Telehealth Considerations for Behavioral Healthcare Providers: Mental Health and Addiction Treatment
[Music] so so with that we’re gonna get started as soon as I figure out how to make my slides okay so alright so in just by the way we I wanted to say we are trying to put together some future resources you know they’re the rules around telehealth are different in different spaces and so we’re working on some additional programs and additional resources and look forward to sharing that in the coming too later today and in the coming days so what I wanted to cover today is the following I wanted to just give some introductory comments about the moment in time where we find ourselves and how we want to encourage people to think about it a few disclaimers I want to talk about where behavioral health mental health substance use disorder treatment fit in in the current kovat nineteen world how much has changed in the short term for telehealth and then I think it’s very important still to go through some key telehealth definitions and concepts that need to be operationalized to ensure that even in this time where so much has been liberalized that you that that organ providers are doing things the right way so that providers get paid for them and we don’t have problems that come later and finally I want to go into some specific reimbursement issues I want to stay up front they’re gonna if for anybody there are a lot of coding billing and coding questions that came up on our last presentation and well I’m happy to take questions a lot of the detailed coding questions are not going to be necessarily appropriate although I do have some very very specific information on use of modifiers which has been a source of confusion and common reasons for denials to focus on I’ve already gotten a couple of questions in the QA about codes so I just replied in the chat that that should be payer specific so just make sure to get that in writing from your payer about which codes are being approved by the way thanks Sarah I was gonna say if you see questions because I’m not looking at the questions while I’m presenting but if you see questions you think are pertinent feel free to stop me yep so right so just a couple a couple quick disclaimers I always feel obligated to say this is intended to be informational it’s not legal advice simply by listening for this webinar my goal today is to ensure that as many behavioral health providers as possible understand how to navigate the particularity of telehealth compliance I’m going to use some California centric examples on services there are significant variation state to state and particularly just underscore what Sarah just said plan to plan it’s very important to to understand the state specific rules and the plans the plan specific rules so I wanted to just start with kind of an introductory comment before we get into the telehealth of a question that keeps coming up I’ve been getting this from two different sides the question is where do behavioral health services fit in in this period of a lockdown a shelter in place travel and work restrictions for kovat 19 so one of the things we’re seeing is that although there is not uniformity in the different public health orders being issued from state to state and cities and county and federally even even though we’re seeing a lot of missing definitions and a lack of clarity there’s no question that mental health substance use disorder treatment and all behavioral health services are very squarely considered to be healthcare operations there’s a there seems to be in many of the public health orders a clear intention to just to stop or put the pause non-elect you know elective care meaning things that are voluntary but there’s no suggestion that mental health or behavioral health is anyway not a necessary health care service another place in which this has been coming up is some companies have been asking whether what about the definition of health care workers in the family first coronavirus response act and whether whether behavioral health employees are workers they’re here to same answer the law is very vague but I think the safest approach is to assume that that that anybody working for a mental health addiction treatment or other behavioral health company will be deemed to help health care worker and so not covered by the leave protection alright so I to offer some some introductory thoughts about where we are we’re in a watershed moment in interning the challenges facing all of healthcare but it’s particularly behavioral health clients patients and staff are cancelling and refusing to come for come into programs outpatient programs further we’re running or for professional services because they’re sheltering in place and there’s been intense pressure to convert to telehealth and I’m going to talk by the way about the residential and inpatient settings where it’s different issue but this is still intense pressure for telehealth we’ve had physicians doing behavioral health services in hospitals who have been asking questions about their right to remain at home and have communicate via telehealth with patients through nurse cooperation so we’re seeing the enormous and unprecedented liberalisation of all the rules by both government and health plans to make telehealth more successful and so the most important takeaway from this this webinar today at a high level is in the short term the critical thing that I want to urge providers to focus on is ensuring that in the conversion of the service from an in-person service to telehealth that you’re doing all the things that you need to do to get to be reimbursed there are a lot of places to make mistakes in the billing in the documentation and and there’s a whole bunch of issues that we’ll cover today the other issue that sometimes comes up in some parts of behavioral health and are the clinical safety issues and can you meet standard of care are there risk issues that are unique to tell the house and I want to talk a little bit about that I also want to raise a more long-term issue even though we’re in a very different environment in the long term you know one of the things that that we I always sort of principles that I see and I take no joy in sharing this it’s just the reality of is that every time a new reimbursement opportunity opens up in healthcare a year later it’s a fraud and abuse issue and so today the the gateway opening today with the plant plan after plan promising reimbursement I can tell you I’ve already heard from four people at high level in Syria in several plans is coming with a concern that some well while these changes are being made out of necessity there’s a concern