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Alex Krouse, JD, MHA Christine Wernert, MBA, CPMA Understanding the Implementation and Compliance Issues Concerning Telemedicine What Legal and Regulatory Issues Should We Know?

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Telehealth vs. Telemedicine vs. Telecommuting What do these terms mean? Differences between services Differences in provider contracts, equipment, EPs Differences in payments

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Licensure of Professionals Are patients located in the State? Are all practitioners located in the same State? Licensing requirements must be met in the State in which services are provided Location of Patient Be aware of licensure issues for border providers

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Credentialing of Professionals Originating Site Hospital can rely on Distant Site for credentialing matters. Written Agreement Confidentiality Ownership of Records Distant Site Requirements Medicare Participating Hospital or Ensures Medicare Compliance Practitioner is Privileged at Distant Site Distant Site Provides Current list of All Privileges

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Prescribing A documented patient evaluation, including history and physical evaluation adequate to establish diagnoses and identify underlying conditions or contraindications to the treatment recommended or provided, must be obtained prior to providing treatment, including issuing prescriptions, electronically or otherwise. 844 IAC 5-3-2

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Prescribing Except in institutional settings, on-call situations, cross-coverage situations, and situations involving advanced practice nurses with prescriptive authority practicing in accordance with standard care arrangements, as described in subsection (d), a physician shall not prescribe, dispense, or otherwise provide, or cause to be provided, any controlled substance to a person who the physician has never personally physically examined and diagnosed... unless the physician is providing care in consultation with another physician who has an ongoing professional relationship with the patient, and who has agreed to supervise... 844 IAC 5-4-1

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Malpractice Concerns Malpractice Still an Issue! Physician Patient Relationship What are the requirements? Multiple Physicians? Patient Abandonment Informed Consent Provide Choice of Traditional vs. Telemedicine Practitioners coverage online Hub site coverage

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Non-Physician Providers 180,233 Nurse Practitioners 3,000+ in Indiana 83,466 Physician Assistants 397,130 Primary Care Physicians Pediatrics 70,967 OBGYN 45,043 Family Medicine 116,933 Internal Medicine - 164,187 2020: Shortage of 91,500 Physicians Including 45,000 Primary Care Physicians Source: Assoc. of American Medical Colleges

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Non-Physician Providers Nurse Practitioners/PAs Supervision or Collaboration? NP = Collaboration PA = Supervision Scope of Practice Incident to billing Who are we billing under?

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Anti-Kickback Risks Under the Anti-kickback Statute it is illegal to knowingly or willfully: offer, pay, solicit, or receive remuneration; directly or indirectly; in cash or in kind; In exchange for; referring an individual; or furnishing or arranging for a good or service; and for which payment may be made under Medicare or Medicaid.

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Is the Government Focused on Telemedicine? Office of Inspector General Guidance Case Law United States vs. Greber United States v. Polin Safe Harbors EHR Donations Anti-Kickback Risks

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Stark Law Risks The Stark Law prohibits a physician from making a Referral To an entity For the furnishing of a designated health service For which payment may be made under Medicare If the physician (or an immediate family member) Has a financial relationship with the entity

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Stark Law Risks Strict Liability Stark Law Applies to ANYTHING of VALUE NOT $$$ Only How does the Stark Law impact telemedicine? EHR Exceptions Rural Exception Analyze Every Arrangement!

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False Claims Act Risks Generally a false/fraudulent claim/statement made or caused to be made for payment to the United States, 31 U.S.C. 3729(a) Includes conspiracy and reverse false claims provisions Claim must be submitted knowingly Actual knowledge Deliberate ignorance Reckless disregard No specific intent to defraud required

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Indiana Medicaid Medical necessity in every clarification of reimbursed services Behavioral Health rapid expansion 15 states require tele-health reimbursement to be same as face-to- face (IN not one of them) IHCP does reimburse for consultations, outpatient E/M, behavioral health, MTM, and end stage renal disease services 20 miles from hub and spoke No home care reimbursement

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Implementation Concerns Area serving a HPSA? Security and HIPAA Who and where is the patient and how am I sure? Reimbursement for interactive services Modifier codes Reporting with documentation! EHR concerns and things to watch out for

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ServiceCPT/HCPCS Code Telehealth consultationsG0425-G0527 Follow up inpatient telehealth consultationG0406-G0408 Office/outpatient visits99201-99215 Subsequent hospital care services99231-99233 Subsequent nursing facility care services99307-99310 Kidney disease education servicesG0420, G0109 Diabetes self- management trainingG0108, G0109 Behavioral assessment and intervention96150-96154 Psychotherapy90832-90834, 90836-90838 Psychiatric diagnostic interview exam90791, 90792 ESRDmany Nutrition therapyG0270,97802-97804 Neurobehavioral status exam96116 Smoking CessationG0436, G0437; 99406-99407 Alcohol and/or substance interventionG0396, G0397 Behavioral counseling, screenings, etc.many

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Take-awayson Indiana What to tell health care professional looking to implement a tele-health plan Legislature to watch for on state/federal level Access of care and patient services in remote areas increase quality and access PQRS! New technologies and policies for implementation to be on look out for Ensure there are processes in place for licensure and credentialing of professionals Educate providers on the practical concerns related to malpractice Analyze every new telemedicine arrangement, from the onset, from a fraud and abuse perspective

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Christine Wernert, MBA, CPMA President Practice Management Solutions, LLC 317-410-2010 wernert.pmsolutions@gmail.com Christine Wernert, MBA, CPMA President Practice Management Solutions, LLC 317-410-2010 wernert.pmsolutions@gmail.com Alex T. Krouse, JD, MHA Attorney Krieg DeVault LLP 574-485-2003 akrouse@kdlegal.com Alex T. Krouse, JD, MHA Attorney Krieg DeVault LLP 574-485-2003 akrouse@kdlegal.com