Episode 117:
How Telehealth and Chronic Care Management Drive Modern Reimbursement

Episode Transcript

CJ Wolf: Hello, everybody. Welcome to another episode of Compliance Conversations. My name is CJ Wolf with Healthicity, and today's guest is a return guest. It is Maya Turner. Maya, welcome back.  

Maya Turner: Hey, everybody. Hi, CJ. I'm so glad to be back. Hello, hello, hello. 

CJ Wolf: Yes, we're so glad to have you back. And we know you're doing lots of good things. We were talking before we started how we're kind of like always passing each other at conferences and this and that. And now we actually have a chance to sit down and talk a little bit about some substantive things. So I'm so glad that you're here. 

Maya Turner: Yeah, absolutely. It's been a lot. It's been a whirlwind. So much has changed since the last time I've been here. Goodness gracious. to the National Advisory Board. I also work as a virtual instructor-led training, which is through AAPC. And I have gone off on my own. I am now an independent consulting company. The last time I was on, I was working for my prior employer. Now I am flying solo. And it's been a... A different experience, but a very rewarding experience. And it's all about stepping out and doing something and being brave. And now I get to explore these wonderful topics, especially the one that we're going to be talking about today, to provide some insight and maybe some clarity for folks who may not understand about it. 

CJ Wolf: Yeah. Well, good, good. And it's good to know that you're kind of on your own, your own consulting services. We'll make sure that in the show notes that you get us a link to that so that if people are interested in contacting you, they have a way to reach out and ask you questions about what you do. Oh, I would love that. Hello. Good. Okay. Well, awesome. Well, so we'll do all that behind the scenes and show notes and that sort of thing. But today we wanted to talk about... value-based care and a little bit about telehealth, maybe how those go together. And maybe just to set the stage, you could tell us a little bit, just in your own words or your understanding, what is value-based care and why should someone even need to know what it is? Like, why is this even important? 

Maya Turner: You know what? There's a lot of things that I can say about value-based care. And I think there's many terms that people use But it really is peripheral care outside of the office, whether it's ongoing or if it's starting from. Thank you so much. things are types of value-based care and the list goes on and on. But I think the biggest takeaway for me is that the providers who are managing these patients can now create value for the services that they're already doing, um, post-hospitalization. And you would be so surprised about how many providers who are actually doing these services don't even know that they can build them. So, you know, I'm standing on my soapbox, uh, to say, get paid for the work that you do. And there are people who can help you navigate this process. And I, and it's just, um, a really good thing because the value of the dollar for the physician is going lower and lower, but they're adding more services as the dollar goes lower for the physician to capture these types of services to enhance the revenue in their office. 

CJ Wolf: That's a great kind of summary. I deal with clients all the time in these spaces as well as you are. And we've been doing this a long time. So let's just kind of as painful of it as it is, let's go back to when I were 12 years old or whatever. So let's look back 20 years. A lot of codes, a lot of those services that you mentioned, there were no codes, chronic care management, et cetera. And Providers just did those services because it was good care and it kind of got lumped into an E&M code that they did a week ago or that they're going to do in two weeks. And, you know, in the last 10 years or so, like, you know, I think it was 2015 when the chronic care management program. final rule came out from Medicare. And then all of these other services that you started to mention, they're now recognized with codes, they're being paid. And these, and like you said, some physicians and practices might not even know that you get paid separately for these, because if you're like us that have been around 30 years and you're just basing your knowledge off of what we did 20 years ago, you'd think, yeah, there are no codes, but there are codes and that list is growing. Yeah. Yeah. So, Yeah, I think you're spot on. Another one, I don't know if you'd put it in this same category, but the advanced care planning code. Oh, yes. Right, where as you get older adults and doctors are trying to do good by them and making sure that they have advanced care planning, meaning they have power of attorney or they've thought through will or those, not that the doctor just makes those decisions, but he offers the conversation and there are codes for that now too. Yeah. 

Maya Turner: Absolutely. And the advanced care planning came out in 2017 finals, 2017's final rule. And then there were, I mean, and to be quite honest with you, there are a lot of codes that have been around forever, right? I mean, and it's just now being tagged this value-based care, but it kind of coincides again with the care that's outside of the office or outside of the visit. So think about transitional care that came out in 2013, you know, so we think about all these different things that are kind of tie it together. And then we think about how this can add value, like you say, to the office. But physicians are just like, well, well, well. And they don't think about the return on investment for consultants like us to say, well, let's optimize your revenue. Well, I do that all the time. Well, duh, you should be billing for it, you know. And then they get concerned about the patient's out-of-pocket expense. But is the out-of-pocket expense for the patient going to outweigh the quality of life that you're providing? And the answer is no. So you should be able to bill for these services confidently with the patient's consent, wink, you need patient consent for some of these, to provide these services and make it so that it's a collaborative effort of patient care and the quality of life that's surrounding that care that the patients are receiving. 

