Hello everyone. My name is Rebecca Camino and I'm here to present the telemedicine rules of the road, for the road to recovery program. I have no disclosures. I want to be very clear that this is a snapshot in time. The telemedicine regulations, legislation pair requirements are changing constantly, especially now during the pandemic. What we're going to talk about is we're going to talk about what the rules were before the pandemic, and how they were changed, and then I don't have a crystal ball for how things will be, but we'll talk a little bit about that. Let's get started. Some of our learning objectives today is that you'll understand what telemedicine is. You'll understand national legislation and CMS landscape. You'll understand how the state in which you are practicing impacts your telemedicine program. You'll learn what to think about when you think about program considerations, what licensing is and credentialing, and some of the hurdles around those and the road marks. Then how COVID has impacted your telemedicine programs and what you can and can't do, and how it is paved the way for the future. When you think about telemedicine, there are key questions to ask. You're going to want to ask what, who, how, and why, and where in there as well. Some of the things why you're going to be asking these questions, so what, what type of telemedicine program are you doing [inaudible]? Or you're going to be practicing medicine and treating, or is this a support group? The "what" is going to really tell you the role that's going to need to perform those, whether they're practicing medicine or not and what are the requirements and restrictions around that. That is also why we ask who because your role and your scope of practice is going to determine what you can and can't do. It's also going to determine what licensure you're going to need and where which leads us into where. When we ask where, we want to know where is the provider and where is the patient. This is going to have a large impact on credentialing, a large impact on licensure. Then there's going to be some rules around it. Is the patient in a residential treatment? Are they at home? Is this an outpatient date program? These are all the where questions that we're going to need to ask to get to the layers of your telemedicine program. How we're going to do it is really going to decide what technology we're going to use. Is the patient at home? What are they going to be using at that end? Are they going to be in an inpatient facility. What are they using there? How are we going to build this, also is around what they're using. Are they going to be using video or is it just going to be telephone? There's separate billing rules. We're going to be talking about some HIPAA Compliant Platforms , pre-COVID and post-COVID. Then we're going to get to why and determining what's the best vehicle for this the "why" is going to answer that, the "why" is also going to be answering some of your coverage, depending on is this substance use disorder or is this something else? Other's going to be rules around that and there's also going to be rules around the role of the person in the how Let's get started now that we have our key questions. What is telemedicine? Telemedicine simply is healing at a distance. It is remote care. We have some different definitions. Each state defines telemedicine differently. When we talk about states, that's going to be really important. Some define it as only video, audio, two-way, and carve out telephone. Some folks include it. Most carve out faxes as not telemedicine. What's happening through email is determined to be telemedicine state by state and pair by pair. The definitions are very important. Let's talk about CMS and national legislation. Pre-COVID, CMS basically set the standard. They had some site restrictions in that they required the patient, which is the originating site, to be at another facility, and then put strict guidelines around what types of facility. It also required the patient to be in a geographical location that was deemed rural by national standards, not by what we would consider rural, but it actually is on a map and it would say this zip code is rural, this zip code is not. Also in that rural was where they enter provider shortage area. When we think of Maryland, there were two tiny dots on our Maryland map that are considered rural, and so we had very few areas where we could reach patients at home because home was not an approved site. Also not approved are different types of telemedicine. An eVisit is an asynchronous visit type and until this year actually, that was not an approved modality for telemedicine and now is only approved in a small subset of patients or a small subset of use. They don't cover E visits, they don't cover patients at home, and they don't cover urban or non provider shortage areas. CMS pre-COVID was very narrow as in who could be covered. Now, substance abuse or substance use disorder had a whole different standards. Starting in calendar year 20, our calendar year, you could reach patients at home for substance use disorder. They did have some blocks around that in that while you can reach them at home, a lot of substance use disorder programs bundled with or did billing with bundles and said for every four visits you could do this or for this, and telemedicine wasn't part of that or wasn't part of the practice. Very few substance use disorders clinics