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Telehealth Advocates Respond to CMS ‘Virtual Visit’ Proposal

July 16, 2018
by David Raths
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To get around legal restrictions on telehealth reimbursement, CMS expands its definition of ‘communication technology–based services’

Among all the proposed changes the Centers for Medicare and Medicaid Services (CMS) rolled out last week, ones related to telehealth drew considerable interest. Although it can’t use its regulatory power to change the laws that restrict telehealth services paid for by Medicare to rural settings, the agency has instead defined new “communication technology–based services” that could be used for virtual visits with established Medicare patients regardless of such patients’ location, effective Jan. 1, 2019.

In its proposed rule about virtual visits, CMS is seeking comment on whether telephone interactions are sufficient or whether interactions enhanced with video or other kinds of data transmission should be required. CMS also proposes to create a new code to permit separate Medicare payment for store-and-forward technology such as when a dermatologist examines an image of a patient’s skin asynchronously.

The CMS proposal brought a mix of enthusiasm and concerns from groups advocating for greater usage of telehealth. “What they have done is creative and brilliant, and it goes further than CMS has ever gone previously to ensure that seniors have services everyone else in the marketplace has,” said Krista Drobac, executive director of the Alliance for Connected Care. On the other hand, she expressed concern that CMS paying for brief e-visits is going to create an environment where providers are going to weigh whether it is worth it to invest in telehealth systems. “What they will probably find is that the reimbursement is not enough to transform their practice and make telehealth part of their work flow,” she said.

Drobac believes CMS has gone as far as it can go within the existing law. She said Congress needs to give the Secretary the authority to waive the telehealth restrictions on all provider codes. “On the one hand, I am excited about the progress; on the other hand, it makes me even more determined that Congress act. CMS has gone as far as any of us could have asked on a regulatory level.”

Drobac also noted that CMS has plans to make the program budget-neutral by cutting base payments for providers to counter increased spending on virtual visits. “The more this gets used, the lower those E&M code reimbursements might be,” she said.

Aside from actual proposal itself, Mei Wa Kwong, executive director of the nonprofit Center for Connected Health Policy, was intrigued by the reasoning CMS used for how they can make this proposal and not face the same limitations other telehealth services do. “That raises the question: are we creating two separate things, communication technology vs. telehealth. Are they going to be separate? They started down this path a few years earlier with chronic care management and remote patient monitoring,” she said.

The way the virtual check-in proposal stands now stands, providers would have to have a telehealth system set up. “But CMS asked for comments on whether they could be done on the phone, which I think would be a lot more common,” Kwong said. “The reimbursement for that proposal is $14 per check-in. People have asked me whether physicians would see that as worthwhile to go through the administrative tasks and I don’t have an answer. There are still a lot of questions.”

In its proposal, CMS noted that the virtual visit service could be used as part of a treatment regimen in follow-up visits for patients on medication-assisted therapy for opioid use disorders. “We have been very active on that issue on Capitol Hill,” Drobac said. “We have been an advocate for the e-TREAT Act, which is part of the Senate opioid bill. That would lift the telehealth restrictions for substance use disorders. It would give CMS even more authority to work in the substance use disorder area. We are pushing for Congressional action on that.”

Kwong said virtual visits could be very useful for patients, “but there are a bunch of policy complications related to medication-assisted therapy. It might not be as widely used as they hope.”

Overall, how the proposed rule is tweaked could make a big difference, she added. If the asynchronous store-and-forward service can be used for new patients, that would benefit the direct-to-consumer companies, she said. “Is CMS policy going to be that you can establish a patient-provider policy this way? If so, it could have a wider impact. Or if they allow the patient check-ins via phone, that could have a wider impact.”
 
Other provider organization and informatics group represenatives weighed in on the subtle nuances of the proposal:

“I think all types of patients can benefit from a policy like this, as it gives them an opportunity to touch base with a provider without having to schedule an office visit,” said Darryl Drevna, director of regulatory and public policy at the American Medical Group Association (AMGA). “Previously, the way that telehealth was paid was if an office visit was scheduled and then the payment would get wrapped up in that office visit. Here, you can look at the film or have a call with your patient, as sort of a triage, and if you don’t end up having to schedule an office visit, you’ll still get reimbursed for that. So, this is a positive; this is something that we’ve long supported, to expand the use of telehealth as a program.”

“Telehealth advocates have been clamoring for CMS to jump in with both feet on reimbursement of telehealth, and I think this proposal does that,” said Jeff Smith, vice president of public policy at the Bethesda, Md.-based American Medical Informatics Association (AMIA). “Whether or not they are jumping six feet in the water or have both toes in the water is up for debate. But I think telehealth advocates will score this as a major win, and it is a major win.”

