COVID-19 Updates & Alerts 03/18/20

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Links to resources discussed in this update:

• Medicare Telemedicine Fact Sheet 
• President Expands Telehealth benefits for Medicare Beneficiaries
• Telemedicine and HIPAA  (3/17/2020)
• Medicare 1135 Waiver Policy
• Existing Telehealth State Laws and Reimbursement Policies
• Medicaid Covid-19 FAQs  (select [PDF]
• COVID-19 FAQs for State Medicaid and CHIP agencies)
• MedCity News Article December 5, 2019 on Payment Parity for Telehealth
  (refer to Waivers at a Glance PDF download)

The following content consists of excerpts and key takeaways on information published in the above referenced Medicare fact sheets. This does not guarantee coverage by Medicare Advantage Plans, Medicaid, Medicaid Managed Care, or Commercial Payers. V2V additional remarks are provided in green italics.

1. Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances. These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home. We have identified no clear documentation to support providing care to patients in their cars or outside of a “medical facility” setting. Be cautious of payment expectations and how this is documented within your medical records.
2. The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs. The government makes no statements about reimbursing practitioners for the co-pays they are just allowing you to waive them without creating a finable policy violation.
3. To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. Per CMS, the 1135 waiver policy documents, while blanket authority for these modifications may be allowed, the provider should still notify the State Survey Agency and CMS Regional Office if operating under these modifications to ensure proper payment. This is most critical for hospitals, SNFs, and nursing homes. Providers and suppliers have been asked to keep careful records of beneficiaries to whom they provide services, in order to ensure that proper payment may be made. Something else to note is that RHCs and FQHCs are not covered under these waivers as it relates to Medicare, telehealth, e-visits, and virtual check-ins. Check with your state agencies for specific program policies as the states have been granted authority to use their discretion on implementation of emergency protocol provisions.
4. Even before the availability of this waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal. Doctors and certain practitioners may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010) and creates a billable event. Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication. This was previously available in specific rural areas. Under the health emergency declaration this is available in all areas. Review the payment policy for the specifics on what qualifies and who may bill for these codes. Emergency provision only removes the previous geographic limitations.
5. Medicare will cover the use of telephones with audio and video capabilities to conduct telehealth visits. Additionally, HHS and OCR have provided relief of HIPAA provisions to allow for use of non-vetted and potentially risky applications such as: Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom basic, or Skype. Platforms that had previously declared BAA level secure resources include Skype for business, Updox, VSee, Zoom for healthcare, Doxy.me, Google G Suites Hangouts Meet. Telecommunication carriers not covered under this waiver and not acceptable for use are Facebook live, Twitch, TikTok, and similar mainstream video communication apps.  
6.  Medicare E-visits services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. E-visits are an acceptable and reimbursable care modality. The patient must have an established relationship with the practice. This is conducted through an online patient portal and services must be initiated by the patient. There are no geographic boundaries and all routine coinsurance and deductibles apply during the emergency coverage period.
7. If you are embarking on telehealth for the first time be sure to review state and commercial payer specific policies and payment rules. While the State of Emergency declarations relieve some barriers there are still policies and protocols you will be expected to adhere to in adding this to your service types.
8. State Medicaid Agency’s have broad authority to make decisions around emergency protocols relating to telehealth services. This will require you to monitor what is happening at your local level. State actions vary widely, and many have not yet fully clarified their plans. Many states have not yet issued provisions that allow for the "originating site of service" to be from the patients location versus a medical facility.
9. Monitor your State and local medical society’s and rural health associations for distribution of this information.
10. Commercial Payers will have many variations in what they offer during this emergency declaration. You will need to follow the alerts and notices provided directly from your payers for telehealth program requirements, credentialing of providers to be recognized as telehealth providers, and regulations on reimbursement models for telehealth payments.
11. Many insurance payers require specific notification that you will be credentialing as a telehealth provider be sure to look into this parameter if you are embarking on this service model for the first time.
12. As of December 2019, only 11 state have commercial plan telehealth payment parity for telehealth services delivered remotely compared to those delivered in person. Those are Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, Utah, Virginia and California. Be sure to investigate all the implications of adding this service model to our organization from both clinical care perspectives and the overall financial footprint of providing the access.
13.  Providers should contact their CMS Regional Medicaid Office as soon as possible to discuss anticipated changes to waiver operations or needed authorities.  https://www.medicaid.gov/about-us/contact-us/index.htm

Excerpt from: MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET Mar 17, 2020

Excerpt from: CCHP's updates: Telehealth Coverage Policies in the Time of COVID-19; March 17, 2020 - 3 pm PT