During the coronavirus pandemic, a visit to the doctor's office can be risky. This crisis has become a moment for telehealth, which connects patients to doctors wherever they may be. Although telehealth has been around for a while, recent updates to regulations and a surge in demand has made it the easiest way to deliver care. Waller's Beth Pitman and Nathan Kottkamp examine the emergence of telehealth, addressing the opportunities and considerations.
During the coronavirus pandemic, a visit to the doctor's office can be risky. This crisis has become a moment for telehealth, which connects patients to doctors wherever they may be. Although telehealth has been around for a while, recent updates to regulations and a surge in demand has made it the easiest way to deliver care. Waller's Beth Pitman and Nathan Kottkamp examine the emergence of telehealth, addressing the opportunities and considerations.
Morgan: 0:05
welcome to point by point conversations, interviews and legal commentary for today's business professionals brought to you by Waller. Even during a pandemic, hospitals and healthcare providers are required to protect and preserve patient privacy. But there are plenty of realized scenarios that are always black and white, and Waller's Beth Pittman and Nathan Kottkamp will help listeners and navigate HIPPA and other privacy concerns during this challenging time. Help here in the United States has never been easy. But with the Corona virus pandemic, a visit to the doctor's office could be risky or not an option altogether. This crisis has become a moment for telehealth, which connects patients to doctors wherever they may be. Although Telehealth has been around for a while, recent updates to regulations and a surge in demand has made it the easiest way to deliver care. On today's episode, a point by point, I'm joined by Beth Pittman and Nathan prop You up that Nathan are both partners in our Healthcare Compliance and Operations practice group. We work with healthcare providers and health care I T. Companies on a variety of compliance and regulatory matters, particularly around patient privacy, data security and telehealth bath and Nathan were really looking forward to talking to you today. In a short period of time, the covert 19 pandemic has impacted a variety of industries. But most of all health care providers can you first beat to the drivers for the shifts and care delivery models and why telehealth has really taken off in the last couple weeks?
Beth: 1:32
Sure, Morgan, thank you for having us on the show today. There are a few drivers to the push towards telehealth. The first is in the midst the crown, A virus outbreak, the Centers for Medicaid and Medicare service is, and the officer Civil Rise has taken steps to make health care. Service is more accessible for Tele help particular for desert high risk of complications from the virus. In addition, there are a number of care settings are limiting our altogether. Closing access to kicked in person service is in order for those providers to continue to see patients there now, shifting into more of a telehealth setting. Just think of dermatology, dentistry, other areas of health care there that are able to carry out much of their work through a telehealth platform.
Morgan: 2:13
So you mentioned certain patients who are at risk, or maybe have high risk of complications. So maybe, you know, patients with diabetes, heart disease, how our patients. Maybe they don't have Corona virus. But just those patients that are, um, you know, dealing with chronic diseases. Um, how would you say that is a particular are dealing with this would be a telehealth
Beth: 2:37
where the position isn't treat. Patients that have chronic illnesses are able to do remote patient monitoring through these blood pressure cuffs or other types of devices that help help in the information to them. They can call the patients what the audio visit. An audio visual visit can meet with an almond, determine how they're how they're complying with the requirements. Are they? Are they taking their medications? Are they eating the right kind of food? So they're getting out and exercising like they're supposed to. It helps significantly impatient compliance with Guardo chronic care management.
Morgan: 3:10
So, Nathan, I'm curious. Are you seeing that there are certain areas of health care in particular that are most ideal, or telehealth are certain clients that are asking you the most questions about this right now?
Nathan: 3:24
I'd say the obvious one is mental health service is ordinarily they're delivered in person, but it's an easy sort of thing to do. It doesn't have limitations of having to be concerned about is the diagnostic elements could be good enough. If you're doing your apology over video, for example, those those challenges don't exist. I think anything that involves regular interventions with positions where you yours simply checking in?
Morgan: 4:02
You mentioned earlier CMS The Centers for Medicare Medicaid service is Are there particular regulations that expand the use of telehealth that providers should be aware
Beth: 4:12
of? Yes, under C. M s. Under the Medicare rules, they have expanded the definition of tell help and to till now, delivery service is from a pay to a patient who's at their home. And also they also expanded it beyond the rural areas where originally it was limited to a certain geographic area but now is expanded to into all healthcare providers. And in any geographic area, the main advantage is that they can provide services to a patient as I shelter at home.