were using telemedicine in calendar year. Let's put our questions to CMS. Where, so beginning like we said, in July 1, 2019 for calendar year, you could have home in substance use, what was allowed, you could do individual and group behavior assessment and intervention, so those are CPT Codes 96153-154. You could do individual psychotherapy, so you've got your 90832-338, and you could do alcohol or substance abuse structured assessment and intervention services, which are your G codes, which are GO 396 and 7. When you get to your WHO this is, when you start seeing some of that narrowing and you start seeing why a lot of substance use disorder clinics did not use this. Clinical psychologists and clinical social workers and CSW could not bill Medicare for psychiatric diagnostic interview examinations , or for E&M. This made a lot of program staff using these roles, and so they were carved out and could not use it. They could also not bill or get paid for Current Procedural CPT codes, 90792-90833-908836, and 838. This really put some limits around programs, that's why you didn't see a big uptake in usage. Now if you want to learn more, the Support Act opened up some doors, and also CMS, telehealth services has a tip sheet for providers, I'll put those links into this presentation, into the notes so that you could follow those up and learn more. But let's talk about state level requirements now. At the state level, a lot of telemedicine is governed by a board of governors or board of physicians. They put out telemedicine rights, so those are the coma rates. There is a separate set of coma rates for behavioral health. It's interesting because you have to look at both and you have to make sure that you look at the Behavioral Health ones. Now, some differences between the behavioral health ones and the general ones, there's some language in there for residential treatment that you're going to want to look at, and there's also some differences now in the COVID arena that there are differences between the two. I have some links on here. When we get to the WHO, it means a Maryland licensed physician or licensed allied health practitioner can do these within their scope of practice, and that becomes really interesting because your scope of practice would be determined by your licensing or your Certification Board, and so you would have to go back there, and if it's not explicitly listed, then you're dead in the water. There's a lot of work happening at various levels to make sure that telemedicine is explicitly mentioned within scope of practice for different allied health providers so that they can do telemedicine. Board of physicians stood back and said, "We're only going to tell you what you can do if we license you and everything else is going to have to be handled by your licensing or governing board." That's something you want to look into when you want to look at embedding telemedicine into your program is looking at who's doing it and by state and by governing board isn't allowable under scope of practice. Let's talk about Medicaid. There are definite Medicaid restrictions and allowances, and you're going to want to go to the link below in the notes to really look at those, and there's also a separate substance use disorder fee schedule that's put out by beacon, and so you want to take a look at that. Then you want to look at the Medicaid behavioral health link specifically, and then the third link that you want to look at is your residential treatment service. To make sure that you're hitting each one of those. When we look at post COVID or in the midst of COVID, there are some differences. In your residential treatments and for your group therapy, you're allowed to use phone, even know Maryland state regulations said phones aren't a part of telemedicine. You really have to look at there are some seeming disconnects. You want to look at your program specifically also with COVID, there's not a waving of the HIPAA requirements, but we will not prosecute for HIPAA violations. But in residential programs, you're not allowed to use FaceTime, versus in the National, we're not looking you can use FaceTime. There're some nuances there that you really want to look at. You also want to look at under HSCRC, they are actually providing payment for hospital charges. In the Telemedicine world at large, you're only getting paid for coffees, but under HSCRC there's some expansion of what you could be billing for under the facility side and so you want to take a look at that as well. Let's move on to Licensing and Credentialing. Now, really this is where it gets interesting when you look at licensure and credentialing. The what here is the practice of medicine. What are you doing via telemedicine? If you are educating in general or doing a support group in general where you're not going to talk about personal medical information of the folks on the video call, then you don't necessarily need to be licensed in the state where those folks are. If you're going to be doing any direct treatment assessment, record review, if you're going to be practicing medicine, then you're going to need to hold the license in the state where the patient is at the time of that visit. If you're doing a session with someone in New York, you're going to need to be licensed in New York to provide that services. Now, this gets tricky because maybe you have allied health providers that don't require certification in that state. What