eligible Services

Covered BIPA - Consultations - Office or
other outpatient visits - Individual
psychotherapy - Pharmacologic management
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Telemedicine Reimbursement

• Medicare
• Eligible Services

• Covered
• Added since BIPA
• - ESRD services, 2-3, or 4 or more visits per
  month
• - Individual nutritional therapy

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Telemedicine Reimbursement

• Medicare
• Eligible Services

• Requested but not yet approved
• - Nursing facility care
• - Speech language pathology
• - Audiology
• - - Physical therapy services.

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Telemedicine Reimbursement

• Medicaid

• State administered program, Federal Match
• Each state sets its Medicaid telemedicine
• reimbursement policy

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Telemedicine Reimbursement

• Medicaid

35 States Reimburse for Telemedicine
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.
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Telemedicine Reimbursement

• Medicaid

Reimbursement models vary among
states -Internal agency decision -Legislative
initiatives -Regulatory initiatives -Other
SCHIP, Waivers
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Telemedicine Reimbursement
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 -Psychologi
cal consultations or treatment-12 states -Home
health-2 states -Case management-2 states -
Patient education (diabetes)-1 state
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Telemedicine Reimbursement
Private Payers -Less published information on
private payer reimbursement -Progress is being
made..
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Telemedicine Reimbursement
Private Payers

• 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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Telemedicine Reimbursement
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

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Telemedicine Reimbursement
Private Payers

• 2005 SurveyAmerican (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
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Telemedicine Reimbursement
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

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Telemedicine Reimbursement

• What is happening in Oregon

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Telemedicine Reimbursement

• Oregon

• Oregons Landscape
• HJR4
• Whats Next

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Oregons Landscape
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Telemedicine Reimbursement

• 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

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Telemedicine Reimbursement
Oregon

• 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)

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Telemedicine Reimbursement
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

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Telemedicine Reimbursement
Oregon

• Recommended contract language
• Matches existing Medicare language, with the
  following exceptions
• Originating sites are not specific to geographic
  locations
• Eligible originating sites

Additions Skilled Nursing Facilities Community
Mental Health Centers County Mental Health
Departments Public Health Departments Indian
Health Service Sites
Medicare includes Office of a Physician Hospital
Critical Access Hospital Rural Health
Clinic Federally Qualified Health Center
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Telemedicine Reimbursement
Oregon

• Recommended Contract Language
• Matches existing Medicare language, with the
  following exceptions
• Payment is permitted for asynchronous store and
  forward technology
• Eligible Medical Practitioners

Medicare Includes Physician Nurse
Practioner Physician Assistant Nurse
Midwife Clinical Nurse Specialist Clinical
Psychologist Clinical Social Worker
Recommended Additions Dieticians Genetics
Counselors Physical Therapists Occupational
Therapists Speech Therapists
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Telemedicine Reimbursement Criteria By Payer
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Telemedicine Reimbursement Criteria By Payer
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Telemedicine Reimbursement
Oregon
Whats Next?
Convene workgroup to draft telemedicine
reimbursement bill for 2009 legislative
session. -Who should be at the table? -What
is our strategy?
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Telemedicine Reimbursement
Whats Next?
Convene workgroup to draft telemedicine
reimbursement bill for 2009 legislative
session. -What should language
contain? Eligibel Services? Eligible
Originating Sites? Eligible Providers? Shou
ld vs. Will?
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Contact Us
Kim HoffmanOutreach Coordinator, ITG,
OHSUSenior Manager, HERONTelehealth
Coordinator, ITG, OHSU1515 SW 5th Avenue, 9th
FloorPortland, Or  97201Mail Code  MSB 9th
FloorOffice [phone]Email
hoffman_at_ohsu.edu
Catherine S. BritainCSBritain Consulting Secretar
y, Telehealth Alliance of OregonEmail
csbritain_at_ gmail.com