on the part of plans that the there’s going to be an explosive amount of claim growth and inevitably some of it will be abusive and so part of what you need to be focusing on is how to make sure that you stand out from that and that you are doing the things as a provider that you need to do to make sure that you are standing clear as a provider who’s doing things appropriately and I also think you know there the the opening the telehealth that is happening in this in this crisis will be long-term but over time it will be more and more important to understand the sort of core compliance issues we’ll talk about so my goal today was really to cover sort of five different areas one was mental health professional services for anybody who’s listening was an MFP LCSW any kind of mental health professional to provide some guidance I’ve had a lot of conversations in the last couple weeks with outpatient programs and also with m80 providers these are all areas at the bottom as I noted where it’s possible to come to go entirely to a telehealth mode that is to have no more in-person service on the right side of the column I have residential programs and inpatient hospital settings these are places where the use of telehealth is different because obviously a residential program requires some staffing and there’s a limit to what can be done by telehealth so go to in inpatient settings it’s a very interesting thing it’s really unprecedented to see an opening to telehealth but we are 4 / 4 patient who’s in a hospital bed for example but we’re seeing partial opportunities to use telehealth so this is what I was trying to cover today so the question the first question that I think you always have to ask with telehealth is which services translate effectively to telehealth the first question that every provider needs to ask is can you deliver the critical services you need to deliver in a remote a remote modality and we’ll talk more about it but I’m talking on the in this teleconference about which is what we call synchronous or video live video audio conferencing and the and the fundamental question that comes down to the bottom line question in every telehealth services can you meet the standard of care to to perform that procedure is there data that you need that you that you don’t have right if for example in many medical services you may need lab tests you may need a blood pressure reading but with behavioral health services there’s a lot more opportunity to meet standard of care through telehealth and can you assess the effectiveness of treatment for in some sectors there are issues of safety are there are there particular issues with this patient that require some kind of immediate presence or staffing or is that an issue that’s addressable otherwise another question that comes up that I want to talk about is can you mix telehealth and in-person services in residential and inpatient settings are prescribing rules for medication assisted treatment or other prescribe medications relaxed to eliminate in-person requirements and what about what do you do with patients whose plans don’t include a home-based behavioral health telehealth benefit these are some of the issues I want to I want to talk about today so in general the ordinary on the left side of this page I listed kind of the main questions that we normally ask when it comes to considering a new telehealth service are first and foremost can you meet the standard of care for this particular service via telehealth that’s always the first question and then the second question that we that as a healthcare lawyer we always look at is okay what licenses do we need does the person who’s providing the service need does the program or facility need to provide a service by telehealth and then finally that that’s the end of the equation if you’re if you’re in a cash pay environment well if you’re if you’re providing a service for insurance reimbursement the question is can you secure a plan contract or do are you operating under a plan in a network plan contract that includes telehealth coverage I’m going to talk more about this later but in that out of network telehealth billing in behavioral health has been extremely limited historically so now I want to shift over to the right side of the page because the questions you need to be asking in this crisis are and we’ll talk about these has the government has a government agency authorized in the federal level or in the state authorized a particular use of telehealth has a particular plan a payer authorized coverage of telehealth and and then and then the last question on this right side of the page is for people in residential settings and particularly in hospitals is the facility going to permit delivery via telehealth and I’ll share with you you know we’ve had several examples where a doctor in a hospital setting wanted to use telehealth brought a device like an iPhone with an application on it to have a secure visit with a patient but the hospital said no that was a case where the government has said the service was okay the the plan of the patients would approve it but the peer review body of the hospital overrode the issue so those are the questions that that need to be asked so you know the question that comes up in behavioral health in some parts of behavioral health that need to be asked are um is this person appropriate for telehealth and the issues that come up in different places in behavioral health are does this client does this patient have the organizational and cognitive capacity to participate in telehealth telehealth requires a much more active and cooperative role in the treatment process relative to in-person treatment for a patient right it requires somebody to be incredibly focused and communicative across the platform that’s much more difficult so that may be a limiting factor another issue that comes up and this can be navigated but it’s a question for providers to ask is can we meet client expectations reasonable client expectations and and this has time in this area I’m thinking particularly of a subset of patients who need frequent contact who and and and and may or may not be able to get their needs met in a telehealth remote treatment model and and and many would and what we’re finding is the providers can’t address this by managing expectations of what kind of contact there will be between telehealth sessions how frequently will happen what the response time will happen but that’s another issue and then finally and this may be the most serious issue for anyone who’s working with high-risk client paid client paid patients you know the the how do you deal with the risk of emergencies right the