Telehealth

• Distant Site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.
• Originating Site: Location of the patient at the time the service being furnished via a telecommunications system occurs

• Live Audio-Visual: Live two-way connection between a patient and provider via video conference software
• Audio-Only: Live two-way connection between a patient and provider via phone
• Store and Forward: Provider sends recorded health information (such as scans or photos) to a specialist
• Remote Patient Monitoring: Monitoring vital signs and transmitting information to a provider
• Virtual Check-ins (Medicare): Synchronous discussion over a telephone or exchange of information through video or image initiated by established patient to determine if a visit is needed
• E-visits (Medicare): Non-face-to-face patient-initiated communication with their doctor via the online patient portal where provider evaluates, plans, or provides treatment
• Chronic Care Management (Medicare): Non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.

Medicare (and some other payors) define telehealth as a live audio-visual visit only.

Form a Team and Gather Information

• Include all stakeholders in the planning team such as: providers, nursing and other clinical staff, compliance/regulatory, billing/coding and registration, administrative/finance and IT Staff
• Determine what patient and community needs are and consider patient barriers
• Determine software and equipment needs and consider what need you are trying to meet and what barriers you have to overcome (both patient and organizational)

Plan for Reimbursement

• Familiarize yourself with payment and policy including legal/regulatory and billing requirements (for all payors) and reach out to your largest/highest payor
• Talk with other telehealth providers about challenges and successes
• Learn about your payor’s telehealth payment policy
• Ensure telemedicine/telehealth is part of your managed care contracts
• Ensure billers and coders have the information they need to bill correctly—provide ongoing education when rules change

Implement Program Planning and Education

• Develop policies, procedures and contingency plans
• Provide education to and get buy-in from providers and staff through: software and hardware, pre-visit, during visit and after-visit processes (registration, consent, etc.), virtual etiquette and how to conduct a virtual exam (recorded mock sessions may be helpful) and telemedicine rules and regulations
• Evaluate your program! You will make mistakes—collect data so you can learn from them and continue to improve

Some regulations outlined in this section are specific to Louisiana and may vary in other states. The regulations outlined in this section are the rules under normal circumstances.  Some rules have been changed or waived during the COVID-19 Public Health Emergency. Please refer to the Impact of Covid-19 section for changes and waivers during the COVID-19 Public Health Emergency.

Federal laws and regulations do not always supersede state laws and regulations. Usually, the stricter rule is the one that must be followed.

How should we think about telemedicine?

Telemedicine is simply a different modality of delivering care to patients. It is not intended to replace in-person care but should be used to optimize the use of provider resources and specialties in order to increase patient access to care, as well as improve overall care. Physicians and other healthcare providers practicing telemedicine are held to the same standard of care as they are when providing face-to-face, in-person care.

Licensing

The originating site (the location of the patient) is considered the place of service, and therefore the distant site provider must adhere to the licensing rules and regulations of that state.

• Each state has their own laws and regulations around licensing which are typically enforced by the state medical board.
• Most state medical boards enforce strict licensure rules, requiring providers to have a full medical license in the state the patient is physically located in.
• Nine states’ medical boards will issue special licenses or certificates related in some way to telehealth. These states include Alabama, Louisiana, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee and Texas.

Louisiana law allows all currently licensed healthcare professionals to provide telemedicine services. Special telehealth licenses for out of state providers are required in nine states, including Louisiana. Please be advised to verify what is allowed by your licensing board.

Standard of Care

• The healthcare provider must ensure same standard of care as if in person (LA RS 37:1271)
• To the extent possible, the technology component of telemedicine should be incorporated in the normal workflow of all clinical processes so the care given via telemedicine is integrated with the providers’ other oversight procedures
• Communication with patients should be altered to suit the delivery mode. If technical limitations negatively impact the quality of the encounter so that minimum standards cannot be met, then the use of telemedicine should be terminated
• Providers using telemedicine should monitor and improve the quality of their services to achieve best outcomes
• Review and adopt treatment protocols

Informed Consent Requirements

Although it is not required by federal law, some states require some sort of informed consent from the patient before a provider can use telehealth.  In telehealth, informed consent is used to explain what telehealth is, and lay out the expected benefits, delays, equipment failures, security breaches and other possible risks associated with it to a patient. Patients should be provided sufficient information to adequately address and explain the limitations of computer technology. Consent should be written with signature or via electronic affirmation, if possible, conducted via oral acknowledgment and noted in the patient’s medical record for the telemedicine visit.

