PreSERVE THE GAiNS IN TELEHEALTh

Ask Policy Makers and the Governor to Allow Facilities to Bill the "Facility Fee" when Providing Home-Based, Direct-To-Consumer Telehealth Services

July 17, 2020

As a result of the Novel Coronavirus Pandemic (Covid-19), there has been a dramatic increase in the use of Home-Based, Direct-To-Consumer Telehealth services, and the benefits have been enormous. No longer is it limited to non-emergency treatment and care (discussed below). It is now used to treat people suffering from congestive heart failure, epilepsy, obstructive pulmonary disease, and even cancer. In addition to helping to reduce infection rates by allowing people to receive needed medical care at home thereby reducing their exposure to infection and reducing those who are infected from infecting others, Home-Based Telehealth services have significantly reduced the number of people using emergency room services (a critical goal of Value Based Payment programs), increased family and caregiver’s involvement in the treatment and care of patients, increased coordination and collaboration with local health providers, emergency services and local primary care physicians, increased the sharing of patient health information stored in electronic health record (EHR) systems, and increased people’s comfort and acceptance of Home-Based, Direct-To-Consumer Telehealth services.

As we enter the post-emergency phase of the Covid-19 pandemic, the benefits gained from Home-Based Telehealth services should be preserved, but may be lost without help from policy makers and the Governor.

Telehealth’s Administrative, Technical and Security Requirements

Telehealth is the two-way, real time interactive communication between a patient at an originating (spoke) site with a clinician at a distant (hub) site using telecommunication technology. Best practice guidelines developed by national organizations such as the American Telemedicine Association (ATA) and the American Academy of Child and Adolescent Psychiatry (AACAP) state that a patient’s enrollment into Telehealth should occur at the originating site and begin with an assessment of their appropriateness for Telehealth. This should take the form of assessing a patient’s clinical condition, a patient’s awareness and familiarization with the process, a patient’s stability, suicidal ideation and violence, whether the patient has a psychosis with interacting with technical/video equipment, whether the patient has medical issues, cognitive/sensory problems, and whether the patient should be accompanied by staff during a Telehealth session.

If found appropriate, the patient should be orientated on what to expect during a Telehealth session. They should be told about the risks and benefits of Telehealth and their ability to discontinue a Telehealth session at any time. The orientation should be designed to provide the patient with enough information about Telehealth such that they can make an informed decision about participating. The orientation concludes with the patient completing (or refusing to complete) a consent form authorizing their participation in Telehealth sessions.

Staff at the originating site is responsible for enrolling and assessing a patient’s appropriateness for Telehealth. They are also responsible for setting up and maintaining the operational efficiency of the telecommunication equipment. During Virtual Telehealth sessions using audio/video telecommunication, they are responsible for identifying and purchasing the necessary computer equipment and in securing a HIPAA compliant Televideo Service Provider. Staff at the origination site is responsible for setting up and maintaining a private space for the Telehealth session. They are responsible for transferring the patient’s medical record to the clinician located at the distant hub site and scheduling the appointment for the Telehealth session based on the clinician’s availability. If the originating site is a hospital, the staff coordinates credentialing the clinician at the hospital. If the clinician at the distant site will be using the originating site’s electronic health records (EHR) system for charting, prescribing medication and ordering lab reports, the staff at the origination site will coordinate the clinician’s training on their EHR system. Staff will also coordinate training on the originating site’s policy and procedures for conducting the Telehealth sessions. This training should include what constitutes proper etiquette during Telehealth sessions, cultural competency and protocols for both medical and technical emergencies—who to contact, staff support made available to clinicians, local regulations on hospital commitments, alternative methods of communicating in case of equipment failure. Finally, the staff at the originating site will coordinate patient follow-up appointments and filling prescriptions if not proscribed electronically.

What is a Facility Fee and Who Can Bill for It

The cost associated with these administrative, technical and security services performed by the staff is covered by a Facility Fee. The Facility Fee covers the administrative, technical and security cost of delivering Telehealth services to patients. The HCPCS code for billing the Facility Fee is Q3014. It can be used to bill Medicare, Medicaid, Medicaid Managed Care and in some instances commercial third-party payers. Currently, Medicare pays $26.65 per session for the Facility Fee. New York State Medicaid pays $25.76 per session. The overall objective of the Facility Fee is to assist hospitals, clinics, doctor’s offices and other facilities recoup administrative, technical and security expenses associated with the Telehealth encounter.

The Facility Fee can be billed by the facility where the patient is receiving Telehealth services—the Originating Site. This includes hospitals, clinics, doctor’s offices, community health centers, skilled nursing facilities and in some instances school health centers. When a patient is receiving Telehealth services at one of these sites, the facility can only bill the Facility Fee. The professional service fee associated with the clinical Telehealth service the patient receives is billed by the clinician at the distant (hub) site.