CJ Wolf: Yeah. Like when I talk to people about chronic care management, they see all the things they have to do. And to your point, kind of that consent is one of those first things, right? Where you might have an initiating visit of some sort. That's a good opportunity to also get the patient's consent. It can be verbal, right? It doesn't have to be in writing, but you have to document somehow that you did get consent and you let the patient know that, look, there could be cost-sharing responsibilities on your part, um, and, um, only one practitioner can build chronic care management at a time. And, you know, so kind of all these kinds of disclaimers, um, have you been like successful in helping people get over that fear of, of that consent discussion?  

Maya Turner: You know what? I mean, and I'm gonna be honest with you. I, um, I definitely have been able to, um, to provide some insight. And I actually helped design a couple of programs through my former organization in regards to that. I helped design their ACO program to help them implement this process. And technically, what typically happens is that they are... able to do a lot more once it's structuralized for the ancillary staff to help assist with that process. They have to explain, and the vendors that are out there, it has to be the ancillary staff that's educated, but the vendors who are assisting with that, there has to be some collaborative communication. There has to be the documentation. There has to be a a process that's involved. And once you get that process in place and everybody, quote unquote, is educated like we do, CJ, you know, then it becomes a more streamlined process and patients aren't afraid. They're not forced to do something that you can't explain well because you have people who are assisting with that process. So, you know, all of those things need to come into play when it comes to that. Yeah. 

CJ Wolf: Yeah. Yeah, good point. And I think that you hit on a really important point that, well, let's just kind of stick with chronic care management for a second. Like most of those services are done by the ancillary staff, right? They're done by clinical staff, like maybe a nurse or somebody who is probably already doing that management, right? Like they're reconciling medications and they're, oh, did home health come by yet? No, they didn't. And, you know, all these phone calls and all of this kind of coordination, right? the doctor's not necessarily doing it, but it's under his or her direction. And there's appropriate ways to make that work. And, you know, once, like you said, once the process is set up, the doc's involvement still needs to be there, but a lot of the work is done by the clinical staff. 

Maya Turner: Yeah. I mean, and, and again, I, I'm a firm believer, and we all know this, that the ancillary staff, the front desk staff outside of the physician's encounter is really the strength of the provider. Because at the end of the day, they're going to remember the care that they received when they were in the room, but they're also going to be remembered how the way that they were treated. So the patient feels that they have been paid attention to and their health is catered to them. They feel like they're being treated like royalty. Right. But then when you think about how, you know, it's kind of somebody kind of dropped the ball and then they're looking like there's no empathy or empathetic approach of them dropping the ball or even no apology, then it becomes difficult. a lost cause, to say the least. And so we need to also place value on the ancillary staff, the ancillary care and the collaboration for any type of vendor who's working with them so that, you know, the end of the day, the patient feels valued and feels that it's worth paying for, you know, because there is going to be some sort of out of pocket expense. But you have to make the patient want to know that it's worth it so that they'll be willing to pay for it. 

CJ Wolf: Yeah, no, good point. So tell me how telehealth integrates into all of this. 

Maya Turner: OMG. Okay. I'm trying not to, I mean, I'm trying not to get excited because I think, you know, with all this stuff that's happening with Congress spoon feeding us, oh, it's going to be for September 30th, but now it's March 30th. You're just like, seriously, can we just get something that's just going to be forever and not just spoon feed us? And it's all about funding, but I won't even go into there. I'll get off my soapbox there, CJ, I promise. And I said I would behave today, so I'm sorry. I'd rather ask for forgiveness rather than for permission. Totally understand. Yeah, so- I think telehealth comes into a big play because, you know, a lot of this value-based care is not, it's always driven by the initial visit, but it doesn't always have to happen in the office. And that's what's important. Like we talked about the ancillary staff. We talked about transitional care management. We talked about remote patient management. We also talked about, you know, these, you know, advanced care planning. Based upon the current rules, they can be performed up to September 30th, some of them. But advanced primary care management, remote care monitoring, chronic care management, all of these services are not considered telehealth. They are considered services that are generated by phone calls, not necessary audio video visits, and they still are payable without telehealth care status. 

