Home Is Where The Patient Is – The New Washington State Telemedicine Bill

It is official. The Washington State Legislature appears to have bought into the promise of telemedicine. For the second year in a row, the Legislature has passed a bill (Senate Bill 6519) that helps reduce the barriers to patient access to remote healthcare.

Senate Bill 6519 builds on the 2015 telemedicine bill in the following ways:

  1.  It establishes a collaborative that is tasked with determining the best course for telemedicine in Washington; and
  2. It requires health insurers to pay providers for telemedicine services provided to a patient who is located at his or her home.

Telemedicine Collaborative

The bill creates a telemedicine collaborative, to be convened by July 1, 2016, whose purpose is to “enhance the understanding and use of health services provided to telemedicine and other similar models in Washington State.”

The members of the collaborative will include representatives from the Washington State House and Senate, academic community, hospitals, clinics, health care providers, insurers, and other interested parties.

The collaborative will focus on developing recommendations on improving telemedicine reimbursement and access to services. It will also determine best practices for telemedicine, including billing and fraud and abuse compliance, and explore other priorities identified by the members.

One specific item that the collaborative must consider is the creation of a “technical assistance center” to support providers in implementing or expanding telemedicine services. The bill does not specify how such a center would be funded.

The collaborative must submit an initial progress report on its activities by December 1, 2016, and follow-up reports by December 1, 2017, and December 1, 2018.

Reimbursement for Home-Based Telemedicine Services

One key requirement in the 2015 telemedicine bill was that insurers must reimburse providers for telemedicine services if:

  1. The insurer provides coverage of the health care service when provided in person by the provider;
  2. The health care service is medically necessary; and
  3. The health care service is a service recognized as an essential health benefit under the Patient Protection and Affordable Care Act.

Also, the bill only required an insurer to pay a provider if the patient receiving telemedicine services was located in a healthcare facility that met the definition of “originating site.”

Under the 2015 bill, if a patient receiving telemedicine services was located in his or her home, the insurer had no obligation to reimburse the provider for the services. This was a major limitation for many healthcare professionals, including mental health providers, who desired to provide telemedicine services to patients in the security and privacy of their home.

The new bill does away with this limitation. A patient’s “home” is now listed as an “originating site.” Therefore, an insurer is required to reimburse a provider for telemedicine services that are provided to a patient located in his or her home.

However, presumably to make the “home” change palatable to insurers, the bill also includes new requirements on telemedicine services, including the following:

  1.  The health care service must be determined to be safely and effectively provided;
  2. The health care service must be provided according to generally accepted health care practices and standards, and
  3. The technology used to provide the health care service must meet the standards required by state and federal privacy and security laws (e.g. HIPAA).

These standards are relatively vague and could allow an insurer to deny reimbursement for a service if it determines that the service did not meet professional standards or HIPAA requirements.

For example, if a patient who is located at his or her home utilizes a video conferencing system to speak with a provider, the provider needs to ensure that the system meets HIPAA standards for the transmission of electronic health information.

Conclusion

The 2016 Washington telemedicine bill is a step in the right direction for remote healthcare in Washington. With that said, the true success of the bill is dependent on the ability of the collaborative to understand and address the current barriers to telemedicine in Washington.

The bill’s option for patients to receive telemedicine services at home could help to remove some of these barriers; however, the usefulness of this change is dependent on how insurers interpret the increased standards that require services to be provided according to “accepted practices” and in accordance with “privacy and security laws.”

For more information about telemedicine, please contact Casey Moriarty.

Finally! Washington Has A Telemedicine Bill. But What’s In It?

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.

Conclusion

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.

Washington Earns “F”s on its Telemedicine Report Card

On September 9, 2014, the American Telemedicine Association issued two reports in which it graded all fifty states on telemedicine gaps in coverage and reimbursement and  physician practice standards and licensure.  Not surprisingly, in the area of telemedicine parity Washington received predominantly failing grades.  Washington fared better in the area of Medicaid coverage and conditions of payment but still racked up three failing grades in the ten categories that were graded.  In the report on physician practice standard and licensure, Washington averaged less than a C.

On September 23, 2014 Ogden Murphy Wallace presented the first of two webinar sessions on telemedicine covering CMS, Joint Commission, and Washington rules pertaining to the ability of a site receiving telemedicine services to rely on the credentialing and privileging of the site from which the services are provided.  On October 7, 2014, Ogden Murphy Wallace will present the second session of its telemedicine webinars addressing additional regulatory requirements relevant to telemedicine services in Washington including licensure, informed consent, Washington’s Stark, Anti-Kickback and Anti-Rebating laws, HIPAA compliance and reimbursement.  To register for the October 7 telemedicine webinar click here.