Louisiana Law (Louisiana Administrative Code 46:XLV.7511) requires that in addition to any informed consent and right to privacy and confidentiality that may be required by state or federal law or regulation, a physician shall ensure that each patient to whom he or she provides medical services by telemedicine is:

• Informed of the relationship between the physician and patient and the respective role of any other health care provider with respect to management of the patient; and
• Notified that he or she may decline to receive medical services by telemedicine and may withdraw from such care at any time.

Medicare requires specific consents for virtual check-ins and e-visits which must be done once per year.

HIPAA Privacy and Secuirty

The general HIPAA Privacy and Security requirements for patient encounters apply for telemedicine visits.

• Providers must confirm patient identity as would be required if the patient presented to clinic in person.  One way to accomplish this is to have the patient show their ID on camera.
• Providers should conduct visits in a secure location and take good faith efforts to ensure that information is not shared or overheard by individuals who are not directly involved in the patient’s care.
• Ask others to leave the room (and verify they are gone) if you would ask them to leave during an in-person visit.
• Physicians that communicate with patients by electronic means other than telephone or facsimile must provide patients with written notification of the physicians’ privacy practices prior to evaluation or treatment.  In addition, a good faith effort must be made to obtain the patient’s written acknowledgment, including by e-mail, of the notice.

Telemedicine can also create some unique challenges to ensuring privacy and security.

• HIPAA compliant software must be used to ensure security.
• Just as you would not record an in-person visit, it is not recommended to record a telemedicine visit.
• Encourage the patient to conduct the visit in a private/secure location.
• Compliance can be complicated because documentation is in variety of forms (video, audio, image), not just as part of a paper or electronic medical record.  Ensure that software that stores protected health information (PHI) is HIPAA compliant.  Do not enter or store any PHI in unsecure locations.
• Risk assessments should be performed and include all aspects of the telemedicine program to assess additional security risks.

Online Prescribing Limitations

Louisiana Administrative Code 46:XLV.7513 sets limitations on online prescribing for controlled substances.  This code states that physicians shall not use telemedicine to authorize or order the prescription, dispensation or administration of any controlled substance unless:

• The physician has had at least one in-person visit with the patient within the past year; or
• The physician holds an unrestricted license to practice medicine in this state AND the patient is being treated at a healthcare facility that is required to be licensed pursuant to the laws of this state and which holds a current registration with the U.S. Drug Enforcement Administration

Prescribing professionals should consult their state licensing board regulations to determine the online prescribing limitations set for their particular license.

Credentialing and Privileging

In order for a provider (at a distant site) to render services via telehealth to a patient in the hospital (the originating site), that provider must be credentialed and be granted the appropriate privileges at the hospital where the patient is located. The Joint Commission (TJC) has issued standards allowing smaller, rural hospital to accept a privilege by proxy, permitting hospitals to accept the distant site hospital’s credentialing and privileging decisions. Certain requirements need to be met, including implementation of a policy to reflect the privilege by proxy process.

Additional information can be found at the Center for Connected Health Policy website.

Malpractice Insurance

Many malpractice insurance plans may cover only face-to-face encounters. Providers are advised to review their Liability Insurance plans for coverage of telemedicine related claims.

Telemedicine Related Tort Claims Examples

• Exam should have been performed in-person rather than by video conferencing
• Image distortion causing misdiagnosis
• Incomplete telemedicine examination
• Negligent prescribing based on video examination; and
• Negligent failure to provide telemedical support

Fraud and Abuse

A telemedicine program will be subject to the federal Stark and Anti-Kickback laws and any self-referral and anti-kickback laws of the states into which the telemedicine program may reach. Most telemedicine fraud and abuse issues arise from the infrastructure, equipment and support. The Anti-Kickback law is often implicated when a party offers free technology or related services to promote the use of telemedicine or referrals resulting from telemedicine arrangements. Ensure that your legal team reviews any physician arrangements to ensure no implication or violation of these laws.

Connectivity

Broadband connectivity enables critical services to remote and home-bound patients. Audio-video telemedicine visits will require suitable internet bandwidth to support at least a 512kbs video call with overhead. A minimum of 1000kbs (1MBPS) of bandwidth uplink and downlink is recommended, although a higher bandwidth is preferred and will yield a higher quality audio and video connection. A DSL, cable, or direct fiber connection, rather than 4G data network or Wi-Fi hot spot, is recommended.