Morgan: 4:47
Great. Nathan, do you have anything noteworthy that you know, in terms of reimbursement, if I'm a health care provider, okay? Their advantages for us we will do this. This is going to provide an additional revenue stream where otherwise our practice may be limited or completely cut off. And then the number of patients that we can see right now.
Nathan: 5:06
Oh, absolutely, obviously, cash flows a major issue for providers across the country. There's obviously a lag time in providing service and getting paid for. But keeping the pipeline of patients and reimbursement open is really an important bridge from where we are today and where we need to get to once we're out of this situation. So I think we'll probably over time to see some evolution in the way in which tell health is reimbursed. Obviously, we're not there yet, but that's got to be a place we're gonna be moving to after this situation.
Beth: 5:42
And Morgan, we've also saying not only has CMS expanded till help reimbursement, but most the commercial players have followed suit and have have also made investments to increase, increase their reimbursements or tell help.
Nathan: 5:57
One other thing to keep in mind is that these expansions these measures at least of the moment or temporary. So just be mindful when thes air cut off, there may be some adjustments need to be made.
Beth: 6:10
One thing clear is that we've had a lot of questions about how to code for the Medicare billing, and CMS has been changing that. And so as they as they have made the changes, they've also made it clear that if if claims have been submitted under under their proper guidance, those will be paid and there won't there should not be a delay. But they have specific requirements for telehealth during this emergency. Okay, that makes sense.
Morgan: 6:35
And it seems like a good option, obviously, for those that are either face with a Corona virus or those that are sheltering in place. And it's a great option for these physician practices, in particular, if I'm a pariah, what are the key pieces of information that I should be aware of in terms of compliance and reimbursement changes? You've obviously obviously noted a few of those, but making I'll start with you. Is there anything you know as a provider that I should be aware off?
Nathan: 6:59
Well, I think first and foremost is to recognize that Theo, the expansion telehealth is not a free for all. Uh, you still need to be worried about all the ordinary things that you worry about in medical practice. Good documentation, patient confidentiality and privacy. Are these air, not consulates? You want to do it in your kitchen while your kids are doing their homework with remote schooling and things like that. Um, I also think it's a good idea when you're talking with patients, and there is that element of, um, diagnostic component to it toe. Let patients understand that there may be limitations. It's not the same as being able to lay hands on a patient on helping them understand that I think can go a long way and not only assuring the patient but also helping with some, uh, liability risk issues.
Morgan: 7:51
Anything from a you know, a license. You're our insurance perspective.
Nathan: 7:56
Yeah, license. There is a big deal when it comes to tell health and Tele medicine. Right now, the licensor is handled at the state level, out seeing change, coming to that any time soon. On there is some suspension of some of the rules, but on the backside of when this crisis is over, certain states require registrations of positions in other practice. Sorry. In other states, some have specific rules as to where telemedicine can be performed either on the patient end or the provider end again. I think we're going to see changes in all those. But once these rules air lifted, at least for a new initial period time, we're gonna have to go back to the existing bulls here on the boat.
Beth: 8:39
That's right for the any anything that's not Medicare reimburse. The state rules would definitely govern what you know what we can do or can't do until help. And may the States do you require my hip a compliant until it technology you. So even the Medicare have made something. Mrs made Cem some waivers in that regard. They still need you, you know, check the state law and make sure that the technology that's being news does make the requirements.
Nathan: 9:07
And on the license your front. There are several states that are waving some of their license requirements. You don't have to go through the Board of Medicine, for example, if you find it, find a patient, you can help, and you just so going and do it during the period of emergency declaration, they're going to allow that. But obviously, once the emergency is finished, then you'd have to register for license. You're for telemedicine, things like that.
Morgan: 9:33
Are there any areas in particular where you're seeing? There is some confusion around, um, you know, codes that look what They're on the list and are able to provide distance site providers of curious. If there's any confusion that's out there right now that is worth clearing her.