CJ Wolf: Exactly. And that's important for people to realize because it's not contingent upon the telehealth rules. They can take advantage of this right now and not be limited to originating and distant sites. This is all contingent about consent for treatment. That's it. 

Maya Turner: Yeah, exactly. Because a lot of like with chronic care management, the majority of those services are like phone calls and emails and communication, right? So, and it's not always with the patient. It could be, I'm trying to coordinate that your home health does come by your house this week. Absolutely. These drug interactions are taken care of or, right? And so it's people calling around, it's people emailing around, it's communicating. And you're right. It's not, in that case, it's not what we think of as falling under, you know, telehealth coverage. These are activities that are a part of the codes, irrespective of health. 

Right. Irrespective. I mean, online minutes, phone calls. I mean, and if they're audio video, then so be it. But they are not considered telehealth codes. Some of the codes that are E&M, like the advanced care management, that is not advanced care, advanced care planning, I should say, that is telehealth that can be done. But there's also a contingency for those advanced care planning codes where you don't have to, this could be something that could be done with the caregiver and it doesn't have to be over the phone. I mean, it doesn't have to be audio video. So I take that back. It's not a telehealth driven code. It can be, but it can be services that could be done on over the phone with the caregiver and or the patient themselves. So, you know, there's just so many opportunities that people are failing to understand when it comes to these types of services that can be provided for the quality of life for the patient. 

CJ Wolf: Yeah, yeah, great point. Let's take a quick break, everybody, and we'll be right back and we'll be asking some more questions. Welcome back from the break, everybody. We're talking to Maya Turner about some of these services that providers you know, historically have done just kind of without payment, separate payment. And for many years now, there's been recognized separate payment and codes for a lot of these kind of ancillary staff services, kind of coordinating care and management and those sorts of things. And we were talking about telehealth a little bit before the break. I wanna ask a little bit, Maya, about, is there risk? So like if you're a provider or a practice that hasn't been doing these, types of services, or I should say billing for these types of services, is there risk in becoming heavily involved in this? And then what are the benefits? 

Maya Turner: Well, the benefit, well, let's first answer the first question, because again, I'm like, I'm so excited about this because I really do think that, uh, providers really need to understand that this is an opportunity. This is a high-level opportunity to create value. The first thing is making sure that you're documenting appropriately. The risk of compliance and documenting consent is important. And then, you know, once the consent is made, you know, there should be some clarity about the scope of the services. Someone would be calling and that kind of thing, or to check on your care. That's the first thing. The risk that's involved is making sure that the documentation supports the level of services provided. So if you're billing and that the code requires 30 minutes or the code requires 20 minutes and you're going over that, make sure that each encounter that's related to this value-based care, whatever type of service it is that we discussed, the categories of service it is, that it's documented, right? So if you're monitoring a patient for a chronic condition and the only documentation is for a non- chronic condition then you gotta be really careful about how that's being monitored and for the services that you're monitoring them for. Because in most instances, these value-based codes are based upon chronic conditions that require additional management. If you're not addressing a chronic condition, then you need to be billing the G20 to 11 that indicates longitudinal care, which is ongoing. But if there are chronic conditions for advanced primary care, remote patient monitoring, then it becomes chronic, then you need additional consent, then you should be billing as well as documenting the appropriate diagnoses to negate the kind of care that you're providing for the patient. 

CJ Wolf: Yeah, that's such a great point. And like with chronic care management, you have to have two diagnosed chronic conditions, right, that are anticipated to last 12 months or longer or until the patient, you know, Right, right. Yes. has to be met as well, right? 

Maya Turner: Yeah, and then there's also principal care management services, which is three months or more. So, you know, and when you think about, you know, these types of services, and if there's education, hint, hint, wink, wink, me and CJ, hello, to provide this kind of advice for you to take advantage of these types of care, then I really do believe that there is an opportunity for providers to really capture that, especially when you're dealing with post-hospitalizations. Post-hospitalizations and the annual Medicare preventive visits, those are the most opportune times to capture those types of care because you are typically monitoring a moderate to high severity level of care. based upon a post-hospitalization. And then, and with the Medicare visit, unless you're some 70 year old bodybuilder with zero body fat, you're going to have some sort of chronic conditions that are being managed. So in those particular instances, you need to take advantage of these types of care, not to mention social determinants of health. We haven't even talked about that, you know, about how, I mean, and there's so, like I said, there's so many opportunities, you know, in regards to this and, you know, the community health integration. I mean, there's, I can't talk about all of this in one setting. It's just so many. And I just think that if providers were aware of the amount of missed opportunity, I think that there would be such a turnaround in the usage of these codes. It's just that a lot of providers are just failing to realize the return on investment to have somebody come in to tell them about all of this stuff. 