Software and Equipment

Software and equipment needs will depend on several factors, including budget, services to be provided, and organizational and patient resources and barriers. General telemedicine software and equipment may include:

• Videoconferencing software
• Desktop or laptop, tablet, camera, speakers
• Peripheral devices
• Telemedicine carts
• Remote patient monitoring equipment

Selecting a Vendor

When selecting telehealth software and hardware vendors, consider:

• Software and hardware compatibility
• Integration into your electronic health record
• Cost (one time and monthly/annual)
• End-user/patient experience and ease of use
• Provider experience/ease of use
• Regulatory requirements (HIPAA, documentation, etc.)

Note: Always test equipment and software before purchasing.

Inform your patients of availability and how to participate with our Marketing Your Telehealth Program Toolkit.

• Educate and offer service to who would most benefit
• Use this Email and Social Media Sample Language to promote as appropriate
• Using the following print promotion and patient education tools may be helpful:
  • Brochure template
  • Flyer template: Got Your Hands Full?
  • Flyer template: Home Visits Are Back
  • Flyer template: Skip the Wait

In addition, the Turn to Telehealth Partner Toolkit has additional tools to promote your telehealth services.

Note: Virtual Check-Ins and E-Visits must be initiated by the patient, but providers can educate patients on the availability of these services and how to contact/connect with providers.

Prior to Visit: Clinical Staff

Ask staff to call the patient ahead of visit with healthcare provider to:

• Collect registration information and consent for treatment (recommend adding telehealth language to written consent)
• Provide HIPAA advisory (email, mail, patient portal, etc.)
• Collect history, medications, etc.
• Explain process of telehealth visit—ensure patient knows how to connect

Note: Schedule extra time with the provider for the first visit to ensure time to manage technical issues.

Prior to Visit: Healthcare Provider

• Review patient’s information in advance
• Establish private, secure, and quiet location to conduct visit
• Ensure equipment is connected and working properly
• Double check your background and position in relation to the camera
• Wear what you would wear during an in-person visit (i.e. lab coat, professional attire, badge if appropriate)

Starting the Visit

• Introduce yourself (and other team members in the room) and verify the patient’s identity
• Document method of connect (audio-video, audio-only, etc.) in medical record
• Document any others involved in the visit on both the patient and provider side
• Encourage patient to take the visit in a secure/private location
• Get verbal consent from the patient, including all required telehealth disclosures, and document in medical record

Conducting a Visit

• Limit (eliminate if possible) distractions and background noise
• Allow the patient to play an active role in the experience
• Express empathy and verbalize understanding by actively listening to the patient
• Do not record the session
• Protect the patient’s privacy as you would in an in-person visit (ask others to leave the room, etc.)
• Direct the patient to in-person care for further evaluation or testing if medically necessary
• Document at the same level as an in-person visit

For additional information, please refer to Dr. Ted Hudspeth’s Conducting a Telemedicine Visit presentation from the 2020 Virtual Rural Health Workshop. Access the recorded presentation here.

The guidance outlined in this section are the rules under normal circumstances. Some rules have been changed or waived during the COVID-19 Public Health Emergency. Please refer to the Impact of COVID-19 for any changes or waives during the COVID-19 Public Health Emergency.

Medicare: Geography and Setting

The patient must be in an eligible area:

• Health Professional Shortage Area (HPSA)
• County/parish that is not included in metropolitan statistical area (MSA)

AND in an eligible facility:

• Provider offices
• Hospitals
• Critical access hospitals
• Rural health clinics
• Federally qualified health centers
• Skilled nursing facilities
• Community mental health centers
• Hospital-based or critical access hospital-based renal dialysis centers

Medicare: Provider and Service Types

Be sure that the services you want to provide via telehealth are covered and allowed to be provided by your practitioner.

Practitioners eligible to bill:

• Physician
• Nurse practitioner (NP)
• Physician assistant (PA)
• Nurse midwife
• Clinical nurse specialist (CNS)
• Certified registered nurse anesthetists
• Clinical psychologist (CP) and clinical social workers (CSW)
• Registered dietitians or nutrition professionals

Service Types:

• There are specific codes approved for telemedicine. Click here for more.
• Use the appropriate CPT or HCPCS code service with the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service.
• 2023 Originating site facility fee (Approximately $ 28.64) (HCPCS Code Q3014)

Medicare: Additional Information

• Must be real-time interactive audio and video telecommunications
• RHCs and FQHCs do not qualify to serve as the distant site for Medicare
• Reimbursement for covered telehealth services is equivalent to provider facility rate

Medicare: Other Virtual Services

Medicare Virtual Check-Ins

• 5 Minute (minimum) check-in where established patient contacts provider, presents problem, and provider decides if visit is needed.