For more information regarding telemedicine laws in Washington please contact Greg Montgomery.

AMA Adopts Telemedicine Guidelines

On June 11, 2014, the American Medical Association (“AMA”) approved a list of guiding principles regarding the practice of telemedicine.  The AMA’s adoption of the telemedicine guiding principles follows the trend of position statements, guidelines, and other policy statements addressing the practice of telemedicine already adopted by other medical specialty societies and state medical associations, which follows the increased use of telemedicine in the delivery of health care services.

The guiding principles approved by the AMA stem from a report developed by the AMA’s Council on Medical Service.  In its report, the Council recommends a set of principles to ensure the appropriate coverage and payment for telemedicine services.  The principles are aimed at supporting future innovation in the use of telemedicine, while ensuring patient safety, quality of care and the privacy of patient information, as well as protecting the patient-physician relationship and promoting care coordination and communication.  The AMA’s announcement of its policy adoption can be found here; access to the Council’s report is included in the announcement.

The principles recommended in the Council’s report and adopted by the AMA include the following:

  • A valid patient-physician relationship must be established before telemedicine services are provided.  This relationship may be established through a face-to-face examination, a consultation with another physician who has an ongoing patient-physician relationship with the patient, or meeting other standards of establishing a patient-physician relationship as developed by major medical specialties.  Exceptions to the foregoing include on-call, cross coverage, emergency medical treatment, and other exceptions that become recognized as meeting or improving the standard of care, where establishing such a relationship may not be applicable or necessary.
  • Telemedicine providers must abide by state licensure laws and state medical practice laws and requirements in the state in which the patient receives services.
  • Telemedicine providers must be licensed in the state where the patient receives services, or be providing these services as otherwise authorized by that state’s medical board.
  • Patients seeking care delivered via telemedicine must be offered a choice of providers.  Patients must also have access to the licensure and board certification qualifications of the telemedicine providers in advance of their visit.
  • The delivery of telemedicine services must be consistent with state scope of practice laws.
  • The standard and scope of telemedicine services should be consistent with related in-person services.  The services must follow evidence-based practice guidelines, to the degree they are available, to ensure patient safety, quality of care, and positive health outcomes.
  • The patient’s medical history must be collected as part of the telemedicine service.  The telemedicine service provided must be properly documented and should include providing a summary of the visit to the patent.
  • The telemedicine services must include care coordination with the patient’s medical home and/or existing treating physicians.  At a minimum, this includes identifying the patient’s existing medical home and treating physician(s) and providing such physician(s) with a copy of the medical record.
  • The delivery of telemedicine services must abide by laws addressing the privacy and security of patients’ medical information.

In addition to the above standards, the AMA also adopted recommendations offered in the Council’s report supporting additional research, pilot programs, and demonstration projects regarding telemedicine.

For more information about telemedicine services, please contact Lee Kuo.

 

Providing Telemedicine Services? Pay Attention To State Licensing Requirements

Advancements in telemedicine offer exciting treatment possibilities for rural communities. Through audio-visual technology, patients in small communities now have the opportunity to access the expertise of specialists at large medical facilities in metropolitan areas.

However, along with all of the promise of telemedicine technologies, there are also some important legal issues that health care providers need to understand.  One of the most important issues is whether physicians who provide treatment advice to a patient through telemedicine must be licensed in the state where the patient is located.  For example, if a patient is located in Washington State, can a physician who is only licensed in Oregon provide telemedicine services to the patient?

The Federation of State Medical Boards (FSMB) has recently addressed the licensure issue in the Model Policy for the Appropriate Use of Telemedicine Technologies.  The Policy  makes it clear that a physician must be licensed by, or under the jurisdiction of, the medical boards of the state where the patient is located.

It is unclear whether state medical boards will follow the Model Policy from FSMB.  For example, Washington State law currently allows physicians licensed in another state to “practice medicine” in Washington so long as they do not open an office or appoint a place of meeting patients or receiving calls within Washington. (RCW 18.71.030). Of course, this provision could change in the future.

In order to avoid the unlawful practice of medicine when providing telemedicine services, physicians and healthcare facilities should take time to understand the licensing regulations in the state where the patient is located.

For more information on the legal issues related to telemedicine, please contact Casey Moriarty.