Beth: 9:50
There's there was some confusion about the place of service. Usually would have. You would have a certain certain place of service he had to use for Tele help. But what they've done now is I've changed that so that they a place of service, that using cutting it is the normal place and purpose of working. You provide that face to face visit, and then they have a specific model bar that you attached to that which is 95 that does, then explained to the to the you know that it is a telehealth for this emergency specific event.
Nathan: 10:20
One of the other areas of confusion in sort of curiosity, is dental practices. Dentists can still do some telehealth. It's pretty amazing to think that using a phone and sticking the camera in your mouth would be effective, but that does exist. Obviously, it has limitations, but I I've heard some general about that. The
Beth: 10:42
way we've had a lot of clients with questions about that and that is that's definitely a dental board or state specific issues. And some of the states have have specific dental tele dentistry laws. But not many others have telehealth flaws and include dentists and then some, like Texas, for instance, don't allow it at all. So it is. That's definitely a state specific question, and it's and it's confusing for For the dentists,
Morgan: 11:12
that definitely makes sense. What about physical therapy, your occupational therapy? It seems like there's been some confusion around that
Beth: 11:19
has. There are codes for that. However, at this time, CMS does not include physical therapist, occupational therapists In their definition of tele help. I'm qualified providers. But some states do for Medicaid and a lot of the commercial. Most of commercial players also do provide. The service is and reimburse forthem.
Morgan: 11:41
So do you all think that the shift towards telehealth is here to stay? Some of these changes will stay in place for a while, or how will things look once the pandemic has. I
Beth: 11:54
think it's really a game changer for a lot of physicians because they can. They can provide. Service is to their clients that that wouldn't require the clock the patient to come into the office normally, and it frees up some additional space for them so they could use. They can use exam rooms for appointments that require face to face visits. And, um, that really gives them additional additional reimbursement. Albany,
Nathan: 12:19
I couldn't agree more. I think what we're probably going to see is, um, return to the previous arrangements with respect to help tell health for a very short period of time. And then everyone's gonna realize how good it was all things considered with respect to this particular element of health care delivery in this current time. And then I think we're gonna see state laws loosening federal laws gonna loosen as well. I think the parts that air I'm gonna be watching their interesting. It is some of the turf protection that I'm sure that we're gonna be seeing, uh, do we want providers from other states coming in and providing care for our patients? There's also raise some ethical questions which is, you know, were you caring for those patients right now? Anyway, um, so are they really stealing patients? But those are things that are sort of social questions we're gonna have to be answering. But I do think this this whole tell help, um, initiative has the potential to really provide some necessary service is an underserved communities.
Morgan: 13:30
Both of you have mentioned some state specific differences. Annabeth, you're referencing earlier just on the dental for us. You know some of the differences on the state by state level, any other state specific differences that may be noteworthy for our listeners.
Beth: 13:44
The many of the states have have specific requirements about the type of telehealth technology that could be used or the toilet type of Tele Health Service's. Some states will allow audio only. Some require audiovisual, and some do also allow where the patient can take a photograph, sent it to the provider. The broader can review that. Let a later time so that does vary from state state about what it's starting the type of technology until a health service that could be provided.
Nathan: 14:14
The other thing that differs from state to state is the requirements for an initial patient relationship there. Certain states that require tell a health to be conducted on Lee after a position has met with the patient for the first time in person. So that's obviously a big deal as we're trying to roll this out. The other thing that comes to the play, too, is that various states have different rules with respect to their controlled substances, rules and what could be prescribed by a telemedicine eso again, I suspect we'll see Maur harmony of that as things go for right now, it really is a state by state thing that you need to be careful about what it is you're
Beth: 14:57
that there's. There's one other thing. Patient consent. Many of the states do require that the patient consent these to tell help, and the OCR enforcement discretion does advise the providers to notify the patients prior to the parties until health it that there will be used until health and there's a risk of releasing information world. The unit may not be as private as it would in a face to face conversation, so that's that is something that needs to be included in the service. Is is to make sure they have inappropriately designed consent form for the patients to execute.
Morgan: 15:30
So that's interesting. Have the have the patient privacy rolls loosened as a result of the regulations passed recently? What changes are happening on the hip? A front that you would want to know.