do you need to do? You're going to have some legal guidance specific to your program before you move forward just to make sure that you're in compliance. Now, when we talk about credentialing, this is when the patient is in another facility. Are they in another hospital? Are they in a clinic? Are they in a residential program? Are they in a nursing home? Are they in a school? Are they in a correctional facility? If they're in any of those types, then you need to be credentialed in that facility in order to provide care to the person sitting in that facility. You cannot just do patient to provider and ignore their setting, you're going to need credentialing in that setting. Now some places will happen there bylaws that they will accept delegated credentialing. That is basically in their bylaws they're saying we will accept that you are credentialed in your location, we will accept that credentialing as valid in hours. This is you and far between it has to be outlined in their bylaws. There are institutions that aren't allowed to have delegated credentialing, like nursing homes, skilled nursing facilities aren't allowed to do this. You would need to be credentialed specifically in that facility. Now, when you're talking about skilled nursing facilities, you could have a place like youtricare which is an entity and have multiple sites. They will credential you at the entity level, but you're going to need sign-off from the medical directors at each site in order to be credentialed at that site. There's a lot of nuance and minutia that needs to be really gone in here to make sure that you are in compliance when you're doing programs. You also want to look at when you're looking at providing services to a location or to an entity, you want to look at how you're billing. Are you going to bill on a contract subscription between you and that entity or are you doing fee for service between you and that patient and all of that is really going to have to be hammered out and part of an agreement that your department is going to have to come to with that entity so that everything is clear and above board. When you're looking at these things, you really want to be looking at things, let's say you're going to be doing methadone treatments and management to a patient in a skilled nursing facility or in a rehab location. You're going to have to not only look at being licensed in that state, where that facility is, and if it's a state-like or if it's a facility-like laureate, which is multi-stage and you could have patients in Delaware, Virginia, and Maryland, you're going to need licensure and all those areas because you don't know where the patient is going to be. You're going to need to be credentialed at the entity level and at the specific location. You're going to have to have clinical services agreements to make sure that the provider time is being reimbursed. Appropriately, and legally, and compliant, and you're going to need to, what is the chain of control for that methadone? Are you bringing it there? Are you sending it there? How are they storing it? How are they dispensing it? There's lots of questions to ask when you're looking at substance use disorders and you want a partner in this that's going to be asking those questions. If you are a Hopkins provider, you have the office of telemedicine at Hopkins, I would suggest wherever you are a provider, whatever health system you're part of, that you reach out to your centralized office and have your legal teams and everyone taking a look at this with you. Now, when we talk about licensure, there are some shortcuts to licensure. There is the interstate medical license compact. The link is in the notes under this presentation. This is just a centralized portal that will allow you to get licensure in about 30-34 states. I don't know what they are right now. What it does, is these states have signed on to the agreement to say that, we will respect the licensure in your home state and grant you licensure in our state based upon that. It doesn't say that you don't need licensure in those 32 states, you still do, but they're going to take your paperwork from your home state. You're going to need a fresh set of fingerprints and a background check at the IMLC level. You go online, you apply, you give them your fresh set of fingerprints, they reach out to your home state. Your home state sends over all of your paperwork from your previously approved license that you're currently carrying, you have to be board certified. Then they're going to run a fresh background check, they're going to stamp it and say yes, your set to jet, and then you're going to say, I want licensure in these five states, check those boxes. You're going to pay each of those five states, as well as the centralized licensure fee, which I believe is $700. Then those states will grant you licensure within two weeks. You would have licensure in five states very quickly based on your home state's approval and the fresh set of fingerprints. That is a shortcut. It is not cheaper. You still have to build the requirements of each of those five states. Let's a state number 1 requires that you do eight hours of domestic violence training, you still have to do that. State number 2 says, you need to jump through these hooks in order to prescribe, you still have to do those things, but you will get licensure much faster in those states through this centralized Interstate Medical License Compact