Telehealth Reimbursement During COVID-19

Date: March 30, 2020
Good afternoon, thank you for joining us today for our third generation of telehealth updates, focusing today on telehealth reimbursement during COVID 19. My name is Marshall Jackson, I’m joined today by our panelists, Amanda Enyeart, Emily Cook and Ankur Goel, who are partners at McDermott Will & Emery, and Sheila Madhani, who is a vice president with McDermott + Consulting. Here’s the agenda that we will be going through today. We’re focusing our presentations today on, excuse me, billing and coding and reimbursement. Starting with Medicare coding and payment policies, we’ll be addressing Medicare and Medicaid enrollment requirements. We’ll also be walking through some of the changes and updates and guidance coming out of the CARES Act, and also discussing insurance health plan issues. Before we start the presentation today, on behalf of myself, on behalf of McDermott, we first want to say thank you to all of the first responders, clinicians, providers who are really on the front lines, helping to really flatten the curve and assist in the time of need and emergency across the country. We also want to thank our health system and health hospital clients and others who are helping to provide a much needed, an emerging resource to the country, and to our telehealth providers who are rolling out their programs, expanding their operations and doing what they can to continue patient care and to address the needs of patients across the country. Again, thank you for all that you’re doing. And hopefully what we were doing through this, and through the other webinars is be able to provide a little bit of
information on what is really a daily update on both state and federal legislation, board guidance and other guidance to assist in a lot of these efforts. First, I’ll turn it over to
my partner, Emily Cook, who will walk us through, excuse me, to Sheila Madhani,
who will walk us through Medicare coding and payment policies.

Well, thank you, Marshall, and thanks to all of you who are joining us today. And I echo Marshall’s comments, and I know these are busy and difficult times for everyone, and I hope this information is helpful as you move forward in your work. I’m going to focus on Medicare coding and payment policy for telehealth services, and I want to emphasize that these
comments are really focused on Medicare fee for service, Medicare advantage and Medicaid, as well as commercial payers will have different kinds of policies that then Medicare. So, in these remarks, I want to focus on the coding, the actual codes, the coding policies as well as payment policy. So, within Medicare, when they talk about telehealth codes, we’re really talking
about services that are generally, generally provided in office, but through technology you can
provide them, clinicians can provide them virtually. The agency maintains a list of codes that
they cover off or through Medicare telehealth, and this list is updated annually through
the physician fee schedule process. You can find the 2020 list off at the link that’s on your screen. Currently, there’s about 100 codes on the list, then there’s the new and established office visit codes, which I think are gaining, you know, a lot of attention recently with the loosening of some of these regulations, so codes 99201-99215. But the list also includes services like mental health counseling, preventive health screenings, as well as things like ESRD home services. So, it’s really a wide range of services. Really before the emergency started, historically, mental health counseling services were the most common telehealth service reported within the Medicare population. Next slide, please.

So, you have your Medicare telehealth services that a lot of attention and has been focused on, and it is the focus of this webinar. And these are services, like I said, that are generally
provided face to face, but through technology, you can provide them virtually. But then,
in recent years, CMS has also created other virtual services that clinicians can report, and these were included in the March 6th fact sheet. And so, sometimes I think there has been some confusion about—are these telehealth services? And these are really inherently virtual services, you only really provide them virtually. You have two buckets here. You have the virtual check ins, and this is where there’s a communication, often by telephone between the practitioner and the patient, and it’s really to decide—do you need to come in for a visit often? And if there isn’t an E/M visit within 7 days, the clinician can bill for the virtual check in.
Then there are a bucket of codes called E-visits, and these are really patient-initiated
communications through the patient portal. The patient will submit some information, the clinician will assess it, and report back to the patient. So, these two sets of codes are
for established patients only, and I think they’re also worth mentioning that their payment value is much less than an E/M service because they are for, you know, a much narrower set of
services, a much shorter amount of time, so their payment rates are, you know, run from $12 to about $17 per code. So, it is not the same as in-office visit service. Next slide, please.

