Telehealth Insights for Compliance and Auditing Professionals
Tune in to our latest Compliance Conversations interview with Maya Turner, a seasoned expert in the healthcare industry with close to 30 years of experience in auditing, coding, billing, compliance – you name it.
Maya shares her perspective on the evolution of telehealth, especially in the context of recent changes and challenges brought by the COVID-19 pandemic.
Maya and CJ also discuss:
- Significant changes in telehealth regulations from its early days to the present
- Telehealth’s crucial role in addressing healthcare disparities
- The importance of proper documentation in telehealth visits
- Compliance issues and risks that auditors and coders should be aware of
We welcomed an unexpected guest during the episode – Maya's dog! See if you can hear the friendly canine interruption.
Maya is a seasoned certified coder and auditor, boasting nearly 30 years of experience and subject matter expertise to many coding compliance subjects; she especially is sought after for her in-depth knowledge base of pro fee multi-specialty practice, primary care, hospitalists, telehealth, in-patient and SNF billing.
She is also a published author, having written articles for AAPC and HCCA, and currently is a part of the ACDIS Leadership Council. She showcases her unmatched three-dimensional thinking in complex subject matters, Mayas’ success is marked by her clear and well received presentation style, reflecting her profound understanding and expertise. Maya also has a consulting company, Turner Expert Consulting Services, LLC.
CJ: Welcome everybody to another episode of compliance conversations. I am CJ Wolf with Healthicity and today's guest is Maya Turner. Welcome, Maya!
Maya: Hello, everybody! Hope everyone is having a great day. It's good to be here.
CJ: We are so excited to have Maya. She is a bundle of joy. I've attended some of her presentations live before she got great personality and great expertise. And Maya, before we kind of jump into our topic. We'd love to hear a little bit about yourself how you kind of got into what you're doing, you know whatever you feel comfortable sharing.
Maya: Wow! Well, I have been around for close to 30 years. I started in, a long time ago...
CJ: And you started when you were three! We get it!
Maya: I'm actually 51 years old. So yeah, I've been around for a while, and I started out in the dental field. I started out working in dental doing some claims adjudication and then I wanted something more. And so, I found myself getting involved with the medical piece. So, I took some classes. And then, you know, I got certified, and then I found myself to be in an office manager position, and then I got into coding. But before I did all of that, first I wanted to adjudication for claims that I wanted to adjudication for medical claims and dental claims, and then I got into coding. Well, first I got into billing, and then I got into coding. So, you know, it is a kind of a building a relationship because I was posting payments and things like that. And I think when you're dealing with that kind of thing and you understand off that facets of both sides of the coin. It really makes it more transparent for you when you're hearing and seeing all of the kinds of gaps and problems and stuff so you can look at it from all sides.
Maya: Then I got into education for my organization, and we have close to 1,000 positions and pretty much every specialty you could probably think of. So, you know, when you think about all the different specialties are out there and then they're looking for someone to provide education you stop wanting to read books for pleasure because you're always reading books for work. So, you're just like, okay. So yeah, I kind of got into that. And then, I started speaking at different venues like HealthCon and Healthcare Compliance, Compliance Institute. Speaking at local chapters in that regard.
So, it definitely makes a difference to being well rounded and kind of understanding all of the people that are involved and the areas that they're involved in it really makes it easier to kind of relay the information that's come into them.
CJ: Yeah, I love that. That's why we kind of ask this question because we all kind of come from different backgrounds, and it's I love hearing kind of the journey. And then we all kind of end up in this space, and it's cool to see how we've kind of ended up here.
Maya: Right? Yeah, definitely. Because I've been to a couple of your sessions too, and I'm like, "Oh, my gosh!" And so, it's to be in a realm, and to be on a podcast with you is very much an honor.
CJ: Ah! Thank you!
Maya: And I've enjoyed having the opportunity to talk to some folks about telehealth today.