risk of potential clients self-harm or need for hospitalization is very very different in telehealth context right the same level of supervision staffing support that might be available well with an in-person encounter is very different and these require much more advanced thought and planning okay I wanted to just talk about where we’re seeing behavioral health fit in in a you know kovat nineteen world so so this was going to the point that I made earlier about the fact that if you are if you if you are traveling in an area where there is a travel restriction or work restriction we are recommending that providers document and self certify that any staff who are traveling are verified to be working for health care operations we are we are concerned that this is going to be a bigger issue with more enforcement to reduce travel we think it’s critical to and by the way we’ve recommended for example it’s you know self certification can include creating your own photographic ID to identify who a person is and that they are associated with a particular health care vital health care operation it’s critical to think about who are the meant what’s the minimum personnel that are necessary for your operations in a centralized place where we are having some programs that are choosing to have staff come and deliver telehealth from centralized offices and we’ll talk about that issue and to have safety protocols for anything that’s still happening in person so some of the changes that have happened in the last couple weeks are truly breathtaking we’ve saw but last week we saw the Medicare system CMS expand telehealth for all services to take off the restrictions previously telehealth have been very narrowly available for people in rural areas most perhaps the biggest single change we saw at the federal level was CMS stating that HIPAA enforcement that is health data privacy and security enforcement for against violations is going to be waived throughout this crisis if a provider is acting in good faith right and so that that that in itself is a probably the most for me the most staggering change in the relevant to certain areas of behavioral health we’ve seen the DEA relaxed the Ryan hate act requirement last week of an in we the requirement since 2008 has been an initial in person the exam must occur before any controlled substances are prescribed that has been relaxed to allow for initial prescribing subject to an appropriate exam across telehealth and prescribing in that manner likewise we’ve seen relaxation by the states by the substance abuse mental health service administration of new procedures for make greater flexibility in all forms of m80 and then at the plan level we’ve seen plans issuing new policies new codes new new guidance and what we’ve seen that most interestingly as we’ve seen plans go from selectively approving telehealth and really focusing on was a truly necessary or was it and really being disapproving of telehealth just as a convenience to an approach of global approval in this crisis by the way the question of how long the crisis is gonna last is an interesting one we’re seeing in general not these are not there are exceptions but a lot of plans are describing the changes as being in effect through as long as there’s a national emergency in place others have picked a fixed date in some cases may 31 and you should check the date on any plan that you’re as to what their plan their policies and all right so I want to dive into kind of core telehealth concepts so the first question that comes up in every state is what who is allowed to deliver services by telehealth in general the requirement is there’s a definition in the state and in general the states require licensure in the state to to provide telehealth the there are some states that are more restrictive on these there are many states that have allowed for certifications from national organizations to be treated the same as licensure and in this crisis this rule does not is being relaxed so what we’re seeing is that this is not a problem in the short term but in the long term it’s important to remember that there are definitions of who’s actually permitted to provide services through telehealth I mentioned before this today we’re talking about synchronous telehealth synchronous telehealth means real time the doctor or the provider the health professional and the patient are on line at the same time and they are they have interactive audio and video they can hear and and see each other across the computer as if they were in the same room there are different kinds of telehealth and there are for example their forms of telehealth asynchronous forms of telehealth where people message back and forth or exchange data for for behavioral health purposes today we’re talking about a live video conferencing although one of the things we are seeing from both number of state Medicaid plans and some private payers is that in the absence of video in emergency situations clients are being allowed to use telephone this is this may be problematic for billing with regard to most of the big behavioral of payers but in the Medicaid context particularly we’re seeing that there’s an issue that some Medicaid enrollees don’t do not actually have the technology necessary for synchronous which would be a smart phone at least or a tablet or a computer so so we’re seeing an exceptional approach but again this is another important telehealth concept just to keep in mind okay very important the location of the of the provider and the patient so we use two terms of telehealth the distance site and the originating site the distance site is where the provider is located the originating site is where the patient is located and so there there are very there are no restrictions that I’m aware of of where the the provider may be there there there were some such restrictions in the law but these are largely have been gone away in the last 10-15 years but they basically the provider can the professional delivering the service can be pretty much anywhere during the telehealth service I’ll talk about other restrictions about being in a private place in a secure connection but but there’s no requirement that a provider be in an office location there has been much much more restriction over the years of the originating site that is where the patients located this has been a concern under many many states laws we’ve seen a real movement across the states of which of which they’d still restrict this there are 29 states that over the last decade or so have removed the limitations and said the patient can be anywhere during the telehealth encounter there are still 21 states that specify