CJ Wolf: Yeah. And I think some of them fear too, like, do they have the internal structure and resources to kind of do everything that's required of that code? So like, again, sorry, I keep going back to chronic care management because that's one I'm very familiar with recently. And there's this requirement of the patient has to have 24-7 access, right? So that means they can come and see you 24 seven, but they should be able to have a phone number or some sort of way of contacting 24 seven access. And so that throws a lot of providers like, whoa, wait, I don't know if I can provide that. And so some feel like they have the infrastructure to do it. Any thoughts on those kinds of requirements if providers are a little bit afraid of those?  

Maya Turner: Oh, yes, CJ. And you know, what's really interesting is that even with those chronic care management codes, you have to be available for 24-7, but the max time for those codes to bill it is 20 minutes. So it's a time-based code. And so when you have the principal care management, that's 30 minutes, the chronic care management is 20 minutes. So you really have to keep in mind that So, yeah. You know, the advanced primary care codes that came out in 2025, those codes are not time-based, but they do bundle a lot of the services that would traditionally be unbundled. Like it bundles traditional transitional care management, and I believe it bundles with chronic care management services. But in the same breath, you're going to build one or the other, but you still... think about the amount of time you're spending and then think about the time that you're using to manage. So what's going to take precedence? You got to make some decisions. That's why consultants like us can advise you on how to do that. So, you know, there's just so much, so much going on.  

CJ Wolf: Yeah. So are these, these services we've been discussing, are they only for primary care providers? What about specialists? What are your thoughts on those? 

Maya Turner: Well, Transitional care is for everybody. Principal care management is for everybody, but only one provider can bill it a month. So it's kind of like the preventive care visits, you know, like first come, first serve. Oh, sorry, I can't do it. Oh, so you're mad. But I mean, some of them are primary care. Some of them are just one provider base. And a lot of times you just have to check your edits to make sure who's gonna be billing to see, or your eligibility to see if you're able to bill for their services. But the most important thing is that to know that they are available and to get consent where it's needed and to make sure that if they do overlap, that you make sure that you can unbundle what isn't so you can get paid appropriately. Because some of these codes don't overlap and you are able to get paid for both, but you just got to watch because there's a lot of edits that may hit if you try to build them on the same day. So you got to watch all of that. 

CJ Wolf: Gotcha. Makes a lot of sense. So, so you may have already kind of addressed this. I think we probably have that, you know, if telehealth has the possibility of ending, can providers still perform these and get paid? I think the answer to that is yes, but let me just confirm. Does anything change if, you know, and who knows what will happen, right? Yeah. You know, we get closer to September. They always wait to the last second to pass some, law or extension, but let's say it were to end, the extension that we have through September were to end, does that affect any of this? 

Maya Turner: It doesn't. That's what I love about this. It does not. It doesn't. You know, it's such a platform that is undervalued. I mean, and just remember that transitional care management services can be performed. It's an E&M service, so it can be performed audio-video, but it's not contingent upon audio-video. If they come to the office and you bill for it, you know, it still meets it. But all of the categories of service that relate to value-based care are not contingent upon telehealth services. They can be performed via telehealth, but it's not contingent upon telehealth services. So it will be ongoing and the list will continue to expand. It will continue forever. Yeah, exactly. 

CJ Wolf: As more and more medical studies are done to show that, look, when you have this care program, that kind of helps bridge gaps, right? Somebody gets discharged from the hospital. What do you want to do? You want to prevent them from being readmitted. So it's like, you can't just wish for the best upon discharge. There are actual things that you can do. And that's what these services are, right? These are the services that you can, that you as a provider can do to try. So number one, you're providing better care when you do this stuff to begin with. And number two, you get paid for it. So, I think that's really kind of the take-home message that I get from what I'm hearing you say. 