Okay, so then, so those are really the codes. And then the next step is, and there have been some questions about a coding for telehealth services. And I know coding can be kind of dry, and there’s a lot of technical lingo involved, which can be confusing if you don’t do this every day, and if you don’t do it every day, you should be thankful because it is very dry. But I thought it would be helpful to spend a minute just on some of the terminology used within
the telehealth, sort of sphere. And there’s two terms, one is the distant site and the other is the originating site. So, the distant site is the location of the clinician providing the service. And if you are that clinician or that system, you would report the HCPCS code of the service you reported. So, if you reported a Level 3 E/M code, you would report 99213 and any appropriate modifiers. And you just bill it as if it was in person, but then what you do is, for your Place
of Service Code on your claim, you hit 02 or you would report 02 the telehealth service, and
that indicates to CMS that this was provided virtually and then is an indication on what their payment policy that they would use. In terms of the originating site, that’s the location of the Medicare beneficiary. So now that in this situation that we’re in right now, and with the loosening of the rules, the patients are at home, so there really is no originating
site and there’s no reporting going on. But I think it’s worth mentioning that in the in the instances where maybe a patient does travel to an originating site, which is a facility or an office, that originating site will bill Q3014 which is the Medicare telehealth originating site facility fee, and that runs around $20 or $25. So next slide, please.

And so finally, we get to the Medicare payment policy around these codes, and I think this is where there has been a little bit of confusion, and, I think, some unexpected surprises and not the good kind of surprises. So, Medicare’s policy is that they pay the same amount for a telehealth service as if it would be furnished in person. And I think what they’re trying to say here, and this has been a historic policy, is that CMS is going to use the Medicare physician fee schedule rates to pay for these services, But, the issue is, when you get to the fee schedule for certain services, including the office visits, CMS has two sets of payment rates. They have when the service is performed in the office, which is called the non- facility rate, and then, when the service is performed in an outpatient setting or other facility, and that’s called the facility rate. And there is a payment differential, and that differential really has to do with that the office services include the costs of supplies and equipment and your nurse time, rent, those types of things, and so they tend to be a little more. So, the agency’s policy has been, that for telehealth services, they will pay the facility rate, which, when you look at the E/M codes there can be a substantial difference. So, on the slide here we have shown you the E/M codes, both the 2020
national non-adjusted, non-facility and facility rates. So, if you go down to the bottom of
the chart, to codes 99213 and 99214, which are the most common visit codes reported, you see that there’s about a 30% difference between the office and the facility rate. So, if you’ve been historically providing these in the office and now, you’re doing them by telehealth, you’re getting 30% less, around. And so, this can be a, practices are facing a difficult time with this policy. It is one thing if you have a practice that has been doing some telehealth services, but it’s a small portion of their practice. But right now, you’re facing, practices are facing a situation where all of their visit codes where they were doing, they were performing them in the office, they now have to perform them out of the office, virtually using the telehealth modifier, our place of service code for both their COVID 19 patients in their non COVID 19 patients. So, they’re experiencing a 30% hit, and the challenge is that, you know, it’s one thing to take a 30% it for two or three weeks. It’s another thing if you’re taking this, this is going on for three or four months. The trade press has been reporting already that some practices are already closing, and others are experiencing dire financial pressure because of both this, you know, the reduction in their office visit rates as well as everything else that’s going on at this time. So, many see this as really an unsustainable issue. Next slide, please.

And so, I just wanted to finish up about, you know, sort of highlighting some of the issues raised by stakeholders. As Marshall mentioned, you know, in the beginning of this webinar, this is a fluid situation, and new policies are emerging and legislation is being passed, and what we’ve tried to provide you today is kind of what the current policies are. But as more clinicians are providing these telehealth services, I think there is pressure to kind of reexamine some of the policies and see if that changes need to be made. So, some of the issues at stakeholders have raised is waving the video requirement, so telehealth services can only use, can be used for audio only devices. I think later in the Webinar we’ll be talking about what was in the CARES Act and if it allowed the agency more authority to sort of waive statutory requirements, and the issue is, you know, will the agency then do that. There’s also a push, you know, obviously to
push back on using the facility rate and requesting the non-facility rate for telehealth services.
And then the other call I’ve heard for his greater guidance on the appropriate reporting and documentation of telehealth services, I think you have clinicians who have never performed these services before, that is, you know, kind of causing this request. And also, these services, even when they were performed in a telehealth environment, they were being performed— the patient, historically had been in a in a facility, and now that now they’re in their home, and so I think there are questions about how do you meet some of those requirements that are necessary to report a code. CMS has indicated that they are releasing more information soon, and I think the team here will continue to monitor this, you know, what the agency puts out and to report back. And then, you know, my only final comment, before I pass it on, is to say that we did receive a number of questions on, you know, reporting E/M codes and is it appropriate to report an E/M code than the telehealth code in? And I think our answer to that, it really is that the telehealth and any of the announcements that the agency has made
really don’t impact how you report the code. So, you have policies in place on when it is a report, appropriate to report a code and what the documentation and the reporting requirements are, and I think you just continue to follow those. So, thank you, and I will pass it on to the next speaker.