that the patient has to be in a particular place to receive tell a recognized telehealth center there are 12 states that recognize that the pay of these 21 that say that the patient’s home or a school is an appropriate place but basically this has been a historic limitation on telehealth again we expect really significant liberalisation during the crisis but a very important rule to pay attention to if you’re in those in one of those states all right so I wanted to just go through some other core telehealth assumptions to be keeping in mind one is that the standard of care for whatever treatment you’re giving is considered to be exactly the same and a telehealth service delivery as in person that’s the standard that licensing agencies apply that’s the standard that health plans will expect to be satisfied the second is that the communication must be secure now we’re seeing an incredible liberalization on this by both the government and the plans I mentioned the relaxation of the HIPAA of HIPAA against HIPAA violations and we’re seeing that there’s been a rejection of some platforms that are obviously not secure kick tock and Facebook but there has been a broad acceptance of mainstream platforms that historically were not can not considered HIPAA compliant we’ve seen zoom and Skype for example be accepted I know that one plan was considering limiting one of them big health plans was considering Skype for business because it had better security restrictions although ultimately release the guidance that Skype itself works again as I mentioned the health plans historically limited telehealth in to places where it was necessary but we’re seeing and and working learned about it being merely a convenience that was a negative thing but that’s we’re seeing that lifted to the extent possible pre-authorization is highly advisable it’s not universally required and finally one of the things that’s consistent across style guidelines is there should be mechanisms for client feedback to ensure that clients are getting effective treatment like bite ll so where can folks find state-by-state guidelines for the originating site oh thank you so I knew you had fun on the be a co e site but I’m a big fan of CC h i– t the connected care health information CC if you google c CH i t 50 states telehealth you’ll pull up their most recent guide from the fall of 2019 you want us you want to get used fairly recent resources and that’s the that’s the most available free resource that’s on that’s available on the internet so i encourage people to use TCH thank you great and then a couple questions just about HIPAA compliance and if you can use telephone for individual sessions or facebook Messenger if your county has approved it so if you have a specific approval for facebook Messenger you could use it I I would generally if you do not have a specific approval I would strongly advise against it because we see so much negative commentary but that’s a but if you have a specific approval then there’s no reason not to use it and again telephone historically the plans would object to telephone you know not being a form of telehealth not being a permissible form in fact many states had laws that specifically said telephone is not telehealth tell email is not telehealth they were very worried that providers would do that if you have a specific approval from the plan that you’re dealing with to use telephone or to use a particular platform then you can feel free to do so so so let me so I want to talk about informed consent there’s there’s a informed consent is a specific issue that comes up in telehealth there are about 20 states there used to be a broader requirement but this is a rule that’s kind of slowly rolling back but there are still about 20 states that require a patient to get of specific informed consent to telehealth being used for their treatment and being documented I have the California version of the rule California is one of those states by the way this is separate from what plan some of many health plans also require providers to sign an attestation in using telehealth and so so that that there’s a difference you pay attention to whether the plan has an ancestor that you need to complete and then whether a consent is required and I have a map here these are the states the states in in light blue are the states that are still consent States there are some variations Texas and Washington are states that have require a patient written acknowledgment and then the 30 states that do not require additional consent this might be linked but you said to look up with that the chp CA is that correct you know if you Sarah notes on your website if you can yeah I’m linking it I just want to confirm that’s the correct one sorry about this yeah thank you all right so this is so what I want to say about just telehealth consent is my I’m an advocate for we’re irrespective of whether you’re in a state that technically requires it the states that did away with the requirement did stow because you know they it was seen as sort of somehow treating telehealth is less than or a different kind of treatment but I actually think it’s useful to along the lines of the comment that I made earlier that telehealth requires a more engaged more cooperative more active patient I’m an advocate for a global use of informed consent by the way there one of the things that you want to do at the same time that you get informed consent is off get an authorization for new kinds of data exchange right for example in many cases you may not want you may want to not only document a telehealth encounter but actually record it and that’s something that patients should consent to there are also issues that should be flagged for patients right is there going to be sufficient quality in the interaction across a platform we are we as human beings depend so much on nonverbal communication that a particular provider particular patient may may have an issue with telehealth there may be problems in the transmission and communication right a disruption and I’ll talk about a little more about that but those are issues to talk about right the the difference of not having in-person support and of course the risks of data breaches I’m a for all these reasons I’m an I’m an advocate for for using informed consent not just having a forum on it but actually having a conversation that gets documented in the record I talked already about the licensure issue a little bit by the way very interesting on march 19th Health and Human Services and Medicare suspended out of state physician licensing restrictions we have not seen this for any other health profession but so for physicians who are working