Nathan: 15:40
I'll start with that. I think the biggest change right now is an enforcement discretion losing of the rules with respect to the specific technology. Um, there is technology that's recognized as being hip, a compliant and more more importantly, several technologies that are recognized by the OCR is not being hip a compliant, but at least for the moment, with certain exceptions, Theo See are essentially said you could go ahead and use a much broader array of options to be able to communicate with patients. The one thing I would caution is that a lot of folks are for a lot of vendors are going to be jumping on the bandwagon, and they're gonna be promoting their service. Is being hip a compliant and there's there's really there's no official way of knowing that s o. Just be careful of who the vendors are. The true using on dhe continued tomorrow the OCR brutal ask questions
Beth: 16:36
and the those ers enforcement discretion is based on a good faith. Use of the teller help, and what that means is that you can't willfully violate HIPAA, Law said. The enforcement question does not suspend the hip of privacy security breach notification laws that it does for this mate for this time period state that they will not enforce penalties against some of the violation of that. So you're still required to comply with the privacy and security laws and the provide notice in the event of a breach. But at this point in time, there is. There has been a suspension of the penalties with regard to good faith, ese. So that means that you know someone if some bad actor comes in and zoom bombs on on uphill Health called, and that person would still be prosecuted by the government for doing that.
Nathan: 17:21
Obviously, when things are available in video form, there may be a tendency to do things like post on social media image of somebody's really wild tattoo or something like that. OCR would consider that to be personally identifiable information, and so just be really careful about the crossover between social media and what you do in your practice privacy rules, we're gonna always apply.
Morgan: 17:48
So what are some about? What are some other risk considerations that these practices should have with particular platforms like zoom or face time? Some of the other ones that we've been hearing her out?
Beth: 17:58
Many of these, like Zone, for instance, have got have received publicity concerning the laugh or absence of security security protocols. So it's important to First of all, make sure that using the most current and up to date software that they have available that is on your phone if you If there's a if you have an update notice, you need to be sure to update the software for resume or face time, and also to put into place the types of privacy restrictions that they recommend. Zoom has a waiting room, and they suggest that you use the waiting room functions that you control. The people who enter enter your telehealth session.
Morgan: 18:34
So Beth, you mentioned earlier the OCR enforcement discretion. Can you see to that a little more? And who's who's covered within that? Who shot
Beth: 18:41
the OCR enforcement discretion is limited to help care providers it does not extend to insurance companies on, for instance, insurance companies that that offer Teladoc Those Teladoc service's did not are not covered by this as you are enforcement discretion. It is also doesn't also not cover this. Associates such as management service is organizations or dental service organizations who might contract for tell tale a dental or tell a health service is on those service's or not would not fall under this enforcement discretion, either, unless, unless the provider is also a contractor,
Nathan: 19:19
however, all chime in and say that those rules may be changing over time. The longer this goes on, the more change we're going to see from the OCR. In fact, they have now released three different enforcement issues or statements, and they aren't coming out any regular intervals. So it's very possible the rules we're gonna expand even further
Morgan: 19:44
along those lines. I'm interested to know. Are there any particular resource is where you would point people to read up on more information on this either on Waller website or through some of the regulatory agencies who are continuing to release of Azure? Waller
Beth: 19:59
has a has a covert 19 race wars page on our website. OCR also has a specific page directed toward the their enforcement discretion that relates to all of the enforcement discretion that's issued with regard to covet. 19. You go to the HHS dot gov and then office Civil rights.
Morgan: 20:17
What sounds like we need to stay tuned for more information as this continues toe play out and evolve. And I think we can all agree that it's a positive evolution for the health care industry and something that we've been talking about for a long time with, um, you know, patients having greater access to tell us how maybe I think Nathan, as you pointed out earlier, there's not a whole lot of positive coming out of this pandemic. But hopefully we can see some some small silver linings, and I think this access to Tele Health and more providers looking into how they might be able to provide at least certain aspects of their care delivery and this kind of setting. So it's it's definitely exciting, and I think you know, there still remains a lot of questions to be answered, and you're a great resource is on that, tracking it regularly. Thank you for listening to this episode of Point by Point Brought to You by Walter. Visit the News and inside section of our website toe. Listen to more episodes. Subscribe to the podcast find show notes in