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Telemedicine: Expanding
       Access to Medicaid
           Services
                          Presentation to:
                    Virginia Telehealth Summit



     Gregg M. Pane, MD, MPA, Director              April 5, 2011
Va. Department of Medical Assistance Services   Wintergreen, Virginia
Federal Guidance on
        Medicaid and Telemedicine

   Centers for Medicare and Medicaid Services issued
    guidance in 2001 on Medicaid and telemedicine. Among the
    items discussed:

    – No formal definition exists for telemedicine under the
      Medicaid program

    – Federal Medicaid law does not recognize telemedicine
      as a distinct service

    – Medicaid reimbursement for services furnished through
      telemedicine is available at the state’s option as a cost-
      effective alternative to the more traditional ways of        2
      providing care
Federal Guidance on
    Medicaid and Telemedicine (Cont)

   Advises that states should consider factors such as the
    quality of the equipment, type of services to be provided
    and location of providers (such as remote rural sites) when
    deciding on the scope of telemedicine coverage

   Medicaid reimbursement must satisfy Federal requirements
    of efficiency, economy, and quality of care




                                                                  3
35 States Provide Medicaid
 Reimbursement for Telemedicine




                                              States With
                                              Medicaid
                                              Reimbursement

Source: Telehealth Alliance of Oregon, 2008              4
States’ Telemedicine Policies Vary
 Widely; But Commonalities Exist

   Medical and psychological consultations/treatments are
    most prevalent services

   Fee-for-service reimbursement is generally provided to
    both the originating site (where the Medicaid recipient is
    located) and remote site where the physician or other
    provider is located

   Primarily physicians but also other providers are eligible for
    reimbursement, depending on the state

   Coding/billing inconsistencies across the states makes it
    difficult to track telemedicine utilization and impact
                                                                     5
Virginia Medicaid’s
Interests in Telemedicine Coverage
   Improved patient access to medical services

   Improved patient compliance with treatment

   Medical services rendered at an earlier stage of disease,
    improving long-term patient outcomes

   Reduction in service expenditures such as hospitalizations
    and transportation

   Allows for an opportunity to work proactively with physicians
    and other providers; has potential to be a “win-win” situation
                                                                     6
Virginia Medicaid at a Glance



                       Approximately 62
                        percent of recipients
                        are currently enrolled in
                        a managed care plan
                        (MCO). Five MCOs are
                        under contract to DMAS
                        serving various parts of
                        Virginia




                                                7
Virginia Medicaid at a Glance

    Among the services covered by DMAS are:

    ‒ Inpatient and Outpatient hospital   ‒Dental care for persons under age
    services                              21
    ‒ Physician and nurse midwife         ‒Prescription drugs
    services                              ‒Occupational therapy and other
    ‒ Laboratories and x-ray services     rehabilitation services
    ‒ Transportation-emergency and        ‒Hospice
    non-emergency                         ‒Some mental health services
    ‒ Nursing facility services           ‒Some substance abuse services
    ‒ Home health                         ‒Federal waiver programs for
    ‒ Early and Periodic Screening,       recipients with AIDS, Alzheimers,
    Diagnosis and Treatment program       Developmental Disabilities,
    for children                          Intellectual Disabilities and others
                                          conditions
                                                                                 8
Virginia Medicaid
    Telemedicine Coverage, Early Years

   Virginia Medicaid started with a telemedicine pilot project in
    1995. Services covered were:
     – Some consultations
     – One psychotherapy service
     – A few clinical services in cardiology and colposcopy
   Used Virginia defined billing codes

   Only physicians recognized as providers

   Reimbursed providers at originating and remote site, using
    the existing fee schedule

                                                                     9
Virginia Medicaid
    Telemedicine Coverage, Early Years


   Pilot project was limited to three Virginia localities; one was
    for psychiatric care and the other two were for medical
    consultations

   Virginia Medicaid was one of the first states with
    telemedicine coverage




                                                                      10
Virginia Medicaid Telemedicine
          Coverage Expansion, 2003

   Virginia Medicaid expanded telemedicine coverage July 1,
    2003 to be statewide.