on providing necessary care based at a federal level the practicing out of state doesn’t matter let me give you that this is I want to make sure people come away from this webinar with the essential rule that you need to know which is that generally you went when wherever the patient is located is is the place of treatment where the provider needs to meet licensing rules that’s the that’s the rule right so sometimes you we’re seeing a slow trend towards more states liberalizing and allowing practice across state for example the state of florida allowed physicians to who are – they’ve created a mechanism for physicians not licensed in florida who are only doing remote telehealth in florida – to provide services there with a much simpler streamlined approach so we’re seeing this go away but in general the important rule to take away here is that providers are need to be licensed where the patient is at the distant site either where the patient lives or if for some reason the patient is temporarily away from their residents but that the the the it’s that’s the critical location and we don’t have any relaxation among all the changes that have happened we haven’t seen any liberalisation on the licensing state by state licensing for other kinds of providers so my argument would be be careful to respect those limits of where you are licensed where your where your organization and where your professionals are licensed to treat people in in the past we’ve seen this is another one of these historic telehealth differences that have slowly faded away we’ve seen a a in person encounters to establish to establish relationship being required saying that you couldn’t start a new relationship online at directly in a telehealth encounter that has largely gone away and it certainly I should I do not see as an issue in the crisis and I also want to say here that in some cases providers are in favor of a partial in person partial telehealth relationship I spoke to a provider who was conducting urine drug testing for example in person if they couldn’t use remote you know labs and and but and then doing all counseling by telehealth so I think all states that allow for telehealth also allow for some kind of mixed service delivery of course it will have to be documented which we can talk about so let’s documentation there are some things that need to be documented ahead of the the encounter that are important to keep in mind there’s a lot of information that we take for granted is going to be covered in an in-person setting but needs to be spelled out much more carefully in the telehealth encounter so one of those is identifying who is the provider right if the provider and patient aren’t in the same room the provider should document who they could say who they are provide their credentials the name of the client should be verified there’s a lot more the way to think about these issues is that the plans who are gonna be paying for these services when they’re built want to verify exactly who was involved in the particular encounter it becomes very important to document the site particularly the originating site I recommend as a best practice documenting the distant site in some cases we have providers who don’t want to include their home address and that there’s you can certainly just note that the professional was at their home without putting the specific address if that’s an issue but the originating site must absolutely be located may be may be mentioned and some description of the professionals location should be included important to include contact information for the professional and the client at and here I want to stress if there’s a risk of disruption on the call which is always the case on digital communications there should be some communication of how contacts going to be restored we’re seeing by the way in the general rules that client financial responsibility is co-pays coinsurance and so on deductibles are the same with telehealth although we are seeing a number of health plans major health plans waive co-pays simply in the name of facilitating more telehealth in this time in general the standards for documentation are the same for in-person care as they are for telehealth the difference that I mentioned them a minute ago that I really want to stress is that there’s a lot of additional communication that happens in telehealth electronic communication emails to set up and give instructions on how the how it’s going to be done an informed consents potentially recordings which are a valuable way of proving what you actually did it’s important to make sure that you get authorization for the patient for that and let patients know patients should know that if you’re going to be recording which is a from a reimbursement standpoint as a best practice in terms of the technical platform ID we talked a little bit about this already historically there was a strong ad there’s been a strong emphasis on being a HIPAA compliant a platform that protects privacy and data security now as we’ve seen it seems that through this crisis its were in a much more liberal period the key things I would encourage people to focus on are talk to your patients have a back-up plan have a phone number so that you know that that everybody knows what’s going to happen if if encounter is disrupted how to get it started as a last resort there is phone although that is an issue for some payers on payment make sure you have decent connectivity for uninterrupted communication and then I’ve had questions come up about what do you do if the family doesn’t have hardware or connectivity certainly it should not be marketed to patients that that particular providers are offering these things that would be potentially an inducement but if you are in a situation where a family or patient needs connectivity or Hardware we are seeing some providers beginning to to do those things if they’re done on a limited and discrete basis without promoted to drive patient business I I think that they are safe a safe activity a couple other things I wanted this is Accord to understand where we are as a country on telehealth is parity parity has two different meanings in in the cappella health context a parody can mean that a can the service be provided and parody can mean am I going to get paid the same thing as an in-person encounter so in terms of services parity there this is a California requirement but it is representative and I’ll show you a map of this of where we are in parody of what many states have done essentially the the payers have said from a sorry the state laws have said that plans health plans may not limit providers to only provide care in person they