After many years of effort, the Washington State Legislature has sent a telemedicine bill to the Governor for signature.
It is an exciting achievement, but now that the bill has passed, we need to answer an important question: “What is actually in the bill?”
Payment for Professional Telemedicine Services
The primary purpose of the bill is to require health insurance companies, Medicaid managed care plans, and health plans offered to Washington State employees to reimburse health care providers who provide professional services via telemedicine technology.
This is critical because, prior to the bill, insurance companies had no obligation to reimburse providers for telemedicine services.
One unfortunate aspect of the new law is that it does not set the specific reimbursement rate for telemedicine services. In other words, nothing requires health plans to pay for telemedicine services at the same rate as an in-person encounter.
Instead, the rate for telemedicine services will be whatever the health plan and provider agree upon in the negotiated provider agreement between the parties.
Additionally, in order to receive the negotiated rate, providers must pay special attention to the detailed reimbursement requirements of the bill:
Health Care Providers
The bill states that only “health care providers” are entitled to reimbursement for telemedicine services. Fortunately, “health care provider” is defined broadly and includes any of the licenses listed in Title 18 of the Revised Code of Washington.
A health plan need only reimburse health care providers that are contracted with the health plan.
“Out of network” reimbursement is not required.
Types of Technology
The bill applies to both real time “telemedicine” technology and “store and forward” services.
“Telemedicine” technology is a real-time, interactive, video and audio conference between a patient and a provider. Think “Skype.”
“Store and forward” technology is a system by which information is sent to an intermediate location where it is kept and, at a later time, sent to the intended destination.
This type of technology is very common in the teleradiology and teledermatology fields in which specialists provide reads for digital images of patients.
Unlike telemedicine technology, the bill has some critical restrictions on the use of store and forward technology:
- The bill requires an associated office visit between the patient and referring health care provider if store and forward technology is used. The use of “telemedicine” technology, as defined above, can meet the office visit requirement; and
- A health plan only has the obligation to provide reimbursement for a service provided via store and forward technology if the service is specified in the negotiated agreement between the health plan and the provider.
The second restriction is a big deal.
Under this restriction, the bill does not require a health plan to pay a provider for services rendered via store and forward technology if such services are not explicitly covered in the provider agreement between the provider and health plan.
Therefore, it is critical that providers using store and forward technology pay close attention to their provider agreements with health plans.
Types of Telemedicine Services
The bill is clear that health plans only have the obligation to provide reimbursement for services that meet all of the following criteria:
- Reimbursement is only required if the health plan provides coverage of the same service when it is provided in person;
- The service must be an “essential health benefit” under the Affordable Care Act; and
- The service is medically necessary.
Health plans have no requirement to provide reimbursement if these three requirements are not met.
Payment For Facility Fees
In discussing the facility fee issue, it is important to understand that there are always two different sites in a telemedicine encounter:
- The Originating Site: This is the location where the patient is physically located. For reimbursement purposes, originating sites can be hospitals, rural health clinics, federally qualified health centers, health care provider offices, community mental health centers, skilled nursing facilities, or renal dialysis centers (except independent renal dialysis centers).
- The Distant Site: This is the location where the health care provider is physically located at the time telemedicine services are rendered.
As described above, the bill requires health plans to reimburse providers for the professional services they perform at the distant site during a telemedicine encounter.
But what about the originating site facility where the patient is located? Are health plans required to reimburse these facilities?
The answer is no.
According to the bill, originating site providers are only entitled to facility fees if such fees have been negotiated in the provider’s contract with the health plan.
The bill does not require any health plan reimbursement to the originating site if a health plan refuses to include reimbursement for facility fees in its provider agreement.
This is unfortunate for rural providers who would have benefited from the requirement for health plans to pay facility fees for telemedicine.
Hospital Credentialing and Privileging of Telemedicine Physicians
Aside from reimbursement, another important part of the bill is the changes to the requirements for hospital credentialing and privileging of telemedicine physicians.
In the hospital world, a physician can only provide services at a hospital if the physician is properly credentialed and privileged. Therefore, a physician that provides telemedicine services an originating site hospital technically must be credentialed and privileged by the hospital.
Prior to the bill, Washington law required hospitals to engage in a detailed credentialing process of requesting information from a physician who was applying for privileges. The hospital also had to request information from hospitals and facilities that had granted privileges or employed the physician.
This cumbersome process could unnecessarily delay the provision of telemedicine services.
Under the bill, the credentialing requirements no longer exist for telemedicine physicians.
The bill states that an originating site hospital may rely on a distant site hospital’s decision to grant or renew privileges for a telemedicine physician if the originating site enters into a written contact with the distant site.
The contract must have the following provisions:
- The distant site hospital providing the telemedicine services must be a Medicare participating hospital;
- Any physician providing telemedicine services at the distant site hospital must be fully privileged to provide such services by the distant site hospital;
- Any physician providing telemedicine services must hold and maintain a valid license to perform such services issued or recognized by the state of Washington; and
- The originating site hospital must have evidence of an internal review of the distant site physician’s performance of the privileges and sends the distant site hospital performance information for use in the periodic appraisal of the distant site physician.
There is much to like in Washington’s new telemedicine bill.
For the first time, private health plans are required to pay for telemedicine services. Additionally, the process of hospital credentialing and privileging of telemedicine physicians has been streamlined.
But the bill is not perfect.
Without specific requirements on rates, health plans have the ability to reimburse telemedicine services at a much lower rate than in-person services. Large health systems may have leverage to negotiate for higher reimbursement in provider agreements, but smaller and rural providers may not have this luxury.
Additionally, teleradiology and teledermatology providers must pay close attention to their negotiated provider agreements with health plans. Under the bill, health plans have no requirement to pay professional services for services rendered via “store and forward” technology if the services are not explicitly covered in the provider agreement.
With that said, no bill is perfect, and the new Washington bill is a good first step into improving the prospects for telemedicine in Washington State.
For more information about telemedicine, please contact Casey Moriarty.