CJ: Awesome! Well, thank you so much. Yeah. Now, everyone, Maya is an expert in lots of different areas. But for today's topic, we thought it would be interesting to talk about telehealth and we'll start with, let me start with asking you this question Maya. You know, before COVID telehealth was one thing, and then now we all lived through that and saw maybe some of the advantages, maybe some disadvantages of telehealth. And now we're living telehealth in a different way. Well, what do you think are some of those biggest differences between telehealth when it first started and today because you've seen that whole journey?
Maya: Oh yeah! I'm trying to keep my answers, kind of condensed because there are a lot of things and just to give you a scenario, I was asked to speak at INAHIMA and AHIMA chapter and we talked about telehealth and some of the problems that we have and how some hospitals could fail because of the lack of the communication, the lack of the technology, the lack, the lack, the lack, right?
Maya: And I mean cause it was the lack of everything, especially if you were dealing with a small budget, you weren't part of a larger organization. You know, those privately owned hospitals or those privately run hospitals kind of suffered from that regard, because they didn't have the technology in order to move forward. And that was November literally. That was November of 2019, COVID, March 2020. So, everyone who was part of that meeting was like, "Oh my gosh, Maya, what did you do?" I said; "I didn't do anything!" It was just like life thing for a lot of people like COVID just hit, so to hear, you know, what happened before and like the first telephone call for or the first telehealth visit was back in 1966 and then the Jetsons had a barbaric created this phone tech. So, you know, you're just like, "Wait a minute! Did Hanna-Barbera kind of talk?" I think Hanna-Barbera is like behind Apple, some people from Hanna-Barbera should be talking to Apple because I think they kind of predicted a lot of the things that make it convenient for us today. But in any case, talking on the phone, seeing pictures on the phone, I don't know. Jetsons may be before a lot of people's time, but.
CJ: I was going to just say, you know, you and I know Jetsons, but some of our listeners are probably wouldn't know what we're talking about!
Maya: You know, but I mean, if you are younger than 30 and you haven't heard of the Jetsons, maybe you can find it on YouTube. But it's, you know, that started back in the 60s that kind of talked about some of the futures and some of the conveniences we have today. So, it's really kind of crazy, but getting back to the point, as far as you know, what's happening today I think that they're catchup, the telehealth and the newness of telehealth kind of catapulted the necessity for people to be seen remotely.
And the transition from the beginning of COVID to today is that because it was so new, everyone was chasing how to regulate it. Now that COVID has kind of declined in the cases and it catapulted a lot of needs. It kind of introduced a lot of social determinants of health, where a lot of people, they found that a lot of people didn't have the resources to take care of themselves or get to the doctor, till now, the OIG is regulating, and auditing everything that's related to telehealth and some things that had been issued when the PHE was first issued by Jose Pazera and now, you know how it's changing. You know, there are a lot of things that have come out years later regarding telehealth.
So, a lot of companies may be self-reporting because of this issue. So, the regulations have been chasing telehealth but it never was really simultaneous in time which kind of makes it a challenge for any healthcare organization to really kind of stay ahead. So, it makes it, you got to be cognizant of some of the regulations that are out there and how it's going to affect the revenue being kept rather than the revenue being, you know, returned by the self-requirement.
CJ: I've experienced some of that kind of what you just explained as well. You know a lot of my clients are, there are just like; "Can I do this via telehealth? Can I do this code? Can I do that service via telehealth and what do I have to do?" And you're spot on like everyone wants to do it. Now, as a consumer, as a patient myself, if my doctor's offering a telehealth visit, I'm all over that because I don't want to drive and waste time and this and that. And most of the things I need to be seen for I can do via telehealth and so it's like this is here to stay and this is what we want.
Maya: Right! Oh, yeah! And you know what's really interesting, too? Do I call you Doctor Wolf, can I call you Doctor Wolf?
CJ: CJ is good.