can’t prevent this they can’t limit particular settings as not being appropriate for telehealth services that are appropriately available through telehealth in terms of standard of care have to be allowed to be delivered under member plan contracts and plan provider contracts that has not been adopted across the country but that’s what we talk about when we talk about services parity the bigger issue is rate parity and we’ve seen by the way in this crisis many plans have come out and said they are going to have rate parity and they are going to pay the same amount for in the crisis for for telehealth services as they would have paid for in person but I just to give you an example this is California’s law passed in the fall 2019 and it’s it provided that effective January 21 all plan contracts must pay all providers this was not specialty specific for diagnosis consultation or treatment by telehealth on the same basis and that said the same extent as in-person care it didn’t stop plans and providers from negotiating different rates but it this law this law has some provisions that are not delayed until January 21 so there is in California and in a handful of other states some restrictions on which on the on a requirement that services that are the same whether it’s in telehealth or in-person be reimbursed at the same level we are in a slow move towards parity this this is a law that this this is a map that shows it although it doesn’t distinguish between great services and and rate parity and service parity but what you see is that the trend the general trend is towards parity and I think we’re gonna see I think one of the outgrowth of this crisis will be a push for for more and more parity so just highlights again I’m using California as an example as a model and I important to check your state but in California there’s this is very important there’s no requirement that plans must cover out of network unless it specifically says so in the law and and California is not a state and I don’t I’m not aware at the time of this weapon of this webinar any state that requires a health plan to cover out of network so in the crisis there is coverage but this is a long-term issue so this is really a place where having a contract with the health plan is critical and we are seeing that under contract plans are paying for behavioral health Fela health no no requirement that telehealth reimbursement be unbundled from other capitated around but or or or bundled risk based services that’s also California specific and and some parity also on cocaine and coinsurance alright I wanted to as a final topic today talk about reimbursement the the big issues you should I would encourage people to think about our and again we’re seeing if you have assurances from the plans then you don’t need to worry about these but the issues that you should generally be thinking about our does the plan that I’m this particular plan that I’m providing care under cover does it include a telehealth benefit there’s that that’s a big question ordinarily in the crisis at this moment there’s mobile liberalisation another big issue I just mentioned out of network right out of network ordinarily would be a problem for telehealth services in the crisis we are seeing a difference and finally can you meet all the requirements of the services necessary in the case of services that are bundled and I’m referring there specifically to things like your indirect testing so some of the what are the common problems that we’re expecting to see with with from the payers probably want to say you know I I have I’ve spoken to a number of senior people in leadership roles at different payers and I think that there is a spirit of good faith that I’m seeing in the moment from payers but when I put this lease out I think the reality is that payers are going to be inundated with claims there’s going to be some processing errors just as many providers will make errors there will be many many payer processing errors and I do think there is that fraud and abuse concern that I mentioned but the main issue is why why telehealth claims are not going to be paid is the number one issue I expect is lack of authorization so it’s very important to speak to the plan and try to get authorization if you can the second biggest reason is and I’ll talk about this this is for professional CPT codes rather than revenue codes is the place of service not being mapped to the authorization I’m Fox specifically on the next slide about that and it’ll make more sense likewise about the lack of use of modifier codes I do think that providers should be prepared for enormous payer processing errors for internal confusion over the requirements and be ready for appeals I am concerned about issues without a network claims and issues around coordination of benefits what I would say is that you should be doing as much checking of plan requirements and updating plan requirements I know it’s not easy to talk to the payers the payers are overwhelmed although I am seeing really if some really good information being put out by many many payers I think it’s important to stay on top of that and and be and and then trying to build communication with payers and building a denial management process if claims are getting denied so I want to talk about modifiers there’s an enormous communicate confusion about this so in when we talk about CPT codes professional codes that get billed on the CMS 1500 form in the professional service context there are generally two important codes that are relevant and I put up the CMS 1500 form to show where those go on line 24 when you put in the service date you can put in under place be the place of service so the place of service that you should use for telehealth on that form is – that is the modifier code that indicates that the services were provided by telehealth from a distance site with the provider at a different location and then likewise on Part D under the modifier for unusual circumstances 95 is the code that signifies that it was a synchronous telehealth service rendered by real-time interactive audio and video I want to note on the left side I put here that there are specific older codes that were actually retired by Medicare there’s a code GT some health plans are still using that code and if your plan wants you to use it instead of 95 they want you to use G team and if plan tells you to use it I would say use it but that’s those are the modifier codes now here’s where a lot of the confusion comes up if you are an outpatient program or an inpatient residential facility you do not you don’t use this if CMS 1500 write your billing under revenue codes on a completely