Thank you, Sheila. I’m Emily Cook, and I am going to talk a little bit about Medicare and
Medicaid enrollment, which is an essential step in order to receive the payments that Sheila was just discussing. So, for Medicare enrollment, the Medicare program will only make
payment to enrolled entities at enrolled locations. And Medicare does require that each
claim for payment include a service location. And for telehealth, the service location is considered to be the location of the practitioner at the time the telehealth service was furnished. And the service location on the form must match an enrolled location of the practitioner or the practitioner’s group practice. So again, in order to receive payment for the telehealth services, the location where that service is furnished must be enrolled with Medicare, and that location is going to be considered the location of the practitioner at the time the telehealth service was furnished. And the service location must be enrolled, and if it is a solo practitioner or a practitioner who is not otherwise reassigned their right to Medicare payment, that is, they have not completed the forms to allow another entity, such as a group practice, to receive payment, that individual practitioner will need to enroll the location where they provide services. If there has been a reassignment of that right to receive payment, the
location of service is considered to be a location of the group to which payment has been reassigned and does need to be enrolled as a location of that group Next slide.

So, if due to COVID 19- related challenges in locations of service, and that includes expanded use of telehealth, the service location where that practitioner is located at the time a service
is furnished is not currently enrolled in Medicare, it should be enrolled. If the service location is permanent, that is, on a go forward basis following the hopeful soon resolution of the COVID 19 national emergency, that location will still be in use, it should be enrolled using PECOS, that
is, the online Medicare enrollment tool, as an update to what’s known as the 855B enrollment,
that is the enrollment record for Medicare practitioners and other suppliers. If that location is temporary, that is, that it will be utilized only during the period of the national emergency, there is an expedited enrollment process. And on the next slide, I will provide the information about how to utilize that expedited enrollment process. One of the areas where oh, sorry, not ready for the next slide just yet. Thanks. So, the, one of the questions we have been getting quite a lot, and whether it’s quite a lot of confusion due to changes in practice, locations are practitioners’ homes. So, we are seeing a lot of movement of services that may have previously been furnished in a hospital or in a physician’s office setting, being relocated into a physician’s
home to provide services. That is still considered by Medicare to be a service location that should be enrolled, and their current published guidance does state that the home address does need to be enrolled as a service location. We are aware that there has been some information that has been circulating in the trade press and among the practitioner community about changes in that policy. CMS has indicated, it appears, that they may be moving away from that requirement to have folks temporarily enroll home addresses, you know, that the AMA published some materials to that effect and that CMS would be revising their current guidance. To date, CMS has not revised that guidance, although again, it does appear
as though there is some indication that they may. So, I’ve provided the link here in the slides and the slides will be available if you do not already have them. That is the current published guidance from CMS on this requirement to enroll practitioner home addresses. It is specifically FAQ #11 in that document. So, if CMS does revise their policy requiring an enrollment on the
addresses, that is where we would expect to see that update. But again, as of right before we began this webinar, they had not yet made that change. So, their current published guidance does remain that home addresses of practitioners where they’re providing services, including telehealth services, do need to be enrolled. Next slide.

So, the good news here is that for purposes of obtaining temporary enrollment of both practitioners and service locations, CMS has required that the Medicare contractors establish
hotlines to provide expedited enrollment. So, here are the list of all of the expedited enrollment hotlines and their operational hours. We do know from hearing from our clients and other stakeholders that these are staffed during those hours, that they are not experiencing tremendous wait times. They’re open on the weekend. You can call, and with fairly limited information, you could get that enrollment records updated immediately, so there is no lag time, there is no processing time, typically. There are some scenarios where if they do need some more information, it is possible it may take slightly longer but, in most cases, the practice locations and entire new enrollments for practitioners can be done on the phone in a very
short period of time and become effective immediately. Next slide.

