COVID-19: Historic Breakthrough in Telemedicine
Article originally published on Communique, October 2023
During the past few weeks, healthcare attorneys have received an unprecedented number of questions from healthcare providers regarding telemedicine.
Before additional data became available, healthcare attorneys were not able to provide much comforting assurance to their clients. Medicare previously only reimbursed providers for certain telemedicine services in rural areas at certain locations or for certain brief “virtual check-ins.” But now, in light of the coronavirus (COVID-19) pandemic, the telemedicine landscape has become dramatically different.
On March 17, 2020, President Trump announced that “Medicare patients can now visit any doctor by phone or video conference at no additional cost, including utilizing commonly used services like FaceTime and Skype—a historic breakthrough. This has not been done before…” This announcement follows the prior announcement that the federal government would authorize $500 million in new spending for the expansion of telemedicine.
Medicare covers a population that is 65 years or older and others who qualify because of a disability—a population that is especially susceptible to the coronavirus. These recent telehealth developments are a meaningful step forward in protecting individuals across the country from the coronavirus and ensuring increased access to healthcare.
One of the most helpful summaries of the new flexibility to provide telehealth services to Medicare beneficiaries is set forth in a Medicare Telemedicine Health Care Provider Fact Sheet, published March 17, 2020 by the Centers for Medicare and Medicaid Services (CMS). See also the related Medicare Telehealth Frequently Asked Questions (FAQs) issued the same day.
Virtual Services
The Fact Sheet clarifies that there are three types of virtual services physicians and other professionals can provide to Medicare beneficiaries: Medicare telehealth visits, virtual check-ins and e-visits. It goes on to summarize the requirements for billing each type of service and a chart comparing them. Medicare will pay the same amount for telehealth services as it would if the services were furnished in person. CMS has clarified that physicians and certain non-physician practitioners such as nurse practitioners, physician assistants and certified nurse midwives may provide telehealth services. Other practitioners, such as certified nurse anesthetists, licensed clinical social workers, clinical psychologists and registered dietitians or nutrition professionals may also furnish services under certain circumstances. Providers that engage in telemedicine are encouraged to take the time to read the guidance referenced in this paragraph to fully understand the billing and other parameters, which go beyond the scope of this article.
The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) also issued a Policy Statement to provide increased flexibility for healthcare providers to reduce or waive beneficiary cost-sharing for telehealth visits paid for by federal healthcare programs and related guidance. The guidance states that “[O]ordinarily, if physicians or practitioners routinely reduce or waive costs owed by Federal healthcare program beneficiaries, including cost-sharing amounts such as coinsurance and deductibles, they would potentially implicate the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the civil monetary penalty law prohibition on inducements to beneficiaries…. OIG will not enforce these statutes if providers choose to reduce or waive cost-sharing for telehealth visits during the COVID-19 public health emergency.”
Further, the DHHS Office of Civil Rights (OCR) announced that it would refrain from enforcing certain aspects of HIPAA to encourage the use of telemedicine for seniors. The OCR Notice states: “OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered healthcare providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” The Notice goes on to identify those applications that may be used without risk that OCR may seek a penalty for noncompliance (e.g., Apple FaceTime, Facebook Messenger video chat, Google Hangouts video or Skype) and those that should not be used in the provision of telehealth by covered healthcare providers (e.g., Facebook Live, TikTok or similar applications that are public facing). During February 2020, OCR also issued a helpful bulletin regarding HIPAA requirements for sharing patient information during the pandemic.
Providers should remember that the CMS guidance announced on March 17, 2020 applies only with respect to services payable by Medicare. The federal government has also encouraged states to expand the use of telehealth in their Medicaid programs for low-income individuals. It is hoped that commercial third-party payers will follow suit. Because the new CMS guidance only applies with respect to Medicare, providers must review the requirements of their state Medicaid programs and commercial third-party payers when applicable. Providers who have opted-out of Medicare and operate on a cash basis have the greatest flexibly with respect to telemedicine.
If providers engage in telemedicine, they must ensure that their program is consistent with applicable state laws, including licensure and prescribing requirements. In particular, note that when providing telemedicine services, providers generally must comply not only with the state law in which the provider is located, but also the state law where the patient is located. Accordingly, providing telemedicine services to a patient in another state may require telemedicine providers to comply with a regulatory regime with which they are not familiar. States are currently in the process of substantially increasing flexibility in this area to respond to the pandemic and providers should stay abreast of current developments regarding state licensure requirements.
It’s important that providers obtain strong healthcare compliance and legal guidance before proceeding with a new telemedicine program to ensure that all applicable state and federal requirements are satisfied. There are several layers of applicable legal requirements. Healthcare attorneys are available to assist providers in identifying these compliance requirements and structuring a telemedicine program to withstand regulatory scrutiny.
From a practical perspective, the American Medical Association (AMA) has also developed an excellent quick guide to telemedicine in practice. The guide includes invaluable and practical advice with respect to professional liability coverage, coding and payment, practice implementation and other helpful resources. Providers offering telemedicine services during the coronavirus pandemic are strongly encouraged to take a few moments to review the AMA materials.