different form and there are no modifiers for those forms unless the plan has given you something specific that they want you to do the appropriate way for outpatient and inpatient services to note that there was telehealth used in the delivery is to actually put it into the record itself so that that can be identified by the plan in reviewing the code there are no modifiers for outpatient programs so that’s a point of confusion I also just want to point out I took here an example from Magellan I included the website if you want to see this particular example in the professional services context there are a lot of guidance is being provided of how they want modifiers to be used I know for example Magellan is encouraging people to use GT even though it’s no longer it’s been retired by as of last year or 95 but we’re seeing that they have specific codes also at the very bottom you’ll notice for for inpatient telehealth so if you’re doing surf stuff if you’re inpatient and you’re doing telehealth those are important codes – at the bottom of this page to be paying attention to all right so I want to have time for some questions and I just want to say this is a final thought I know this was very quick there’s a lot of information here I hope it was useful I do think we’re in an environment where things are moving quickly and as things change we’ll be glad to share more information but I wanted to just try to get a message out there as broadly as possible that there is Ilana there’s an incredible opening that we’ve seen towards telehealth in the behavioral health context the only caveat is that many of the changes are short-term through the emergency period and there’s still significant work that needs to happen for long-term use of telehealth so study the payor guidelines be in touch with your with your payor contacts and and we’ll be providing more information to come so with that I’m going to turn it back to Sarah that was fantastic much appreciated and we’re getting some great feedback in the chat and a couple questions and really yes we will be emailing the presentation yes we will record it yes you will get a copy of this can you confirm Harry no modifier for ub-04 that’s correct we I have spoken into I’ve spoken to multiple plans there that have no modifiers for you before the the description should be in the text of should be on the claim form itself it should be clear but but otherwise it is a we can still see your screen so and then the other piece is on what types of health professionals or credentials are able to practice with telehealth so again so as I said earlier this is it’s a state-by-state issue you have to always the answer that question is always going to be by reference to what is that state provide who’s allowed to provide telehealth and so what we’ve seen is that some sometimes plant you know the I’ll give you an example the plans what we found is that it you know just use California specific example in California you know there’s there are no limits on who allowed to deliver outpatient programs so when it comes to delivering an outpatient program sometimes plans will say well you don’t have the certification which is for substance programs that’s that’s optional and and and providers have the better half of the argument to say to plans you you know you can’t force us we’re allowed to run without a voluntary certification there any we’re allowed to provide outpatient services were we’re authorized by state by the state the barriers will say well you need accreditation but the providers have the stronger legal argument in that context even if it’s it’s simpler just not to argue with the plans but in this context the critical question is what does the state law say about who’s allowed to provide telehealth in your state so California is a state that has made a few exceptions there’s an exception in the telehealth law for autism providers but it’s not it’s it’s very clear that in California for example any licensed health professional it doesn’t matter whether you’re a MFP an LCSW you know it’s not limited in any way the physicians can provide care but it’s ambiguous whether a certified counselor you know can’t is is fully authorized to provide the service by telehealth so the in the in this crisis there’s been a complete authorization of telehealth services that we’ve seen from most most plans and from some states but I think in the long-term that’s an issue that you need to look at on the state-by-state level and then I there’s just a couple questions about HIPAA compliance software just a reminder that OCR has is not enforcing it but you will need to monitor that as it changes but any questions about whether certain platforms are acceptable right now it appears like anything goes so some of the some of the comments I’ve heard in terms of in terms of thinking about the security of of the platform it should be clear to who’s actually you want to come on directly who’s in the platform there should be some way for whoever’s facilitating to remove people from the if they’re not authorized or intended to be included in the encounter so as long as it’s a platform that has some reasonable level of security function in that sense it should be it should be okay you know we’re seeing a really a broad acceptance of the mainstream platforms do you see do you recommend separate claims for in-person vs. yeah sorry I didn’t understand the question he recommends separate claims for in-person vs. telehealth services I would buy for Kate yeah every claim should be bifurcated and separated out I’ve had this but you know just there should be you you want to you want to separate out as much as possible and then there’s some confusion about how do you register the patient or like how do they sign-in and sign-out so how do you kind of document the time spent with them so again I’m advocate of recording in addition to having some documentation before is having if you actually if you actually get approval from the patient and save the recordings of the encounters then you you then you that’s the best documentation you can ever have if you don’t have that you could theoretically you could just record it manually but you know the safest way to do it in my opinion is if possible to actually save the recording itself how do you feel about telephone when it’s not covered and charging cash how do you think that’s a viable option so in the in the historically I’ll just share with you you know I’ve been providing telehealth service advice on telehealth services for 20 years and and that was a big issue that we people got in trouble for in some states California was one of those states that had a real resistance to any health