So, in addition to Medicare enrollment, we are also seeing a lot of activity on the Medicaid side. I will say we do not, we are not seeing as much activity on the Medicaid side because the Medicaid programs at the state level have historically been much more expansive in terms of their coverage of telehealth, and there were many practitioners who are already utilizing
that expanded opportunity, although again, the COVID 19 national emergency has resulted
in an increase in the use of telehealth and possibly a need to enroll new practitioners or new locations. So, the purple box on this slide is really the most important, and that is that the Medicaid enrollment rules of process vary by state. There are more than 50 state Medicaid programs, and that means that there are more than 50 processes to enroll. Medicaid enrollment is state specific. It does require enrollment at the state level. But, the good news
again, here is that in most cases we’re seeing states relax or expand their enrollment processes and their enrollment eligibility to expedite getting practitioners online to provide services to Medicaid beneficiaries. So, as of this weekend, there have been 34 Medicaid, what are known as, section 1135 waivers, those are the documentations that states typically use to expand or provide flexibility among other aspects of their Medicaid programs, their enrollment rules. Of those 34 Medicaid waivers that had been approved as of Saturday, 31 of them explicitly included flexibility for newly enrolling or new out of state practitioners, in most cases through processes that do not require additional screening, if those practitioners are enrolled in either
another state Medicaid program or are enrolled in Medicare, and limited additional screening for most others. So again, this process does vary by state, you will need to reach out to the individual state Medicaid programs to get enrolled. But much like Medicare, there is flexibility and some expedited process to bring additional practitioners or additional locations,
including telehealth services online. With that, I will I will turn it over to the next speaker.

Thanks, Emily. We thought we’d take this opportunity this afternoon to go ahead and just outline, briefly, what the changes are to telehealth payment and provision under the CARES Act, which was, as everyone knows, was adopted on Friday. So, first, I think, and probably most important, is the is the broadening of the ability for CMS to actually waive certain provisions of the telehealth requirements under the Social Security Act. So, what Section 3703 of the CARES Act does is really rolls back some of the restrictions and requirements that had originally been
placed in the 1st two appropriations acts that were implemented earlier this month. So, first of all, and probably what’s been talked about it a little bit more than anything else, is the
restriction that had been placed in Section 1135 of the Social Security Act, which actually set up
the parameters for CMS’s ability to waive certain provisions of telehealth requirements, originally had said that that the technology had to be two-way, real-time audio-visual technology, so that automatically precluded any kind of just voice- phone transmission from qualifying for telehealth reimbursement. What happened, what happened under the CARES Act
is that that provision was taken out, so it was removed from this code, and so now CMS has the ability, if it exercises its authority, to waive the video requirement. So, we have not seen that yet, but that is how the … has actually set that up to happen.

The next thing that I wanted to discuss is that, along the same lines, the requirement
that a provider must have seen a patient within the last three years in order to qualify for reimbursement for telemedicine or telehealth services has also been taken out of the code. And I think, you might recall that it had been placed in the first appropriations as CMS came out
with its telehealth guidance and stated that it was going to exercise enforcement discretion, it would not, actually, enforce that, that that provision so that we’ve seen that that’s actually been rolled back in the code. And then third, with respect to the telehealth, labors, the changes to that section have actually allowed much more expansive authority to CMS to change any of the provisions of what’s in Section 1834, paragraph m, it sets forth the requirements for telehealth services. So, we can see that CMS now has broader authority to make some changes that have been requested, some of the changes that we talked about previously
in this presentation, as well as issues that stakeholders have brought up, so we’re still, of course, waiting for that guidance to come out, but we do expect CMS to come out
with additional waivers in the future. Next slide, please.

In addition to changing the requirements for the Medicare waivers, the CARES Act also has is
implemented a few additional provisions to the telehealth law. First of all, FQHCs and rural health clinics are now able to service distance sites. CMS rolled back, or made more flexible, the required face to face clinical assessment of a nephrologist of a home dialysis patient, I believe that those were required to be face to face, which was considered to be in person,
either monthly if it was a new, a relatively new patient, every three months if it was a more established patient. Now those face to face clinical assessments can happen through a telemedicine or telehealth encounter. And then finally, similarly, the, re-certification for hospice care can now happen via telehealth consultation rather than through a face to face
determination as well. We may be waiting for CMS to actually provide a little bit of color on how they’ll implement that, but that’s what the legislation did. And the next slide, please.

