In an earlier article, we discussed the various aspects that a physician making the transition from an in-person to a virtual practice should consider. We discussed what platform to use, how to conduct a virtual patient encounter, and we also discussed the subject of record-keeping and informed consent. In this article, we shall discuss reimbursement and patient privacy and confidentiality.
The COVID-19 Pandemic has dramatically accelerated the physician’s interest in converting to a virtual form of practice. A 2020 article, for instance, discussed the various factors that Obstetrician/Gynecologists should consider when moving to a virtual practice. Another 2020 report listed resources available to physicians from regulatory and professional agencies to assist in the implementation and management of telehealth practices.
Reimbursement is perhaps the critical issue when physicians are deciding about making the transition from an in-person to a virtual medical practice. A recent article described reimbursement as the most crucial barrier to physicians considering a primary telemedicine practice.
In this context, the decision about what form of platform to select for a virtual practice assumes paramount importance. Physicians who decide upon a consumer platform such as Zoom, for instance, must use their own billing and collecting resources to obtain reimbursement. These services require both administrative time and money for the physicians. Commercial sites such as, for instance, the Illuminate Health site, provide complete billing and collecting services, freeing physicians of those concerns.
Especially for physicians who plan to use consumer platforms and do their own billing and collecting, levels of reimbursement are all-important. The current COVID-19 Pandemic has upended reimbursement restrictions for telemedicine as it has created chaos in society as a whole.
According to recent changes in the law, telemedicine encounters must be reimbursed at rates identical to those for in-person meetings. On March 17th, 2020, Medicare implemented the telehealth waiver under HR 6047. It included an expanded fee for services provision that allowed reimbursement for in-person and telemedicine encounters at the same rates. The change also relaxed HIPAA restrictions to allow patient interactions on consumer platforms such as Zoom and Facetime. The change importantly eliminated site limitations for patients. Now a patient-centered approach can be deployed, allowing for patients to be seen where they wish.
What lies ahead for reimbursement, however, when the Pandemic is over, is unclear. Before the Pandemic, many private insurers, as well as Medicare, reimbursed telemedicine visits at significantly lower rates than in-person visits.
Medicare was formerly even more restrictive, reimbursing only when the beneficiary was in a rural location. However, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) expanded reimbursement and to include bundled-payment formulas for cardiac care and joint replacement. Also, the 21st Century Cures Act requires the federal government to study the effects of telemedicine on Medicare beneficiaries. Prominent physician organizations like the AMA and the California Medical Association are now advocating to maintain equal reimbursements for telemedicine visits as for in-person visits once the COVID-19 Pandemic is over.
Gaps in the current CPT (Current Procedural Terminology) codes related to telemedicine remain as problems in conducting an entirely virtual medical practice. In 2015, the CPT Editorial Panel of the AMA, which oversees the maintenance of the CPT code set, formed a workgroup to support the integration of emerging telehealth services into clinical practice with new coding solutions.
A highly recommended 2020 article presents a detailed analysis and recommendations for the integration of an outpatient telemedicine practice into an existing in-person practice with specific attention to coding for reimbursement.
PATIENT PRIVACY AND CONFIDENTIALITY
HIPAA, the Health Insurance Portability and Accountability Act, provides the legal framework for patient privacy and confidentiality. A recent relaxationof HIPAA regulations now permits providers to use their personal phones to see patients.
The electronic medical record (EMR) can provide a basis for the recording of and retrieval of patient’s medical information. EMRs were widely adopted by large healthcare providers, but they have often offered significant headaches for physicians. A new 2020 studysuggested that EHRs have not caused the desired kinds of increases in safety. The study showed that up to 30% of institutions that employed EHRs still showed medication-related errors.
Whether in the context of a consumer platform such as Zoom or a commercial platform, to offer telemedicine services, participating physicians must ensure that communications are secure. They must further assure themselves that the commercial telemedicine services they work with have appropriate protocols to prevent unauthorized access and to protect the security and integrity of patient information. Physicians should alert telemedicine patients or their surrogates that issues of data security and access can arise and inform them of steps taken to protect confidential information.
A commercial site that provides excellent safeguards of patient privacy and confidentiality is the Illuminate Health site. With that program, physicians can use telemedicine very conveniently with their cell phones without worry about the security of the system.
Reimbursement and patient privacy and confidentiality are significant concerns when physicians convert from an in-person to a virtual medical practice. In this article, we have discussed some of the critical aspects of these factors. In future articles, we shall discuss other considerations such as medico-legal considerations and the use of remote monitoring systems in a telehealth practice.
Ronald Young, M.D.