service just being pure telephone there were some states that were more liberal on it so though historically there’s been a concern that you can’t get enough information to truly assess the patient do an examination by the telephone and and that was a dangerous place where for me like where we would frequently see the Medical Board or other licensing board take action in the midst of this crisis I do not there’s my opinion is that there is no licensing risk as long as what’s being done by telephone is being done in good faith and responsibly I believe that there is a latitude to do to pretty much do any service that you can do in good faith through the telephone if you don’t care about getting paid I do think that that if the it’s that still is a very much a live issue and if you pay attention to what’s going on in some of major you know cash pay commercial website you know sites you see big fights still ahead but those are sort of suspended for this crisis and can you confirm that Tahoe can be used for groups as well as individual sessions absolutely so we first of all there are there are a number of programs that have been doing an outstanding job with out group outpatient group counseling on a Zoom type platform where where everybody can see everybody else and that so that’s been going on for some time and it’s totally appropriate and so as long as you can run a group where people can do the fundamental thing they need to do in groups which is talk to each other across the group and visualize and see people across the group it’s totally appropriate way to conduct and annotation how our residential treatment center is currently addressing safer at home and six are they still operational how to facilitate in a group environment and I’m just gonna jump in and say my understanding is the six foot advisement does not apply to essential services but correct me if I’m wrong Harry I think look what I’m saying is organizations are putting policies and procedures in a place to try to maximize distancing but but you know I’ll just give you some examples of some of the big things we’re seeing a number one is a daily logging of temperature and symptoms for both patients and staff we’re seeing a lot of facilities quarantine some staff so that not everybody is potentially exposed if there is an issue and there are people available for a backup we’re seeing that there’s efforts to stagger stagger any kind of gatherings to try to meet six to eight foot spacing guidelines for meals for four groups for any kind of necessary travel you know there’s there’s there’s a big effort underway to try to space people out and then different states are coming out with different guidelines so here in California for example there were very specific guidelines put out by the department Health Care Services on what to do if you have somebody who’s at a point of exposure you know in general if you can’t get if somebody can’t be taken to a place where they can be safely isolated and they are gonna stay on site you know having them wear a mask you know there’s very specific isolation protocols but so I there definitely are a lot of steps to take to ensure maximal hygiene and safety in in residential settings during this time but there are many we’re finding many facilities are actually having a rising level of capacity you know add of demands some sort of behavioral health challenges driven by this crisis great and some questions are relating to like the assessment intake process and some questions are whether you can use DocuSign type services to for intake paperwork yeah my understanding is yes you can just make sure that it’s HIPAA compliant as you continue so just let me just say this about DocuSign first DocuSign is is in in I believe in every single state DocuSign is is recognized legally as equivalent of signature there are a lot of traditionalists I have some partners who are older than me who who still question whether a doctor Stein is just as good but there’s a law in every state that says it is historically you know we had issues or historically with issues with insurance companies not liking things like before we had DocuSign we had file stamp signature file stamps maybe I’m dating myself by by remembering that but but basically insurance company did not like that and they always wanted a wet fresh signature but in this context DocuSign is totally appropriate and and reliable and I was going to say to you that and just a reminder that if you want template there’s a lot of questions about policies if you want templates for consent and things like that I just put the link for the drawing as a member and we have a number of templates for under the telehealth tab and if that’s helpful to you and we’re coming up with we’re trying to come up with more resources in the coming weeks just to address all of these in the coming days to address these issues so I yeah you have great resources and let’s see and there’s some questions about working with minors if you were working in the school of counseling if you have any suggestions for that so I mean we’re seeing in most I mean most in most parts the United States obviously schools are schools have been shut down in our have moved to remote services so I would I don’t I’m not sure I understand the question but we I would also everything that we’ve said about remote service delivery with minors would apply here would apply we are seeing by the way in the for the and this this the other previous webinar was really about the autism and ABA space but we are seeing still some resistance to like direct therapy with with in that context but in like the more mental health adolescent space for example III would everything that we’ve said today I think is fully applicable in terms of converting even school based services to to remote all you know you know maybe life synchronous hello okay we’re right here up on the hour so I wanted to thank Harry for that wealth of information I know that a lot of folks need it right about now there’s a couple questions that we didn’t get to but Harry’s contact information is there and I’m sure that he would be happy to assist again he’s just a true resource in this space so thank you all for spending your morning or afternoon with him and if you have any questions but we hope that you find your answers and best of luck to everyone stay healthy you
Harry Nelson presented a webinar outlining the concerns Behavioral Healthcare Providers may have when entering the world of telehealth. Amidst the growing concern of the Coronavirus Pandemic, healthcare providers are turning to new means to reach their patients.
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