   Governor Mark Warner announced the coverage in July
    2003 at a community health event in southwest Virginia

   Additional services covered
     – Evaluation and management, office visits
     – Range of individual psychotherapies
     – Full range of consultations
     – Select clinical services such as in cardiology and
       obstetrics
                                                               11
Virginia Medicaid Telemedicine
      Coverage Expansion, 2003

   Providers recognized by DMAS for telemedicine:

    –   Physicians
    –   Nurse practitioners
    –   Nurse midwives
    –   Clinical nurse specialists
    –   Clinical psychologists
    –   Clinical social workers
    –   Licensed professional counselors



                                                     12
Virginia Medicaid
    Current Telemedicine Coverage

   Originating sites (where the recipient is located) were
    expanded in October 2009 to include:

‒Certified Outpatient                   – Rural Health Centers
Rehabilitation Facilities               –Program for All-Inclusive Care
‒ Community Services Boards             for the Elderly
‒ Dialysis Centers                      – Plus physicians and other
                                        providers on previous page
‒ Federally Qualified Health
Centers
‒ Health Department Clinics
‒ Hospitals
‒ Nursing Homes
                                                                          13
Virginia Medicaid
    Current Telemedicine Coverage

   Under fee-for-service, billing telemedicine to DMAS
    involves:

    – Originating site bills a telemedicine code for presenting
      patient

    – Remote practitioner bills for services such as
      consultation

    – Reimbursement is according to Virginia Medicaid fee
      schedule

    – A procedure modifier for telemedicine is to be entered
      on the claim form
                                                                  14
    – No telemedicine equipment costs recognized in
      reimbursement
Virginia Medicaid
    Current Telemedicine Coverage

   Providers of telemedicine services are expected to fully
    comply with service documentation and other coverage
    and billing requirements described in the Virginia Medicaid
    provider manuals

   Providers can only bill for a service using telemedicine,
    which DMAS already covers for the providers when
    delivered conventionally

   Virginia Medicaid telemedicine coverage is similar to
    Medicare coverage but is not tied to rural area definitions
    for the originating site

                                                                  15
Virginia Medicaid
    Current Telemedicine Coverage

   Coverage was expanded in January 2011 to include diabetic
    retinopathy screening. This is the first “store and forward”
    telemedicine coverage for DMAS

    – For diabetics, digital images of the retina are captured
      by community health centers and transmitted to
      ophthalmologists

    – Ophthalmologists perform an evaluation of the image
      and report results

                                                                   16
DMAS Telemedicine
                Billing Experience
   Telemedicine “billing” has been low for Virginia Medicaid with
    about 3300 claims and encounters for FY2010. Other Medicaid
    programs have reported low billing as well

   The predominant service is psychiatric consults, especially
    pharmacologic management

   Possible explanations as to why telemedicine is not appearing in
    data include:

     – Providers not using telemedicine billing modifier on claims
       form

     – Telemedicine as part of the larger bundle of services rendered
       to patients with particular diagnoses

     – Contracts for services with hospitals/clinics do not break out
       telemedicine                                                     17
Telemedicine, Virginia Medicaid
     Managed Care Organizations



   Under the contract with DMAS, MCOs are to cover
    telemedicine at least to the extent the select services are
    covered for the fee-for-service population




                                                                  18
Recent Virginia Legislation
            on Telemedicine

   Virginia Senate Bill 675 Was Signed Into Law by Governor
    McDonnell on April 5, 2010

    – Mandates health insurance coverage for telemedicine in
      the commercial plans

    – The legislation significantly expands the availability of
      telemedicine coverage in the Commonwealth




                                                                  19
Recent National Legislation with
    Reference to Medicaid and Telemedicine


   Section 3011 of the American Recovery and Reinvestment
    Act of 2009 directs the Secretary of Health and Human
    Services to invest in infrastructure necessary to allow for
    and promote electronic exchange and use of health
    information for individuals, consistent with the strategic
    plan developed by the National Coordinator for Health
    Information Technology

   The Centers for Medicare and Medicaid Services is listed as
    one of the participating agencies

   Infrastructure and tools for the promotion of telemedicine
    are included at 3011(a)(4)

                                                                  20
Recent National Legislation with
    Reference to Medicaid and Telemedicine


   National Health Reform (2010)

    – A change under Medicare, which also applies to
      Medicaid, allows physicians to use telehealth to certify
      the need for home health services and durable medical
      equipment also applies to Medicaid

    – A “health home” option is available to states for serving
      persons with chronic conditions. The state is to include
      a proposal for the use of health information technology
      in providing health home services and improving
      service delivery and coordination across the care
      continuum

                                                                  21
Future Possibilities for Virginia
     Medicaid Telemedicine Coverage

   Adding home health services to the telemedicine
    coverage. DMAS currently covers home health
    services when delivered conventionally

   The Medicaid recipient’s home serves as the
    telemedicine originating site with an electronic
    connection to the home health agency office