group. That is one way. There are some other states that have provided some shortcuts as well, like Florida has provided telehealth registration. That is a one-day process, very quick, it's free, and then you're registered to provide telemedicine only to Florida. You cannot open up shop there, you can't go down there and see patients in person, but you can do telemedicine and it's a full license for just that state, for Florida just to do remote care. There's a variety of ways you can do this. Let's move on to how COVID has changed the world right now. With COVID, we had a public health emergency, which is shortened to PAG, and we have that public health emergency both at the national level and at the state level. First we're going to talk about the state level. The national health emergency went out. It allowed governors to add state licensure to that. It also allowed CMS to, under that PHE, waive the geographical restriction, so now you don't have to be just rural, so there's no geographic restrictions. It also allowed them to say, you can do it in the home. What substance use disorder had previously, now everyone has. You can do substance use disorder. It also opened up coverage for telephone, which is really exciting. It expanded the roles that could do telemedicine, and so it brought in a lot of those allied health. Rehab is now in there, behavioral health counseling is in there, a lot of what was previously only deemed impossible, service nutritionists now can provide telemedicine. It opened up the role. There are some things versus new and established, and so home is opened up. From the CMS side, home is new and established, no restrictions there. Telephone opened up at the state level and at the national level, that you could get covered and do telemedicine by telephone. Let's talk about HRSA with 340B. Now, you could do that remotely as opposed to the provider having to be in the hospital clinic that was clear to do 340B. There are some restrictions around that and you need to make sure that you have an audible chain that they can go back and audit. But for joining the National Emergency, they are allowing that remote coverage for those services. There's some pending legislation that I want to talk about at the national level. Three different things are in there. One of them is the Treat Bill, and this was sponsored by Hopkins. It's being put forth with bi-partisan leadership and what this says is, any national emergency that has a PHE, this would include the opioid crisis, it would remove all the state barriers for licensure and allow all the states to provide coverage to each other, during that state of emergency, and for 180 days post that state of emergency closing. It would allow for a tail for both the payers and for the hospital systems and providers to be able to shift coverage and shift modalities of care. What we came up with with this latest PHE is that it wasn't renewed until, I think the day before or the day that it expired. If we had to operationally switch all those people to in-person care, there would definitely be an interruption in care. We would not be able to shift that fast, so we would either have to provide all that care for free until we were able to shift or we would have to delay care for patients, which is something we don't want to do or interrupt care for patients. This tree would allow for that tail. Now, CMS has also put forth a bill that would say, let's do the same thing and do 180 days only after this public health emergency, either 180 days or the calendar year, whichever is shorter, that we would continue our waivers through that time at the national level. At the state level, each waiver that comes out as a state, it doesn't follow a template. The waivers are not the same. Each state put out their own waivers during this PHE and during every PHE. Some states said, okay, you can see established patients without licensure. Some said you can see newer established, some said you can see new if you work in conjunction with a provider who holds licensure in our state. Some said everything goes. They all gave for separate varying times. Some put times on it and then it needed to be adjusted, some linked it to the national PHE, some de-linked it. It's very spotty. There's no one to rule them all. Each one is separate. If you are a Hopkins provider, we have a resource online that you can check at any time. It's being updated daily to say what state has what requirements for which role. That was the other thing that's spotty. Some states said, you can do this for new and return if you are a physician, but not if you are an NP or not, if you are allied health or not, if you are a psychologist, or didn't even say psychiatrists or psychologists. They didn't parse it out and so it became very unclear. In this method, you really want to go back and look. Also if you're in Maryland, you want to look at your facility charges because that's under HSCRC and not under anybody else. But that's very specific to Maryland. Now there are some other considerations that you want to look at. Definitely you want to look at math and the different pieces there and make sure that your program fits in. But that is a basic overview for the state of telemedicine for our road to recovery program. I'm sure there'll be questions. I've listed resources on this last page and also in the notes and I look forward to hearing your questions and being able to interact with you.