Maya: OK, CJ. OK, well, tell me, CJ. All right! So, what's really interesting, CJ, is that when telehealth first came out, CMS stated that they had some things that were; OK this is only for telehealth and now as of 1/1/2024, they've issued things that were provisional, temporary, and permanent. So, if we knew that it was going to happen, we just Congress had a bill they weren't sure if they were going to pass it but now that they see that the venue of a lot of people being scared or not having you know, the means to get to meaning transportation, meaning SDOH. Now, a lot of things that we thought were going to pass away as of 12/31 of 2024 are now permanent on the Medicare telehealth listing, including annual Wellness visits. So, and those could be done via telephone.
So, I think, you know, we're at a day and age where we realize everybody can't drive to the doctor. Everybody doesn't have people to help them get to the doctor, so the fact that it's being recognized as a convenience and permanently as something that is affordable and allowable is definitely something that is a plus for our healthcare scope.
CJ: Yeah! And what you and I may have not imagined happening five years ago. It's happening now! And I think I'm interested in what you think, that the amount, the types of services that are going to be allowed by telehealth will probably only increase as people get used to it. As the quality improves, as medical care improves. So, I think that's really just kind of going to be the future for a lot of things.
Maya: I do. And I think another thing that makes it so profound is that I was actually listening to a telehealth with Terry Fletcher who's kind of like the guru; her and Christine Hall kind of like the gurus of health. And I enjoy speaking with them immensely. And I think she mentioned that as of 2025, some of the telephone calls are going to be deleted, but there also is going to be a specialty code specifically designed for telehealth. Yeah! So, providers will be able to get credentialed through CMF with that telehealth alone because you got all these telehealth entities popping up all over the place. But there's some specialty for them. And I think that that's important from a credentialing perspective to realize that and if you know, it'll be easier to track based upon you know, the state licensure requirements and understanding how their credential is going to make a huge difference. So, the fact that that's happening let you know that it's here to stay. It's not going anywhere.
CJ: So let me ask you this, you do a lot of education with all these providers that you work with. What kind of provider documentation issues, maybe from a compliance perspective or whatever; what are documentation, right? A lot of our listeners want to know; "What are the docs or the nurses have to document?" What are those issues you're seeing in telehealth?
Maya: I'm seeing a lot and I won't make anyone cry. I have like, I don't think I should make anyone else have nightmares, I think it should just be limited, but I will say this; documentation and the consent is a big deal and the type of telehealth as it is you have to say if it's audio or if you have to say it's audio-video that is going to make a difference because that also gauges which kind of modifier you're going because there's a modifier for 9093 for audio-only.
CJ: That's right!
Maya: There's a modifier for audio-visual. And so, even though they're saying some modifiers are going away, I'm not really sure if they are. But if they are, then the consent and the nature of the presenting problem should be extremely evident, and it can't be, you know, for things that are inherent to a service that you would already test that you would give results for and it's got to be good and that goes above and beyond of that. And because telehealth is always driven by the nature of a problem, it can't be all patient is calling here for their results and you're trying to bill for a telehealth visit and their consenting for that. You know, to me that almost is borderline you know that you have the patient has to call. So why would you ask for a consent because it's related to a visit.
So, I think that and then the fact that most of the telephone calls are trying to be billed as separate visits even though they were seen within seven days. So, you got issues with that. And I don't think that a lot of system edits in that regard are capturing that. I mean, I think that's a different thing altogether, but that's the main thing is that making sure they understand the regulations behind telephone calls versus inpatient or inpatient or even, you know, office business, all of that stuff makes a difference. And the consent behind and the type of visit that is being performed.
CJ: Absolutely! We're going to take a quick break everybody and then we'll be right back with Maya.
Welcome back everyone from the break! We're talking with Maya Turner. Wonderful person and an expert in all sorts of coding and compliance things. And we're talking about telehealth.
Maya, we were talking about some of those documentation and compliance issues. I foresee it and be interested in your thoughts that you know, because it's going to be increasing and we've seen OIG already say this, the scrutiny will be increasing. So, audits will be increasing, right? So, from Telehealth 2024 going forward, what do you advise practices to be mindful of to kind of avoid some risks? What are those?