   Medicaid recipient’s condition is monitored via
    telemedicine by the home health agency


                                                       22
Future Possibilities for Virginia Medicaid
    Telemedicine Coverage (Cont.)

    Telemedicine applications for Medicaid recipients at home
     include:

      –   Post-operative care
      –   High risk pregnancies
      –   Asthma
      –   Diabetes
      –   Congestive Heart Failure

    Use of telemedicine for home health patients depends on the
     diagnosis, medical need, permission of the patient, and patient’s
     ability to use the equipment

    Home health providers are interested in telemedicine because
     care is delivered more efficiently. The home health nurse can
     serve more patients in a day than when the care is delivered
     conventionally                                                      23
Future Possibilities for Virginia
Medicaid Telemedicine Coverage (Cont.)


   Studies have documented savings particularly due to fewer
    hospitalizations and shorter hospital lengths of stay.
    Medicaid transportation is reduced

   The telemedicine visit is not intended to substitute for
    needed physical visits to the home by the nurse

   DMAS issue of relatively few recipients have more than a
    small number of home health visits, making telemedicine
    for home care less viable

                                                                24
Future Possibilities for Virginia Medicaid
    Telemedicine Coverage (Cont.)

                   Expanding DMAS telemedicine
                    “store and forward” coverage

                   Store and forward involves electronic
                    medical information, such as video,
                    still images, and MRIs, which is
                    stored and transmitted for review by
                    a physician or other practitioner at a
                    later time.
                     – The patient is not present when
                        the physician conducts the
                        evaluation of the image but
                        findings are reported back to the
                                                           25
                        patient’s primary care provider
Future Possibilities for Virginia Medicaid
    Telemedicine Coverage (Cont.)

   Store and forward applications under consideration
    include:
     – Screening for retinopathy of prematurity
     – Dermatology

   Store and forward can be inexpensive for the originating
    and remote sites because the electronic medical
    information, such as a digital picture, simply needs to be
    captured and transmitted to the physician or other
    practitioner



                                                                 26
Future Possibilities for Virginia Medicaid
    Telemedicine Coverage (Cont.)


   Adding “telepractice” to the DMAS telemedicine coverage, which
    is the delivery of speech therapy services using telemedicine.
    DMAS currently covers speech therapy in the schools and other
    settings

   Current pilot project involves a speech therapist at James
    Madison University performing telepractice with elementary
    school children in Wise County. These sites are approximately
    280 miles apart

   Pilot made possible by a grant from the Virginia Department of
    Education to James Madison University

   DMAS in discussion with CMS due to the reimbursement method
    required for school services

                                                                     27
Questions?


   DMAS Website http://dmasva.dmas.virginia.gov/

   DMAS telemedicine coverage description (“Provider
    Memo”, September 30, 2009) at
    https://www.virginiamedicaid.dmas.virginia.gov/ECMPdfWe
    b/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf

   Contact DMAS staff Jeff Nelson- 804-371-8857 or
    jeff.nelson@dmas.virginia.gov


                                                              28

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Telemedicine: Expanding Access to Medicaid Services