And then finally, just a couple of other points on telehealth. First of all, there is this provision that requires HHS to actually encourage the use of remote patient monitoring, other types of telecommunications systems, consistent with the care plan for the beneficiary. And this is specifically with respect to home house services, I believe, I don’t think that it is on the slide. We’re not sure exactly what this will look like, but it appears to be a directive to publicize what’s already what’s already possible within those within the home health services.
And then I think that in previous webinars we have talked about the IRS provision that actually
permitted the provision of COVID 19 testing and treatment without requiring the patient
to pay a deductible. It’s been expanded now, that relief has been expanded so that any
telehealth services now could be provided to a patient without having to charge the deductible
for the service. So, I think that that was something that had been requested and I know we received a lot of questions about it. So now that has been expanded. And then finally, the CARES Act really does, since it is an appropriations act and has a lot of funding, there are several funding initiatives that are meant to support or establish telehealth programs, telehealth connectivity, and other initiatives that should make telehealth easier to access
across the country. And with that, I think that we just wanted to just give that round up. We’ll go ahead and pass it on to Ankur.

Thank you, Amanda. What I want to do is cover telehealth at a high level from the insurance and health plan perspective. Much of what you’ve just heard relates to original fee for service Medicare or not all of it, there’s some content around Medicaid, and you heard about
high deductible health plans, for example. But just as we think about the health insurance market throughout the United States, we obviously have a number of different lines of business. We have Medicare Advantage a substantial, so I think over 30% of Medicare
beneficiaries now are enrolled in Medicare Advantage. So, CMS has issued guidance providing plans with flexibility to pay for telehealth. I think the guidance that has been put, out the payment structures, are not necessarily applicable all for Medicare Advantage. So, Medicare Advantage is going to be contracting with providers, and their contracts are really what’s going to govern payment rates, for example. So, Medicare Advantage has always historically had broader coverage of telehealth or a broader ability to cover telehealth than has been the case in fee for service, but again, the CMS has said that it would exercise enforcement discretion to allow that to be expanded. I think you may see going forward, questions about trying to bring
policies in sync or in line between Medicare fee for service and Medicare Advantage, but as of now you probably will see variation among the Medicare Advantage plans and some variability in how exactly it’s being implemented. There’s also guidance and mandates that have been issued in the Medicaid managed care market, so CMS has issued guidance that encourages states to implement and expand the use of telehealth, and some state Medicaid agencies have issued guidance or directives to their managed care organizations. Again, that is more of a state by state issue in terms of how it’s being implemented. The same thing for fully insured commercial products, some states have issued telehealth coverage, guidance or requirements, and we’re seeing increasing numbers of those. Many of the guidances that have been issued have been around some of the licenser types of issues that apply to providers, but Massachusetts, for example, has a provision that extends to payment of telehealth visits.
And then, of course, there’s the self- insured market where employers make decisions on their own as to what they will and won’t pay for, and, you know, that presents yet another set of facts. So, as we’re thinking about how coverage for telehealth and allowances for it to be utilized come into play, you do need to think a little bit about which line of business, and unfortunately, there’s a level of complexity there that has to be worked through. But I do think there is some movement towards uniformity, or at least some consistency on key principles, but we probably are not going to get to the point where it is absolutely uniform. So, let’s go to the next slide.