Home-Based Telehealth’s Unique Requirements

Home-Based, Direct-To-Consumer Telehealth has the same administrative, technical and security requirements as Telehealth except Home-Based Telehealth places greater emphasis on effectively managing emergency situations. Unlike a clinic, hospital or office setting, Home-Based Telehealth services do not have clinical staff in close proximity to the patient and readily available in case of an emergency. Accordingly, best practices in Home-Based Telehealth services, as promulgated by the American Telemedicine Association (ATA), require developing and deploying a unique set of emergency protocols and procedures that ensure the safety, confidentiality and privacy of patients receiving services at home. It should include identifying a family member, friend or caregiver in close proximity to the patient who can function as a support person. This person should be trained on how to come to the aid of the patient in case of an emergency. It should include obtaining contact information on local health providers, clinics, hospital emergency rooms, and local EMS units that can be reached and utilized to support patients in an emergency. It should include local guidelines on involuntary hospital commitments. It should include screening procedures for suicidal thoughts and attempts, adverse reactions to video monitors and uncontrolled impulsive behavior to help determine whether a patient is suitable for Home-Based Telehealth services or whether the patient should be accompanied by a support person during Home-Based Telehealth sessions. It should include guidance on how to establish a private space for patients in their home. In the event of technical failure, it should provide instructions on how to setup alternative means of communicating. Finally, Home-Based emergency protocols and procedures should provide guidance on how to collaborate with a patient’s primary care physician (PCP) or other clinical caregivers to coordinate the patient’s overall care and the best possible outcomes.

Can Facilities Bill a Facility Fee When the Patient is Receiving Home-Based Telehealth

Currently, no Facility Fee can be billed to the state (Medicaid or Medicaid Managed Care) when the patient is receiving Telehealth services at their residence. If a facility renders Home-Based Telehealth services to patients in their home, they continue to be responsible for assessing a patient’s appropriateness for receiving Telehealth services and implementing the emergency protocols and procedures unique to Home-Based Telehealth, as per federal and state guidelines (HIPAA, DEA, DOH, OMH, etc.). The cost associated with these administrative, technical and security requirements is normally covered by the Facility Fee. But if the site where the patient is receiving Telehealth services is the patient’s residence and the facility is providing the Telehealth services, the Facility Fee used to pay for administrative, technical and security costs is lost. When delivering Telehealth services to patients in their home, the facility must use their own resources to cover these expenses. They can only bill the professional fee for the clinical Telehealth service they provide.

A notable exception to this prohibition is at the federal level. In response to the Covid-19 emergency and after consultation with public health professionals, on April 30, 2020 the Centers for Medicare and Medicaid Services (CMS) revised its policy on billing Facility Fee Q3014. It now allows hospitals to designate a patient’s home as an off-campus “provider-based-department” (PBD) of the hospital and bill Facility Fee Q3014 when providing Telehealth services to patients in their home to recoup administration expenses.¹ Moreover, since February 2019, Federally Qualified Health Centers (FQHC) have been able to bill an “off-site” service code (4012) to recoup administrative expenses incurred during the delivery of Telehealth services to patients in their home.² More recently, in direct response to the Covid-19 emergency, FQHC have been given permission to bill off-site service code 4012 to recoup expenses when using a telephone to deliver Telehealth services to patients in their home.³ The payable amount when billing off-site service code 4012 is between $65.00 and $75.00 per session, depending on the FQHC facility.

Limited Use of Home-Based Telehealth

Before the Covid-19 pandemic, Home-Based Telehealth services were typically limited to providing non-emergency care. This was due in part to the high demand on staff time and the corresponding revenue needed to coordinate and implement the administrative, technical and security requirements and Home-Based emergency protocols and procedures. When Home-Based Telehealth services were provided by hospitals, they were usually limited to non-emergency, virtual urgent care. These services typically treat flus, sore throats, allergies and infections that can be treated with over-the-counter medicine or prescriptions that do not include Controlled Substances. While some hospitals treated mental illness, very few, if any, treated substance use disorder requiring proscribing buprenorphine or other Schedule III Controlled Substances effective at treating addiction. Home-Based Telehealth providers who did treat more serious conditions were normally “concierge” providers in small group practices or solo practitioners. They covered the high staff cost associated with implementing the administrative, technical and security requirements by requiring patients to self-pay. No insurance was accepted.