Medicare E-Visits

• 5 Minute (minimum) visit where established patient contacts provider through patient portal and provider evaluates, plans or provides treatment.

Virtual Check-Ins and E-Visits

• Cannot be related to/for the same problem as an in-person visit within the last or next seven (7) days
• Have specific codes and lower reimbursement rates than a full visit
• Are not considered telehealth by CMS and are, therefore, not subject to the same regulations, restrictions, and billing guidelines as telehealth encounters

Store & Forward

• Not covered by Medicare (with exception of demonstration projects in Alaska and Hawaii)

Remote Patient Monitoring (Remote Physiologic Monitoring)

• Must be established patient
• Specific codes for set-up and education, 30 days of transmission, and clinical staff/provider communication (20 min or more) with patient
• No limitations based on patient conditions
• Not limited to specific providers (can be “incident to”)

Chronic Care Management

• Must be established patient
• Specific codes dependent on clinical time
• Patient must have two or more chronic conditions
• Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants only

eConsults

• E-consults, also known as electronic consultations or interprofessional consults, are communications between providers only. Providers can use phone, video, or a HIPAA-compliant platform that allows two-way communication and can securely share patient records to get recommendations for complicated conditions from providers in other locations with additional expertise.
• Consulting provider can bill using the following CPT codes:
  • Verbal and written report: 99446, 99447, 99448, 99449
  • Written report only: 99451
• View the eConsult information on the HHS Telehealth site.

Louisiana Medicaid: Patient Setting

• There is no geographic restriction for telemedicine services
• The patient and distant site provider can be in any location
• Does not pay originating site fees

Louisiana Medicaid: Provider and Service Types

Talking with Medicaid Managed Care Organizations (MCOs) is especially important, as they may provide coverage/reimbursement for services that Medicaid does not. Make sure any agreement is in writing (at least in email). Use the same CPT code you would use if the patient were present in person plus the 95 modifier and the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service.

Medicaid recently referred to Appendix P but MCOs may cover additional services. Recent legislation requiring specific list of telehealth covered services to be published by Medicaid.

• Practitioners who may bill includes anyone licensed to practice in the state
• RHCs and FQHCs can provide services as the distant site
• Service Types: refer to CPT Manual Appendix P (may change) and 95 Modifier and the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service
• Reimbursed at same rate as in-person visits
• Telemedicine must be real-time interactive audio and video telecommunication

Louisiana Medicaid: Other Virtual Services

Store & Forward

• Not covered

Remote Patient Monitoring

• Louisiana Medicaid will reimburse an installation fee and a monthly maintenance fee for TeleCare Activity and Sensor Monitoring; Health Status Monitoring; and Medication Dispensing and Monitoring

Click here to view the Louisiana Medicaid Manual.

Under the Community Choices Waiver, Louisiana Medicaid will reimburse an installation fee and a monthly maintenance fee for: TeleCare Activity and Sensor Monitoring, health status monitoring and medication dispensing and monitoring

• There are limitations and services must be pre-approved and based on verified need.
• Benefit must be determined by an independent assessment on any item that costs over $500.
• All items must reduce reliance on other Medicaid state plan or waiver services and must meet applicable standards of manufacture, design and installation
• The items must be on the Plan of Care developed by the support coordinator.
• A recipient is not able to receive Telecare Activity and Sensor Monitoring services and traditional PERS services.

Where applicable, recipients must use Medicaid State Plan, Medicare or other available payors first.

eConsults

• Effective for dates of service on or after March 15, 2021, Louisiana Medicaid will reimburse interprofessional assessment and management services that occur electronically through EHR, through audio/video platforms, or via telephone (e-consults).
• Relevant CPT procedure codes are:
  • 99451: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5 minutes or more of medical consultative time (used by the specialist/subspecialist clinician).

Click to review the Louisiana Medicaid Informational Bulletin 20-5 for more information.

Commercial

Louisiana has a telemedicine payment Parity Law (RS 22:1821)  in place that states “whenever such policy provides for payment, benefit, or reimbursement for any health care service, and such health care service is performed via transmitted electronic imaging or telemedicine, such a payment, benefit, or reimbursement under such policy or contract shall not be denied to a licensed physician. The payment, benefit, or reimbursement to such a licensed physician at the originating facility or terminus shall not be less than seventy-five percent of the reasonable and customary amount of payment, benefit, or reimbursement which that licensed physician receives for an intermediate office visit.”