Maya Turner: Yeah, I mean, there's so... Like I said, I mean... Providers are afraid because they feel like they don't have the bandwidth. But remember, these are time based codes. So and based upon the code descriptors, you have to meet the timeline based upon it's not like a half type of deal, you need to meet the all of the minutes. But the max per month is like 20 to 30 minutes. And then anything that you go over that you have to meet the next interval. But I mean, how much of this are you doing already that you're not getting paid for? Exactly. You're already doing the work. 

 Exactly. You're doing the work, so why not? So start thinking about the return on investment. Start thinking about, okay, well, I'm not getting my money here. Maybe I can start doing this to make the work that I'm already doing worth it and that the patient is aware and I'm getting reimbursed for all of the time and effort that I'm spending behind it. 

CJ Wolf: Yeah. Such good advice. And I think... I think this is a really, really important topic because I think you are spot on. A lot of providers don't realize the opportunities here. And as you mentioned, there's new codes, right? And these things have been building over the years. And so if you haven't really been paying attention, you're probably going to miss out on those opportunities. 

Maya Turner: Oh, and I can't stress enough that, especially with the... the advanced primary care management codes because the primary care has always been the lesser of the providers who aren't specialists to see the decline in the dollar and not realizing that they can get more. And the more offices that I consult with, the more I realize that they are in a bubble because they simply feel that they can't afford it. But when you, you know, you know, solicit or not solicit, but when you, you know, engage with a consultant, you know, you get a whole new world, right? But you don't realize that it's a return on investment to engage the consultant so you could be aware of what's happening. I had one doctor's office who was getting ready to spend an entire EMR system because they got another tax ID number because that's what they thought they needed to do. And I was just like, Are you using the same system? And I'm like, well, you don't need to do that. Oh, we don't. You just saved us so much money. I was like, well, hello. You don't need to do that. So it's just, you know, self self-awareness. But then there also has to be some transparency from the offices to be, you know, to be able to engage in a consultant, because that's the only way that they're going to really understand all of this. 

CJ Wolf: Yeah, I agree with you. So Maya, I could talk all day with you about all this stuff. We are unfortunately kind of running towards the end of time. So I want to give you, if you have any last minute thoughts about this topic or maybe a different topic, anything kind of parting words that you might share with the audience before we wrap up today. 

Maya Turner: I know I'm so sad, but I'll say this. Offices need to be aware that office visits or E&M visits are not the only means of income when you're primary care or when you're a non-procedural office. There's just a lot of value based upon exploring, right? But once you explore, don't be afraid to explore more because more than likely, you're missing out on more than what you think you are if you're only billing for E&M services if you're a primary care office. Yes. And I think that that's just the biggest takeaway. And it's not contingent upon telehealth. It's contingent upon value-based care equaling the quality of life for your patients, no matter what age they are. So you have to really be mindful of the care that you're providing and the codes that you're billing to get the revenue that you want or that you're expecting. Don't expect for... your staff to, or, you know, pressuring your staff for, you know, revenue cycle management when you're only doing 10 E&M codes a day, when you could be billing 20 E&M codes based upon the value-based care alone. So think about that and engage them with a consultant. 

CJ Wolf: Yeah. I think that's such a good point. And that's kind of how we started was, you know, I was saying, look, 20 years ago, it was just those E&M codes, you know, you're your office visit codes. And so I think people can get stuck in that paradigm. And what you just described is spot on. In addition to what those, what you're doing, you're doing all this other stuff already. And you might need to, you know, you might need to boost the way you document it or this or that, but you're doing that kind of care. And so take advantage of those codes. 

Maya Turner: Absolutely. And I think, you know, don't be afraid or don't think that it's the physician practice does not always weigh on just what the physician does. If you have an ancillary staff that is capable with your oversight, because it's general supervision for most of these, you're able to perform these with general supervision and still be paid because general supervision means that you are supervising the service, but the bill goes out in your name and you are certifying that the service was performed under your supervision. So that's extremely important. And it's just a lot of opportunity. And if you haven't done so already, take a look at it and see how it benefits you. 

CJ Wolf: Thank you so much, Maya. And we are going to include your contact information in the show notes because I'm sure there are people out there listening that this will resonate with and they'll want to know how they can do it in their own practices. And so I highly recommend you reach out to Maya and get some more information on this. So thank you, Maya, for being here today. 

Maya Turner: Thank you, CJ. So good to talk to you. Yes. 

CJ Wolf: And thank you to all of our listeners for listening to another episode. As always, we welcome your feedback on topics. What other topics would you like to hear about? And if you know great speakers like Maya or guests that we should have on, please feel free to recommend those to us. Until next time, everybody, take care.