The Evolution of Telehealth and YOU

Telehealth: Here to Stay

Many healthcare professionals predict that telehealth is here to stay in some capacity beyond the pre-pandemic care model. Telehealth has proven to be a valuable platform for patient care in general but particularly among certain demographics and provider specialties. While there is still much to understand and research, these services have filled a gap in healthcare. Telehealth has increased patient compliance, created access to healthcare for patients who may not otherwise have access, reduced no-shows, cancellations and has unexpectedly given healthcare providers a much broader window into their patients’ lives and living circumstances. All things that factor into better outcomes are fantastic for providers and patients, but the guidelines can make it a little complicated for folks on our end.

Let us begin by recapping the current state of telehealth, where we were before Covid-19, where we are now, and what the future looks like for telehealth through the lens of the CMS proposed rule for 2022. Maybe you’re wondering why it even matters.

Telehealth: Changing Guidelines

The guidelines for telehealth have morphed a couple of times since the declaration of the Public Health Emergency. CMS issued guidance on billing telehealth services during the PHE first in March of 2020 and then updated the guidance in April of 2020, with the release of Special Edition MLN Connects.

One of the issues that make these services incredibly complex is that payors are applying different rules. My experience in auditing telehealth services over the last year and a half is that most healthcare organizations have a complex matrix that details what modifiers each payor wants, whether audio-only qualifies for billing the E/M outpatient visit vs. the phone codes, what place of service should be used, and so on.

Telehealth is a hot topic nationwide for a good reason: Health plans across the country are initiating reviews of these services, but there’s also quite a bit of government involvement through various proposed legislation and budget accommodations to expand these services. If you go to the OIG website and search telehealth under work plan items, you will find eight different items. CMS is exploring expansion of these services beyond the PHE and researching payment of these services during the PHE. Because of the complexity, it’s crucial to mitigate your risk with health plans.

What Telehealth looked like before Covid-19

I think it’s a safe assessment that unless you were delivering telehealth services pre-Covid, you probably didn’t know much about them. To truly appreciate the overall impact and the changes to telehealth services as a result of the PHE–not just with the clinical care of patients but the enormous financial and work effort impact on the revenue cycle–we have to look at what Telehealth looked like before.

Telehealth Before the Public Health Emergency:

      • Patients had to be located in a remote or rural area
      • The provider had to be located in an approved distant site (clinic or hospital)
      • Minimal approved types of services
      • Telehealth services could only be performed using HIPAA Approved technology for interactive audio/video communication
      • Patients had to be at an approved originating site, i.e., not their home that meant that pre-pandemic patients couldn’t be at home, and neither could clinicians
      • Only established patients could receive telehealth services
      • Providers had to be licensed in the state where the service was provided as well as the state where the patient was if different
      • Deductible and coinsurance apply

Telehealth Today

Let’s take a look at where we are currently with telehealth services:

      • No restrictions on where you live.
      • No restrictions on where the provider is located (home).
      • We have a significantly expanded list of services. Now we can Google and search “CMS-approved telehealth services,” and it will be the first on your search list. That list will show what services are permanently on the telehealth list, what services are approved through the PHE, and ones approved through the calendar year of the PHE. Also, the list will show if audio-only meets the code requirements.
      • Currently, any platform that supports real-time audio/video can be used.
      • Waived restrictions on originating site.
      • New or Est (NP–significant impact on RCM) There are many things we have to get right on a patient's first visit for payment to flow quickly and efficiently through the revenue cycle.
      • CMS waived the requirement for providers to be licensed in the patient’s state as long as they are licensed in another state.
      • Providers can elect to reduce or waive all cost-sharing which doesn’t mean they are; we will explore a little later on in the presentation the effect this has on the revenue cycle.

The Future of Telehealth

What will telehealth look like in the future? CMS is proposing some pretty significant changes to telehealth services in the 2022 Proposed Rule:

      • Assuming that certain services added to the Medicare telehealth list remain on the list through the end of 2023, CMS is proposing to collect data to determine whether services should be permanently added to the telehealth list following the COVID-19 PHE. The proposed rule for 2022 would limit the use of an audio-only interactive telecommunications system to circumstances where the beneficiary is not capable of using, or does not consent to, the use of two-way audio/video technology.
      • CMS is seeking comments on whether additional documentation should be required in the patient’s medical record to support the clinical appropriateness of audio-only telehealth. Also, whether Audio-only telehealth should be precluded for some high-level services, such as level 4 or 5 E/M visit codes or psychotherapy with crisis and they are taking comment on whether an interval other than six months should be required for audio-only behavioral health services and of course, if there are any additional necessary guardrails.

There are also several proposed changes to Telehealth Services for Mental Health:

      • The proposed rule also would remove geographic location requirements and allow patients in their homes access to telehealth services for diagnosis, evaluation, and treatment of mental health disorders.
      • CMS proposes requiring an in-person, non-telehealth service for mental health services within six months before the initial telehealth service and at least once every six months.
      • The proposed rule permits Medicare to pay for mental health visits furnished via telehealth by Rural Health Clinics and Federally Qualified Health Centers. Currently, RHC/FQHC’s are not allowed to serve as authorized distant health sites after the PHE’s.
      • It would allow payment for behavioral health services to patients via audio-only telephone calls from their homes, including counseling and therapy services provided through Opioid Treatment Programs.

Understand the Past, Examine the Present, Look Forward to the Future

Because it’s widely predicted that telehealth is here to stay because of its proven benefits for patient care, we need to plan accordingly. And to do that, we have to understand the past, examine the present, and look towards (and forward to) the future of telehealth services.


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Stay tuned for part 2 of this 4-Part series, “Part 2: Telehealth Changes: The Impact On Workflow.”

Questions or Comments?