Maya: I think the biggest risk is negating medical necessity and the reason why a patient is there for a visit. I think that's, Terry mentioned that last night and I kind of talked to her in regards to all of this because she's been out there kind of engaging people about telehealth and I think because we're at a day and age where it's about convenience, now we need to say why it's inconvenient for the patient to come to the office, noting that in the note, the patient can't come today due to transportation problems. The patient is seen today via telehealth due to illness or income, you know, sprained ankle or something of that range, so documenting why the visit is necessary is really going to negate why they were seen remotely versus in person.
Another caveat to all of this is that they're going back to the original code descriptors. I think that there were some allowances that were allowing new and established patients to receive these types of services, but I believe they're defaulting back to established visits for telephone calls, which is important, you know. But the bottom line is to unravel the string, right? Unravel the string so that people understand the what, when, where, why and how, literally. And we learned about the 45 W's and the H like a long, long time ago but I think it's still very relevant, right? I don't even know just like they stopped teaching cursive, you know, but anyway.
CJ: Yeah, you're right!
Maya: I'm not going to go there, but yeah. So, I think that you know, understanding that the what, when, where, why, and how and placing that in the documentation and incorporating that as part of the consent. I think that's going to be the biggest takeaway because it's not going away and we need to know that it's going to be audit-proof, so you may get the money initially, but you want to keep the money.
CJ: Exactly! They're going to come after, they're going to follow the money. I really liked what you said, too, about kind of the why. And you mentioned this earlier, kind of the social determinants of health that's such an important for us to recognize in healthcare in general that some people, like you were saying, some people don't have the transportation means some people are bedridden. And so, can they still get some healthcare? Yeah! Through telehealth. And so, I really like kind of the way you framed that.
Maya: My dog was getting ready to come in. Sorry about that!
CJ: So good. Let's have another guest. What's your dog's name?
Maya: His name is King, but I just closed the door, so now he's looking all crazy. Like, "Why are you closing the door with me?" Like get out of here, King.
CJ: I teach some online classes with cameras on and I say; "Look, I'm not offended if a pet or a little child comes on screen, but that means you have to introduce them and tell me who they are.
Maya: Oh! Wow. Okay, well, he's outside of the door now, so I've had kind of closed it. If he tries to push the door open, then you know that he's very intentional about trying to get in here so.
CJ: He has something to say about telehealth.
Maya: Of course, of course. Gosh, I, I lost my train of thought.
CJ: No worries. Let me ask you something else. So do you ever think there will be like this universal alignment regarding telehealth for coverage? Because it seems like there's lots of variables for coverage, right? Like Medicare comes out and says what they'll do, right? They list their codes. They'll say this one can be done with audio only, right? So, they're pretty good about telling us what we can expect. But what about other payers? What about these variables for coverage?
Maya: OMG! Okay, so... That's a loaded question, CJ, so I'm trying my best to kind of stay focused. I do believe that the many variables of telehealth are going to make a lot of difference in, and I hate to say this, but uh, healthcare providers surviving because they're all engaged via contract, right? And because they're engaged via contracts, they make the providers take a smaller amount, but then you add all of these complexities about how to get paid and then what's allowable and what's not, it makes it a problem.
So, there are a couple of payers who just recently introduced something, I believe, Cigna, Aetna, and United Healthcare have all been very transparent of what they would allow. UHC is literally parallel to CMS. Yes, but Aetna and some of them are just creating their own guidelines. So, they're not regulated to do anything other than what they want to do, The only ones regulated to stay within CMS guidelines that are the ones that are contracted by State and Medicare policies. So, those are the ones that you want to stick with, but it's the driving or the underlying component that I really would like to make mention is that make sure that your organization has a policy on which ones you're going to follow, right? For CMS guidelines to be utilized because those are the ones that are going to create less risk if you follow them, right? And the point that I was going to make with the SDOH, is that a lot of those SDOH's fall under the permanent telehealth listing. So, you know, a lot of them can be done via telephone, like the G-0136. Those can be done via telephone because I believe some of them are time-based. So, a lot of them, of the new G codes that are out there, there are a lot of them that are out there that are on that list. So, if you follow CMS regulations then you should be within good standing to keep your payment, but if you don't, and you kind of go willy nilly and you forget which policy is what and you kind of forget which ones you're submitting the payment for it, then you're going to be more at risk.
