The Expansion of Telehealth Provides #Medtech Reimbursement Opportunities

Coding & Billing, Payment System

Background

The rapid spread of COVID-19 has altered how healthcare systems deliver care.  To reduce staff exposure to sick patients and deliver care to patients safely while minimizing the transmission of the virus, health systems and providers use telehealth increasingly.  Telehealth and telemedicine give providers the opportunity to manage the health of their patients remotely.

While telemedicine refers specifically to remote clinical services, telehealth can refer to remote clinical and non-clinical services.  While telehealth technology and its use are not new, widespread adoption among healthcare providers and patients beyond simple telephone correspondence has been relatively slow, until the need to care for patients during a pandemic.

Telehealth Expansion

The President signed into law the Telehealth Services During Certain Emergency Periods Act of 2020 on March 6,2020 and it was followed by the Coronavirus Aid, Relief, and Economic Security Act on March 27.  These laws made way for the Secretary of the Department of Health and Human Services to lift coverage and payment restrictions on Medicare telehealth services and improve access to care for Medicare beneficiaries. 

Prior to the pandemic, Medicare telemedicine and telehealth services were under certain limitations.  Patients were limited geographically, their physical presence at time of service was required, telehealth service options were limited, and specifications on telecommunication devices were narrow. 

Several waivers were issued to ease restrictions and keep up with the pace of technology changes and improve payment for telehealth services for Medicare beneficiaries.  The upgrades include the following:

  • Geographic Restriction on Telehealth Waived

Prior to these waivers, Medicare only supported telehealth for patients in rural areas.  Telehealth services can now be provided to anyone in the emergency area during the emergency period.

  • Restriction on Remote Originating Site Waived

Previous restrictions delegated eight facility-based locations for patients seeking telehealth services from a distant-site provider.  Now, patients can access care from the comfort of their home which is most important during the safer-at-home order.

  • Adjustments to Device Regulations

Devices including audio and video capabilities can be used for real-time interactive communication and are now reimbursable by Medicare for that virtual visit. 

  • Expansion of Sites of Service and Services

After the Secretary restructured Medicare coverage and payment for telehealth, physician, emergency, and hospice visits, nursing facility admit and discharge visits, and therapy services are all covered under Medicare and are considered “types” of telehealth visits. 

  • Expansion of Payer Types Covering Telehealth

Starting in 2020, Medicare Advantage Plans may offer more telehealth benefits than Original Medicare.  These benefits can be available in a variety of places including at home.

Telehealth improves patient access to care, improves compliance, and facilitates the delivery of medicine.

Telehealth Medicare Reimbursement

During the pandemic, insurance payers and healthcare professionals have become more supportive of telehealth services.  President Trump and Centers for Medicare & Medicaid (CMS) have broadened access to the range of services that are covered to give beneficiaries access to Medicare telehealth services. CMS published blanket waivers for healthcare providers.  Some key changes that provide reimbursement opportunities for #medtech include:

  • Eligible Practitioners

Telehealth expansion has provided reimbursement opportunities for physical therapists, occupational therapists, speech language pathologists, and others, previously ineligible providers to bill for and receive payment for Medicare telehealth services.

  • Telemedicine

CMS is waiving the provisions related to telemedicine at 42 CFR §482.12(a) (8)– (9) for hospitals and §485.616(c) for CAHs, making it easier for telemedicine services to be furnished to the hospital’s patients through an agreement with an off-site hospital.  This allows for increased access to necessary care for hospital and CAH patients, including access to specialty care.

  • Physician Services

CMS is waiving requirements under 42 CFR §482.12(c)(1)–(2) and §482.12(c)(4), which requires that Medicare patients be under the care of a physician.  This waiver may be implemented so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan.  This allows hospitals to use other practitioners to the fullest extent possible.                                        

  • Utilization Review

CMS is waiving certain requirements under 42 CFR §482.1(a)(3) and 42 CFR §482.30 which address the statutory basis for hospitals and includes the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements.

Increased ASC services at Hospitals:

The waiver allows Hospitals to expand their services to include ASCs as functioning hospitals. 

Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs):

3-Day Prior Hospitalization. Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19.  In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS):

When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, CMS is allowing DME Medicare Administrative Contractors (MACs) to have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency.

Other Telehealth Changes:

  • Patients can get Medicare telehealth services at renal dialysis facilities and at home.
  • Patients can get Medicare telehealth services for faster diagnosis, evaluation, or treatment of symptoms of an acute stroke no matter where they are located.
  • If you’re being treated for a substance use disorder or a co-occurring mental health disorder, you can get Medicare telehealth services from home.

Commercial Payer Expansion of Telehealth Services

Following in Medicare’s footsteps, some of the large commercial payers have extended their telehealth services to be consistent with the federal public health emergency period, which ends on July 24, 2020. 

UnitedHealthcare announced they are extending their cost share waiver for in-network telehealth services through Sept. 30, 2020.

Cigna extended their telehealth coverage expansions through July 31, 2020.

Anthem extended their COVID-19 telehealth coverage policies through September 30, 2020.

Aetna has extended their telehealth services through August 4, 2020.

Medicaid Expansion of Telehealth Services

All fifty states and DC have expanded telehealth access for Medicaid beneficiaries.  The State Medicaid programs have broad flexibility on how to cover services delivered via telehealth.

What are the opportunities for #medtech with the telehealth expansion?

  1. The expansion of site of service provides greater access to certain procedures, drugs, devices, biologics and diagnostics especially those that address end stage renal disease, substance abuse, stroke and other conditions. 
  2. The reduction of utilization controls and other restrictions also allow for greater access and utilization of some procedures, drugs, devices, biologics and diagnostics. 
  3. The expansion of providers that can bill for telehealth services and the relaxation of supervision requirements allow for increased utilization of certain technologies.
  4. The telehealth billing codes and associated regulations are dynamic and need to be tracked to ascertain the impact of these changes on #medtech.
  5. It is important to understand individual and state regulations, emergency mandates and deadlines. 

The GIRS Payer Advocacy Compass PAC® team that includes a team of reimbursement lawyers, payer policy and payer advocacy experts has over 17 years of experience tracking payer policies and educating providers and stakeholders about changes to the policies to ensure coverage and reimbursement of our client’s medical technologies. 

If you would like to create a telehealth billing guide to assist your accounts or have needs  to analyze the impact of telehealth expansion on your drug, medical device, biologic or diagnostic, please contact us at info@girsinc.com or avail of our Complimentary Review of your reimbursement needs at girsinc.com

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About GIRS

For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need.  To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, Email us at info@girsinc.com or call us at 901-834-9119.