The Rise of Home-Based Telehealth During the Covid-19 Emergency

The Covid-19 pandemic gave rise to the widespread utilization of Home-Based, Direct-To-Consumer Telehealth. According to a White Paper jointly produced by the New York State Council for Community Behavioral Healthcare (NYSCCBH) and the Community Health Care Association of New York State (CHCANYS), the Mental Health Association of Westchester reported that prior to Covid-19, 4.5% of their visits were conducted via Telehealth. During the pandemic, that percentage increased to 92% within a span of only four days. Moreover, as of mid-June, Telehealth comprised 90% of visits and 86% of the revenue generated by behavioral health providers surveyed by NYSCCBH.⁴

Home-Based Telehealth’s widespread utilization was fueled in large measure by waivers enacted at the federal and state level. The waivers had a direct impact on the staff time and funds needed to implement Home-Based emergency protocols and procedures that support patients receiving services at home. For the duration of the Covid-19 emergency, the Department of Health and Human Services (HHS) and the Office of Civil Rights (OCR) waived the requirement that facilities obtain HIPAA compliant Televideo platforms to deliver Telehealth services to patients in their home. The Centers for Medicare and Medicaid Services (CMS) waived the requirement that individuals receiving Telehealth services be located in a Rural or Health Professional Shortage Area (HPSA). The Drug Enforcement Administration (DEA) waived provisions of the Ryan-Haight Act to allow practitioners to prescribe Schedule II-V Controlled Substances without an in-person medical evaluation. At the state level, the New York State Department of Health (DOH) waived the face-to-face management and treatment requirement for individuals in the Assisted Outpatient Treatment (AOT) program. The New York State Office of Mental Health (OMH) waived the requirement that practitioners develop, implement and obtain OMH approval of policy and procedures that ensure the safety, confidentiality and privacy of patients receiving services at home. These waivers allow practitioners to better manage the time and cost associated with implementing best practice administrative, technical and security procedures and the emergency protocols unique to Home-Based Telehealth services.

But the waivers are slated to end when the Covid-19 emergency period expires. Without the ability to offset the administrative, technical and security costs that will be triggered under full compliance, facilities will likely revert back to providing non-emergency Telehealth services to patients once the Covid-19 emergency period ends. For those facilities providing Home-Based, Direct-To-Consumer Telehealth services for the first time in response to the Covid-19 emergency, they will likely discontinue providing Home-Based Telehealth services altogether or severely cut back. The benefits gained from Home-Based Telehealth during the emergency will be lost.

Preserve the Gains in Home-Based Telehealth

One way to preserve the gains made during the Covid-19 emergency is to ask policy makers to join us in asking Governor Cuomo to allow facilities to bill the Facility Fee when providing Home-Based, Direct-To-Consumer Telehealth to patients in their home. On May 24, 2020, Governor Cuomo established a Blue-Ribbon Commission specifically tasked with advising him on ways to improve Telehealth and broadband access in the wake of the Covid-19 pandemic. The commission is chaired by the former CEO of Google, Mr. Eric Schmidt, and includes leaders in technology (Ginni Rometty, Chair of IBM), education (Martha E. Pollack, President of Cornell University) and health (Dr. Toyin Ajayi, Co-founder Cityblock Health). They are charged with determining how best to maintain the gains made in Telehealth during the Covid-19 emergency and preparing a sustainable path forward for the efficient utilization of Telehealth. In addition to this commission, the Governor is relying on the Commissioner of DOH, Howard Zucker, the Commission of OMH, Ann Marie Sullivan, M.D., and the Commissioner of the New York State Office of Addiction Services and Supports (OASAS), Arlene Gonzalez-Sanchez to advise him on enhancements to Telehealth policy that will improve health services to their consumers.

These noted individuals are in the unique position of having expert knowledge on shaping policy as well as the confidence of the Governor to advise him on the best path forward to preserve the gains made by Telehealth during the Covid-19 emergency.

Please join us in asking them to advise the Governor to allow facilities to bill Facility Fee Q3014 when delivering Home-Based, Direct-To-Consumer Telehealth to patients in their home.

Please go to Change.org/Preserve_The_Gains_In_Telehealth to sign the petition.

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Notes:

1. See CMS April 30, 2020 Interim Final Rule (IFR) on Telehealth Changes in Response to Covid-19 at: https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf

2. See February 2019 Medicaid Update Special Edition Volume 35 Number 2 at: https://www.health.ny.gov/health_care/medicaid/program/update/2019/feb19_mu_speced.pdf

3. See FAQ on Medicaid Telehealth Guidance During the Covid-19 State of Emergency at: https://health.ny.gov/health_care/medicaid/covid19/docs/faqs.pdf

4. New York State Council for Community Behavioral Healthcare and Community Health Care Association of New York State, Ensuring Sustained Access to Telehealth in the Post-Pandemic Period. Published online on July 9, 2020 at: https://files.constantcontact.com/b6bde37a401/916db539-774d-477d-86e1-e14b03d7e105.pdf