CJ: Yeah! So, I'm kind of curious what your thoughts might be on, you know, so now that these E&M guidelines have changed from 2021/2023 where you can bill off time or medical decision-making, do you see any issues with providers via telehealth getting those level fives, those highest levels for high medical decision making via telehealth? Meaning if it's high, should they have come in, right? I don't know if I'm making sense with this question.
Maya: Oh yeah, I totally, I'm so there with you, CJ. Trust me and I think it goes back to the why, you know if you're going on level 5 and you're only complaining of nausea, not nausea, but just a fever and a runny nose, then I don't think you need to be spending that much time building the level 5 and one of the reasons why they made the changes so that the disparities between the levels of service can be more, you know, across the board, not because you're a pulmonary and an intensivist and you're being level fives because everybody is dealing with some sort of severity of illness that's respiratory, right?
So I think it's going to be based upon the medical necessity and the benchmarking, because the benchmarking is tracing, you know; "Okay, well, all of your patients had level fives, but you know what was the nature of the presenting problem?" To me that's going to gauge everything and how it's documented one and two, how it's being managed. So you know if they're not seen within the next 24 to 48 hours. And you're building a Level 5 then was it really a Level 5? And they're going to be tracing that. So, you know, I just feel like there's. Just a whole lot of documentation that needs to be monitored. If you're billing on time to negate why you spent so much time that goes back to...
CJ: Yeah! It's kind of like, we've heard, you know, even before telehealth, let's say before telehealth was an issue because you and I have spent a lot of years in doing this. You know, we heard documentation, the importance of documentation like even just when a patient is being seen in the office. Well, now you still have to do that documentation, but then you have to add on all this telehealth documentary.
CJ: So, it's good for the patient, it's good for quality of care, but it also puts a little bit more burden maybe on those who have to document.
Maya: Well, I mean, and that's just it though, I think if it's, I mean, and I you know, I was listening to Sean Weiss and his, the clients guy with his group and one of the coders listed, you know, if it's worth the extra money, then it should be worth the extra lines or the extra paragraph because you're...
CJ: There you go!
Maya: Yeah, it's you're spending the extra time to do that and you want to get recognized for your time, but everything that if you're doing is that phrased, right? Or if it's through a template, then how do we know that you spend that extra time doing it? If it's worth the extra money, then you should put the extra effort behind it.
CJ: Yeah, and I'm really interested, you know because some of these like settlements and these compliance settlements and stuff lagged behind a few years. And so, I think we're going to start seeing more kinds of settlements and cases come out. It'll be interesting at that point to kind of dig deeper into the legal papers to figure out what...
Maya: Oh yeah!
CJ: Right? It's like we don't see a lot of those yet, but I think they're just right around the corner.
Maya: And to be quite honest with you, I think some of the biggest issues that we see is that there's not a lot of across-the-board regulation behind it. Everything is significant per state and like your requirements, I mean you do have some states that are collaborative in that regard. But you still have to be licensed within the state.
Maya: So when you're dealing with across-the-board guidelines or seeing patients across the board, you know the guidelines for 23 are completely different than the guidelines for 2024, meaning or it was driven by where the patient was. Now it's where the patient is being seen. It doesn't mean where was as far as residing where they live. You know, now where the patient is being seen. So, if you don't have licensure for those requirements and you're getting paid and you're thinking that the old 2023 guidelines come into play, then you're going to have some self-reporting and there's going to be some, some issues in regard to that. So that's going to be a whole different ball game if you're not up to date on state policy, and there should be some references that you should be looking at continually for that.