So, what are some of the issues? In the short term, we have issues and questions around whether governmental issuances are requirements or whether they’re flexibility for health plans to provide coverage of telehealth. And, you know, I think that’s going to be important. I think most plans have taking the approach of broadening their coverage. But, when looking at a piece of guidance from a state, it’s important to consider whether it is a requirement or a flexibility in anticipating what is, how it’s going to be applied. Another issue is cost showing waivers. So many Insurers have decided to waive cost sharing in various segments. CMS again,
provided discretion for plans to do so, they also have indicated providers can waive cost sharing
to encourage the use of telehealth. Again, that’s not uniform, but has been something that we’ve seen, and are seeing, a lot of plans implement. Obviously, these are things that
otherwise could raise issues under the benefit plan structure that plans have. They could
raise issues for providers under the … statured, or other types of inducement considerations.
But again, the concept of waving cost sharing is one of the provisions that is increasingly
being seen. There are applicable insurance rules about mid- year changes to benefits. So, when we talk about these guidances or declarations, a lot of times it’s framed from a legal perspective as waiving requirements to our prohibitions on mid-year changes to benefits or statements of non-enforcement. Again, the file benefit in a state is typically what a plan would, and here, too, in Medicare Advantage, there are ordinarily prohibitions on making midyear changes to benefits so those have been waived. Another short-term issue is provider contracting and network considerations. So, questions about whether these expanded telehealth will be paid for out of network or whether it’s necessary to be in network, or whether cost sharing waivers will apply to out of network versus in-network. I think
those are things that also need to be evaluated and may very indifferent geographies and in different marketplaces. So, the contracting relationship will be an overlay on top of a lot of what’s been discussed. And again, that contracting relationship may dictate what the payment amounts will be. There’s credentialing considerations. If a provider is seeking to contract to provide services where they previously haven’t, or to be able to provide the telehealth,
the plans will need to consider how they’re going to approach credentialing and be able to implement on an expeditious basis the appropriate requirements that apply to them to assure that they’re following their credentialing requirements. And then payment rates, again, I think someone mentioned this before, there are some states that are out there with requirements around parity for telehealth visits in terms of the payment rates. Obviously, state issuances don’t apply to Medicare Advantage, typically, because they are preempted by federal law. So, again, when you look at those state law issuances, they may not be reaching all segments of the insurance market. Let’s go to the next slide.

Just thinking a little bit longer term, some of the other issues that will be coming down the pike,
how will telehealth visits be treated for risk adjustment purposes? Some of the Medicare Advantage context premiums to health plans often depend on the diagnoses that air submitted and claims from face to face visits. There’s been some question around whether telehealth benefits provided historically under Medicare Advantage would be permissible. Visits will be
considered face to face for risk adjustment purposes, obviously, with the expansion of telehealth that may become increasingly important, with an effect on plan revenue, and may also affect in scenarios where providers are operating on a downstream risk arrangement
percent of premium, for example, so that risk adjustment question can have implications down the road, as well as the impact on star ratings and quality metrics. So again, in Medicare Advantage star ratings, you may see scenarios where, because visits are being performed through telehealth, some of the other steps that are taken to try to improve performance,
from a quality standpoint and from a star rating standpoint, may not be a as readily
able to be achieved. And I think CMS has an existing policy around disasters and how they approach star ratings, but there’s likely to be some consideration of further modifications and future changes to that. And, there could be similar question about quality metrics that are
in contracts between plans and providers where telehealth may have an impact on how the quality metrics are evaluated or achieved in some discussion around those changes or those dynamics, may be things that come into play a little bit down the road. Again, those are things that are probably not the top of the list of what people are thinking about currently but are likely to be significant as we move forward. So, let me stop there and turn it back to Marshall.

Thanks, Ankur. Before we jump into the Q & A, I want to highlight for everyone on the line. We at McDermott have been maintaining our Coronavirus Resource Center. There, you can
Access, not only this webinar and slides, but other webinar slides that we’ve done across the firm, not only addressing health, but also other reimbursement, IT, HIPPA privacy security, and other updates that are coming down from both the federal government, and state legislature
around response efforts for Coronavirus. We continue to try to populate that, as soon we can with updated information, but do understand that, obviously, this is an ever-changing environment, and so we’ll continue to do updates as necessary. And you can access that through mwe.com/coronavirus. We’ll jump in here now to some Q & A, and actually Sheila, I’ll turn to you first, there’s a question here now regarding the, really the distinction on the facility versus non-facility payment differential and it was asked, does the facility vs non facility payment differential apply to all services listed on the telemedicine code list, or is only a subset of codes that was shared?

I think it applies to many, those beyond what we listed on the slide. We highlighted those because those are the often-reported visit codes that that people are report a lot and that are sort of a focus right now, but there are other codes that may have a facility in non-facility rate. If you download the, it’s an Excel sheet where they list the codes, and then you’d have—there is
a Medicare lookup tool where you can look up the payment rates for specific codes on the Medicare website, and then that will tell you if it has a facility and a non-facility rate. I will say in some cases the differential is not that much, and in other cases it is a little more.