  • 1. Telemedicine: Expanding Access to Medicaid Services Presentation to: Virginia Telehealth Summit Gregg M. Pane, MD, MPA, Director April 5, 2011 Va. Department of Medical Assistance Services Wintergreen, Virginia
  • 2. Federal Guidance on Medicaid and Telemedicine  Centers for Medicare and Medicaid Services issued guidance in 2001 on Medicaid and telemedicine. Among the items discussed: – No formal definition exists for telemedicine under the Medicaid program – Federal Medicaid law does not recognize telemedicine as a distinct service – Medicaid reimbursement for services furnished through telemedicine is available at the state’s option as a cost- effective alternative to the more traditional ways of 2 providing care
  • 3. Federal Guidance on Medicaid and Telemedicine (Cont)  Advises that states should consider factors such as the quality of the equipment, type of services to be provided and location of providers (such as remote rural sites) when deciding on the scope of telemedicine coverage  Medicaid reimbursement must satisfy Federal requirements of efficiency, economy, and quality of care 3
  • 4. 35 States Provide Medicaid Reimbursement for Telemedicine States With Medicaid Reimbursement Source: Telehealth Alliance of Oregon, 2008 4
  • 5. States’ Telemedicine Policies Vary Widely; But Commonalities Exist  Medical and psychological consultations/treatments are most prevalent services  Fee-for-service reimbursement is generally provided to both the originating site (where the Medicaid recipient is located) and remote site where the physician or other provider is located  Primarily physicians but also other providers are eligible for reimbursement, depending on the state  Coding/billing inconsistencies across the states makes it difficult to track telemedicine utilization and impact 5
  • 6. Virginia Medicaid’s Interests in Telemedicine Coverage  Improved patient access to medical services  Improved patient compliance with treatment  Medical services rendered at an earlier stage of disease, improving long-term patient outcomes  Reduction in service expenditures such as hospitalizations and transportation  Allows for an opportunity to work proactively with physicians and other providers; has potential to be a “win-win” situation 6
  • 7. Virginia Medicaid at a Glance  Approximately 62 percent of recipients are currently enrolled in a managed care plan (MCO). Five MCOs are under contract to DMAS serving various parts of Virginia 7
  • 8. Virginia Medicaid at a Glance  Among the services covered by DMAS are: ‒ Inpatient and Outpatient hospital ‒Dental care for persons under age services 21 ‒ Physician and nurse midwife ‒Prescription drugs services ‒Occupational therapy and other ‒ Laboratories and x-ray services rehabilitation services ‒ Transportation-emergency and ‒Hospice non-emergency ‒Some mental health services ‒ Nursing facility services ‒Some substance abuse services ‒ Home health ‒Federal waiver programs for ‒ Early and Periodic Screening, recipients with AIDS, Alzheimers, Diagnosis and Treatment program Developmental Disabilities, for children Intellectual Disabilities and others conditions 8
  • 9. Virginia Medicaid Telemedicine Coverage, Early Years  Virginia Medicaid started with a telemedicine pilot project in 1995. Services covered were: – Some consultations – One psychotherapy service – A few clinical services in cardiology and colposcopy  Used Virginia defined billing codes  Only physicians recognized as providers  Reimbursed providers at originating and remote site, using the existing fee schedule 9
  • 10. Virginia Medicaid Telemedicine Coverage, Early Years  Pilot project was limited to three Virginia localities; one was for psychiatric care and the other two were for medical consultations  Virginia Medicaid was one of the first states with telemedicine coverage 10
  • 11. Virginia Medicaid Telemedicine Coverage Expansion, 2003  Virginia Medicaid expanded telemedicine coverage July 1, 2003 to be statewide.  Governor Mark Warner announced the coverage in July 2003 at a community health event in southwest Virginia  Additional services covered – Evaluation and management, office visits – Range of individual psychotherapies – Full range of consultations – Select clinical services such as in cardiology and obstetrics 11
  • 12. Virginia Medicaid Telemedicine Coverage Expansion, 2003  Providers recognized by DMAS for telemedicine: – Physicians – Nurse practitioners – Nurse midwives – Clinical nurse specialists – Clinical psychologists – Clinical social workers – Licensed professional counselors 12
  • 13. Virginia Medicaid Current Telemedicine Coverage  Originating sites (where the recipient is located) were expanded in October 2009 to include: ‒Certified Outpatient – Rural Health Centers Rehabilitation Facilities –Program for All-Inclusive Care ‒ Community Services Boards for the Elderly ‒ Dialysis Centers – Plus physicians and other providers on previous page ‒ Federally Qualified Health Centers ‒ Health Department Clinics ‒ Hospitals ‒ Nursing Homes 13
  • 14. Virginia Medicaid Current Telemedicine Coverage  Under fee-for-service, billing telemedicine to DMAS involves: – Originating site bills a telemedicine code for presenting patient – Remote practitioner bills for services such as consultation – Reimbursement is according to Virginia Medicaid fee schedule – A procedure modifier for telemedicine is to be entered on the claim form 14 – No telemedicine equipment costs recognized in reimbursement
  • 15. Virginia Medicaid Current Telemedicine Coverage  Providers of telemedicine services are expected to fully comply with service documentation and other coverage and billing requirements described in the Virginia Medicaid provider manuals  Providers can only bill for a service using telemedicine, which DMAS already covers for the providers when delivered conventionally  Virginia Medicaid telemedicine coverage is similar to Medicare coverage but is not tied to rural area definitions for the originating site 15