CJ: Yeah, that's a great point. You know, we're getting kind of towards the end, but I have this other question that I want to spend some minutes on. So, you and I have, you know, had the privilege of being around for a while, but what would you say to someone who's brand new, who's just learning about telehealth or maybe they've just been given the assignment about telehealth? Or they're in a practice that's going to do exclusive telehealth. Are there specific resources, websites, podcasts, audits? What do you think are some of those resources for new people?
Maya: Well, one, you got to know what your state guidelines are because some states don't allow for synchronous communication, asynchronous communication which is the storm forward. So, you got to know which states allow that and if you find that your practice is doing a lot of that then you should know that. The website is Center for Connected Health Policy, that's one. The HHS website has one specifically for telehealth; Telehealth.gov. The podcast obviously Healthicity is one. Terry Fletcher has one, Healthcare Inspired is definitely another one. All of these different venues of podcasts, but the biggest one is CMS and that's where your money is going and that's 60% of your patient-payer mix, then you need to know what CMS guidelines are and you know, make yourself familiar with what's allowable via audio, video or versus just telephone alone. So those types of things are definitely going to be helpful in your success and being able to keep payment.
CJ: Absolutely! And you know, I think this topic of telehealth is also being addressed at a lot of these conferences, like the ones you mentioned, at HealthCon and HCCA, and I'm sure there's others, AHIMA probably does a lot on this too...
Maya: I mean, I'm sorry. Go ahead.
CJ: I was just to say so stay involved in those conferences, but yeah, please go ahead.
Maya: Oh my gosh, I believe that you know, keeping yourself in a box and in a bubble, you know, that's not going to help you at all. You really need to keep yourself with more public platforms that allow for communication and tangibility with the conversation, you know, you need to have that to understand what other people's thoughts are and don't be afraid to ask questions. I think that's part of the problem and you know some officers are really kind of, you know, in a bubble, but the more you reach out, the more you're going to learn, the more you stay to yourself, the less you're going to learn. And the more you're going to be at risk. So, you know, I mean, those kinds of things are going to be really especially important and moving forward and being within you know compliance.
CJ: Yeah, I love that attitude. What you've kind of described, I say, is lifelong learning, right? "So, I got certified! Okay, I'm done!" No, it's like these. And these services are changing. The requirements are changing. I think that's what's kind of exciting and fun about being in encoding and compliance is because it keeps things fresh. So, I love your attitude about just keep learning.
Maya: Yeah, I think you know, and I don't want to promote anything anybody are having for bad habits, but the more you learn, the more you drink! Well, at least you want a drink! You know, you got to find something to vice all of this and to finagle through all of this, because if you don't have anyone to talk to if you don't have any venues to kind of get, you know, the answers that you need, you're going to drive yourself crazy. Because if this is something that you can do alone, you're extremely wrong about that. And you got to make yourself vulnerable to understand that you can't do it alone and to seek help when you need it.
CJ: Yeah, you know, cause a lot of us feel like we're the only one in our organization and that may be true, but you have peers in other organizations. And so, to this point about conferences and staying connected, find those peers whom you know you get along with and who kind of mesh with you, and then you know help each other.
Maya: Absolutely! It's imperative. I mean, you can't do this alone. And if you think you could do this alone without any help, you are very sadly mistaken. And you're not going to be in this field for a long time the biggest plus in our profession is the camaraderie and working with people that you know that you trust or that you can trust for you to be vulnerable and for help and to get the solutions that you need.
CJ: Maya, it has been such a pleasure talking to you. We're kind of out of time. Here we'll probably. Have to have you back because you've got other topics we could talk about, but it's been a real pleasure, and thank you so much for your time and expertise and your personality.
Maya: OK, thank you! I enjoyed being here.
CJ: Awesome! And thank you to all of our listeners. We really appreciate your listening. If you're liking these please, hit the like and subscribe, and share with friends and colleagues and if, we always say this, if you know of anyone who you think might make a good guest or if you want a certain topic discussed, please let us know because we want these to be useful to you. So with that said, happy compliance, everybody until next time.