And could you provide, I guess there’s been a couple more questions this on that why
there may be a differential between the facility and non- facility rates.

Sure. That’s a good question. So, you know, if the Medicare physician fee schedule is a resource-based methodology, and so, the rates are based on the resources used to provide
the service. Physician services are composed of three components. Physician work, medical life, which is a cognitive work of the physician or the health care professional providing the service, the medical liability and then practice expense. And practice expense refers to
supplies, equipment, nurse time, and overhead. So, for the physician work,
if a physician performs a service in an office or a hospital outpatient, wherever they perform it, the actual physician work, cognitive work, would not be different. But it’s really nor with the medical liability, but it’s really the practice expense that varies. So, for those E/M codes that
we listed that that there was a payment differential, the office codes included—the office rate included things like the nurse time and supplies and equipment that you would use when you’re providing this service. I think, you know, I think during this time, clinicians may say, even if they’re doing a visit via telehealth that they may have office staff that is supporting them in a clinical office, staff that supporting them in providing that service, but I think historically, the agency has said if you’re doing it by, via telehealth, you’re not using all your office supplies and equipment, and that’s why we’re going to pay it on the on the facility rate.

Got it. Emily, I’ll turn, I’ll turn to you next. Obviously, there’s continued confusion on the home enrollment requirement. And, you know, obviously CMS has put out its guidance, tow there’s the AMA but another trade press on other guidance, and I think some may have gotten, sort of a confusion, even in reaching out doing the Medicare expedited enrollment process, I guess, where should providers, right now, given this is a fluid situation, be kind of looking for a determination on, you know, do they need to enroll their home for purposes of Medicare?

Of course, so the official CMS guidance on this issue is at the link that I have provided in the slides, and again they are updating their guidance materials very frequently right now. So, I cannot even guarantee that this is not changed during the course of the webinar. But as of the start of webinar, the official guidance from CMS and their published enrollment guidance was still that physicians providing services from home do need to enroll their home address.
There is certainly other information floating around out there, and that, I think, is a scenario where if you do want to proceed under other guidance, you are proceeding somewhat at your own risk. We do not know for a fact that CMS is absolutely intending to change their rules, but their current published rules do indicate that home addresses do need to be enrolled. As I mentioned, it is currently a telephone expedited enrollment process, and there is no particular harm in enrolling in the home address as a conservative approach consistent with the CMS guidance, but certainly, if there are concerns about enrolling home addresses, you know, that that again, is something that may change, but the current official CMS guidance is that those addresses do need to be involved.

And so, Emily, if the providers delegated their payment to a group practice, do they still need to add their home if they’re delivering care or those services from their home? Or is that not needed considering it’s tied to a group entity?

Sure, so in that scenario, the home address gets added as a practice location of the group itself, rather than a practice location of the individual position, so that it is an individual position in solo practice who has not reassigned filling rights, that individual position or other practitioner
would need to enroll their home address as part of what’s known as their 855I enrollment.
If they have reassigned their billing rights to a group, then the group to which they have reassigned that service would enroll their home address as a practice location of the group
using the 855B enrollment.

Got it. Amanda, I’ll turn to you next. There are a couple questions really around, you know, the— for purposes of Medicare audio only, that’s and I would say, audio-only telehealth visits,
not virtual check ins, not e-visits. Obviously, there’s a push from the parity community to
do audio only, but what is your understanding of the current state of whether
Medicare reimbursement is only for, for audio only, or has to be audio video? And how did that square with kind of what’s come out in the CARES Act?

So, what we see in the CARES Act is that the legislation actually opens the doors for CMS to make that decision. But as of yet, we have not seen any guidance from CMS that says that it will waive that requirement, that that it will permit telehealth visits to be conducted through telephone only communications. And I know that we have seen interpretations from elsewhere that are a little bit different than that and may have just skipped the step of making sure that we receive the directive from CMS that is permitted.