  • 16. Virginia Medicaid Current Telemedicine Coverage  Coverage was expanded in January 2011 to include diabetic retinopathy screening. This is the first “store and forward” telemedicine coverage for DMAS – For diabetics, digital images of the retina are captured by community health centers and transmitted to ophthalmologists – Ophthalmologists perform an evaluation of the image and report results 16
  • 17. DMAS Telemedicine Billing Experience  Telemedicine “billing” has been low for Virginia Medicaid with about 3300 claims and encounters for FY2010. Other Medicaid programs have reported low billing as well  The predominant service is psychiatric consults, especially pharmacologic management  Possible explanations as to why telemedicine is not appearing in data include: – Providers not using telemedicine billing modifier on claims form – Telemedicine as part of the larger bundle of services rendered to patients with particular diagnoses – Contracts for services with hospitals/clinics do not break out telemedicine 17
  • 18. Telemedicine, Virginia Medicaid Managed Care Organizations  Under the contract with DMAS, MCOs are to cover telemedicine at least to the extent the select services are covered for the fee-for-service population 18
  • 19. Recent Virginia Legislation on Telemedicine  Virginia Senate Bill 675 Was Signed Into Law by Governor McDonnell on April 5, 2010 – Mandates health insurance coverage for telemedicine in the commercial plans – The legislation significantly expands the availability of telemedicine coverage in the Commonwealth 19
  • 20. Recent National Legislation with Reference to Medicaid and Telemedicine  Section 3011 of the American Recovery and Reinvestment Act of 2009 directs the Secretary of Health and Human Services to invest in infrastructure necessary to allow for and promote electronic exchange and use of health information for individuals, consistent with the strategic plan developed by the National Coordinator for Health Information Technology  The Centers for Medicare and Medicaid Services is listed as one of the participating agencies  Infrastructure and tools for the promotion of telemedicine are included at 3011(a)(4) 20
  • 21. Recent National Legislation with Reference to Medicaid and Telemedicine  National Health Reform (2010) – A change under Medicare, which also applies to Medicaid, allows physicians to use telehealth to certify the need for home health services and durable medical equipment also applies to Medicaid – A “health home” option is available to states for serving persons with chronic conditions. The state is to include a proposal for the use of health information technology in providing health home services and improving service delivery and coordination across the care continuum 21
  • 22. Future Possibilities for Virginia Medicaid Telemedicine Coverage  Adding home health services to the telemedicine coverage. DMAS currently covers home health services when delivered conventionally  The Medicaid recipient’s home serves as the telemedicine originating site with an electronic connection to the home health agency office  Medicaid recipient’s condition is monitored via telemedicine by the home health agency 22
  • 23. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Telemedicine applications for Medicaid recipients at home include: – Post-operative care – High risk pregnancies – Asthma – Diabetes – Congestive Heart Failure  Use of telemedicine for home health patients depends on the diagnosis, medical need, permission of the patient, and patient’s ability to use the equipment  Home health providers are interested in telemedicine because care is delivered more efficiently. The home health nurse can serve more patients in a day than when the care is delivered conventionally 23
  • 24. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Studies have documented savings particularly due to fewer hospitalizations and shorter hospital lengths of stay. Medicaid transportation is reduced  The telemedicine visit is not intended to substitute for needed physical visits to the home by the nurse  DMAS issue of relatively few recipients have more than a small number of home health visits, making telemedicine for home care less viable 24
  • 25. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Expanding DMAS telemedicine “store and forward” coverage  Store and forward involves electronic medical information, such as video, still images, and MRIs, which is stored and transmitted for review by a physician or other practitioner at a later time. – The patient is not present when the physician conducts the evaluation of the image but findings are reported back to the 25 patient’s primary care provider
  • 26. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Store and forward applications under consideration include: – Screening for retinopathy of prematurity – Dermatology  Store and forward can be inexpensive for the originating and remote sites because the electronic medical information, such as a digital picture, simply needs to be captured and transmitted to the physician or other practitioner 26
  • 27. Future Possibilities for Virginia Medicaid Telemedicine Coverage (Cont.)  Adding “telepractice” to the DMAS telemedicine coverage, which is the delivery of speech therapy services using telemedicine. DMAS currently covers speech therapy in the schools and other settings  Current pilot project involves a speech therapist at James Madison University performing telepractice with elementary school children in Wise County. These sites are approximately 280 miles apart  Pilot made possible by a grant from the Virginia Department of Education to James Madison University  DMAS in discussion with CMS due to the reimbursement method required for school services 27
  • 28. Questions?  DMAS Website http://dmasva.dmas.virginia.gov/  DMAS telemedicine coverage description (“Provider Memo”, September 30, 2009) at https://www.virginiamedicaid.dmas.virginia.gov/ECMPdfWe b/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf  Contact DMAS staff Jeff Nelson- 804-371-8857 or jeff.nelson@dmas.virginia.gov 28