This parity mandate does not apply to Employee Retirement Income Security Act of 1974 (ERISA) plans as these self-funded plans do not come under state jurisdiction. ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

Internal CMS analysis has found that before the Public Health Emergency (PHE), only 14,000 beneficiaries received a telehealth service in a week but during the PHE period from mid-March through Early-July, over 10.1 million beneficiaries have received a telehealth service.

• The COVID-19 Public Health Emergency has caused significant temporary changes to telehealth regulations
• Providers and payors have seen a significant increase in telehealth utilization
• Ongoing regulatory changes and legislative proposals to make permanent changes future telehealth policy

Licensing 

The federal government is allowing telehealth across state lines BUT, providers are still bound by state regulations.  Some states require an emergency license and some states have waived the license completely during the PHE. Please review the state license board rules and regulations for more information. Remember that the patient location is considered the originating site of the visit and, therefore, the patient location determines which licensing regulations apply to the visit.

HIPAA

The Department of Health and Human Services Office for Civil Rights (OCR) announced that the Notification of Enforcement Discretion issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) expires on May 11, 2023 when the COVID-19 public health emergency ends. Covered health care providers had a 90-day transition period after this date to come into compliance with the HIPAA Privacy, Security, Breach Notification and Enforcement Rules (HIPAA Rules). The transition period ended on August 9, 2023.

Please ensure you are utilizing a HIPAA compliant platform for all telehealth visits going forward. This means no more unsecure video chats, social media or Face Time can be utilized for purposes of telehealth unless they follow HIPAA Privacy and Security Rules. Facilities had until 11:59PM on Aug. 9, 2023 to get back in compliance.

Medicare

During PHE, all providers who may bill Medicare for their professional services can furnish telehealth services. RHCs and FQHCs can now provide telehealth distant site services using a specific telemedicine code. Medicare restrictions on the originating site are temporarily lifted (patient and provider can be in any location). Medicare has also temporarily added approximately 80 services and telephone only codes to the telehealth list. Certain services (identified on telehealth list) can be delivered via audio-only connection.  CMS is not enforcing or conducting audit to ensure a prior relationship existed for any telemedicine services for Medicare claims submitted during this public health emergency.

Louisiana Medicaid

Louisiana Medicaid has given direction to use telehealth in place of in-person visits, as appropriate during the PHE. Services can be provided via audio-only connection when audio-video connection is not immediately available. Louisiana Medicaid has confirmed that telemedicine visits will be paid at in-person rate (including RHC AIR/FQHC PPS rate). New telemedicine services are covered during the PHE, including teledentistry and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) preventive services (well-child care) for members older than 24 months of age.

To learn more about the impact of COVID-19 on telehealth, click here.

The U.S. Department of Health and Human Services took a range of administrative steps to expedite the adoption and awareness of telehealth during the COVID-19 public health emergency. Some of these telehealth flexibilities have been made permanent while others are temporary.

Permanent Medicare changes

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for behavioral/mental telehealth services
• Medicare patients can receive telehealth services for behavioral/mental health care in their home
• There are no geographic restrictions for originating site for behavioral/mental telehealth services
• Behavioral/mental telehealth services can be delivered using audio-only communication platforms
• Rural Emergency Hospitals (REHs) are eligible originating sites for telehealth

Temporary Medicare changes through December 31, 2024

• FQHCs and RHCs can serve as a distant site provider for non-behavioral/mental telehealth services
• Medicare patients can receive telehealth services in their home
• There are no geographic restrictions for originating site for non-behavioral/mental telehealth services
• Some non-behavioral/mental telehealth services can be delivered using audio-only communication platforms
• An in-person visit within six months of an initial behavioral/mental telehealth service, and annually thereafter, is not required
• Telehealth services can be provided by all eligible Medicare providers

Drug Enforcement Authority (DEA) regulations:

• DEA Extends Prescribing for Controlled Substances Via Telehealth.  On October 10, the U.S. Drug Enforcement Agency joined with the Department of Health & Human Services to announce an extension telemedicine flexibilities put in place during the COVID-19 public health emergency.  Now through December 31, 2024, authorized providers can prescribe controlled substances to new and existing patients based on a telephone evaluation, or through other means of telemedicine.

Link Sources:

• Consolidated Appropriations Act, 2023 (PDF)
• Telehealth policy changes after the COVID-19 public health emergency