Got it. And, I want to put, there’s been several questions around, kind of the distinctions on kind of what’s happening with Medicare and at the state level, and you know, I will say this, and I think everyone can probably chime in here as needed, but it is an onion, and you have to kind of peel back the various layers of the onion. Obviously, the federal legislation that’s coming down from CMS and other federal bodies is one piece of the puzzle. There are state level
mandates and requirements with respect to reimbursement, informed consent, scope of practice and other things that you know, really, all providers need to be kind of paying attention to. And you know, there’s, there’s actually, on the state level, some greater flexibility, whether it be state Medicaid or even private pay or commercial pay situations where some states are actually loosening the requirement and no longer need, you know, audio- video, but may allow for an audio only consultation so long as other, other requirements are
being met. I wanted to make sure that’s, you know, kind of amplified here because I know we have various, you know, kind of segments that we’re talking about in terms of reimbursement.
So, on the, Sheila, I’ll turn back to you real quick on, even if it’s in virtual check ins has there actually been any modifications to the rules around, even with virtual check ins, and are any kind of CR modifiers required for those services?

I have not seen any modifications in terms of these still have to be established patients and those types of things. I think there have been some confusion because in the fact sheet that was released by CMS on March 6, where they talked about expanding, sort of in loosening the rules around telehealth, they included the e-visits and the check ins. And so, but if you if you notice at the, you know, the bottom of that press release fact sheet, they have, like, a table of the Medicare telehealth codes and the e-visits and the and the check ins. There’s a little footnote next to established patients, but that’s for the Medicare telehealth visits, and not
necessarily the e-visits and the check ins. So at least up to this point, and, you know, as we’ve been saying, you know, throughout this presentation, things are fluid, things may change
around that.

Okay, Thank you. Ankur, I’ll turn to you, we have a question here. If you’re not asking the patient to pay the co-pay for a telehealth visit, is insurance paying this or is it just not being collected? Hold on. Ankur, you’ve got to put, you’re on mute here.

Yeah, Thank you for that reminder. So, it’s a good question. I think that, you know, there’s two things that have been stated. One is for the provider being able to waive the co-pay.
The other is if the plan waives the co-pay requirement. And I think, there is not necessarily
complete uniformity around the answer to that question if the plan is waving the co-pay, as to how that comes into play. I think generally, the allowable amount for the service doesn’t change, and so if the if the co-pay is waived by the plan, then that is not necessarily an expectation that the provider is not receiving the full amount of the allowable charge that they would otherwise be able to obtain from the combination of the plan payment and the member payment. But again, as with many things, that’s something worth confirming with the plans and with your contracts as to how that would be applied.

Got it. And I would actually throw this out to all the panelists. There’s a question around,
you know, the length and term of a lot of these changes. Obviously, we’re saying a lot of it is connected to the public health emergency. Ankur, I’ll start with you, but then, you
know Emily, Amanda, Sheila jump in. What are we saying as, in terms of, you know, permanent implementation of some of these changes? It is something that, you know, as addressed in some of the legislation and guidance that contemplate something beyond just the public health emergency?

You know, what I would say to that is I think there will be some downstream impact as people get experience through this emergency. I think that is going to both create demand for telehealth to continue where it has worked well and where it’s convenient, and it will also reveal areas of shortages, or shortcomings, and things that need to be improved. So, I don’t think it’s going to translate directly, but certainly the fact that there is going to be a lot more experience with telehealth, it’s likely to influence what happens in the future and the adoption of telehealth in the future.

Emily, same question to you on the billing and coding side.

Sure, and certainly Sheila can weigh in here, is well, you know, I think there has been quite
a lot of interest for quite a long time in extending opportunities for telehealth under Medicare in particular. Medicaid had already provided for significant additional extension opportunities to the states, so on the Medicare side, I think we are hopeful that there will be some data and information coming out of this emergency that will help assist HHS in determining to expand some of these opportunities post-emergency. And on the same vein, on the Medicaid
side for those states that have not already exercised their opportunities to expand telehealth opportunities that this will provide the data and information they need to continue the expansion post-emergency.

Well, thank you, I think we’re now just over time. I know there’s a lot of questions
we were not able to get to today, but we will be making available not only the webinar, but the slide deck. As part of the slide deck, obviously you have the contact information for everyone on the webinar today, and we’re looking forward to reconnecting and connecting with
those who have questions. So, we’ll continue to follow on and have the engagement and conversation. As updates come, we’ll continue to try to keep our clients and others updated on what we’re saying coming down the pipe. But know this, you know, it’s an ever-changing process. Again, thank you for joining us today, and feel free to reach out for any additional questions.

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