“It’s always good when things like telemedicine are expanded and there are more options to treat patients, but what we’re going to be looking at with a proposal like this is: what are the criteria and what is the payment amount?” said Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association (MGMA). “Some of those additional flexibilities and additional codes for telemedicine can be quite useful, as long as the complexity and the rules and the hoops you have to jump through are not overwhelming so that the return on investment to even provide those [telemedicine services] is there.”

 

 

 

 


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Seven Companies, Four Individuals Indicted in Billion-Dollar Telemedicine Fraud Conspiracy

October 16, 2018
by Rajiv Leventhal, Managing Editor
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Four individuals and seven companies have been indicted in a $1 billion telemedicine fraud scheme, the Department of Justice announced this week.

The District Court for the Eastern District of Tennessee unsealed a 32-count indictment on the individuals and companies. The indictment stated that HealthRight LLC, a telemedicine company with locations in Pennsylvania and Florida, and Scott Roix, 52, of Seminole, Fla., and the CEO of HealthRight, pleaded guilty to felony conspiracy for their roles in the telemedicine healthcare fraud scheme in a criminal information. Roix and HealthRight also pleaded guilty to conspiring to commit wire fraud in a separate scheme for fraudulently telemarketing dietary supplements, skin creams, and testosterone, according to DOJ officials.

In addition, three other individuals were indicted along with their compounding pharmacies, Synergy Pharmacy Services, located in Palm Harbor, Fla. and Precision Pharmacy Management, located in Clearwater, Fla.. Another co-conspirator, Larry Everett Smith, of Pinellas Park, Fla. also a pharmacy compounder, and his companies Tanith Enterprises, ULD Wholesale Group, Alpha-Omega Pharmacy, all located in Clearwater, Germaine Pharmacy located in Tampa, Fla., and Zoetic Pharmacy located in Houston, Texas, were all also named as defendants. All the defendants were charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce, per the indictment.

The indictment alleges that from June 2015 through April 2018, these individuals and companies, together with others, “conspired to deceive tens of thousands of patients and more than 100 doctors” located in Tennessee and elsewhere across the country “for the purpose of defrauding private healthcare benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174 million. The indictment further alleges that the defendants submitted not less than $931 million in fraudulent claims for payment,” according to the indictment.

More specifically, according to the indictment, the defendants “set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products.” The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers.

In addition to their roles in the healthcare fraud conspiracy, Roix and HealthRight were also charged with conspiring to commit wire fraud as part of a scheme to use HealthRight’s telemarketing facilities to fraudulently sell millions of dollars’ worth of products such as weight loss pills, skin creams, and testosterone supplements through concocted claims of efficacy and intentionally deficient customer service designed to stall consumer complaints, according to the indictment.

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With $6.3M PCORI Contract, UPMC Health Plan to Study Tech-Based Approach to Chronic Disease

September 25, 2018
by Heather Landi, Associate Editor
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The UPMC Center for High-Value Health Care was recently awarded a $6.3 million contract from the Patient-Centered Outcomes Research Institute (PCORI) to study different care delivery models to improve outcomes for patients with chronic disease and a co-existing behavioral health condition.

The multi-year study will highlight payer-provider collaboration to support individuals with both physical and behavioral health conditions. The UPMC Center for High-Value Health Care is housed within the UPMC Insurance Services Division, which includes UPMC Health Plan, and is part of Pittsburgh-based UPMC health system.

The focus of the study is to better understand how to design systems to manage chronic disease and will compare a technology-centric approach with a team-based, high-touch intervention, according to UPMC.

PCORI awarded the UPMC Center for High-Value Health Care support for a five-year study with a long-term objective to enhance the ability of health care systems to better support individuals with chronic diseases like inflammatory bowel disease (IBD) and behavioral health conditions, reduce variations in practice, connect patients with care that is best for them, and improve meaningful, patient-centered health outcomes.

This PCORI study is related to a recently completed one-year pilot study, which showed that participation in an IBD specialty medical home, a care delivery model that is uniquely designed to provide comprehensive and well-coordinated health services, increases patients' quality of life while decreasing levels of disease activity and use of unplanned care. In fact, the pilot study demonstrated a 50 percent decline in emergency room visits and a 30 percent decline in hospitalizations among participants.

“The early successes of the pilot study are encouraging and now this multi-year PCORI study will allow us to further align the payer and provider to develop long-term benefits and applications in a variety of clinical settings," William Shrank, M.D., chief medical officer for UPMC Insurance Services Division, said in a statement. "The use of technology as a key component of the study underscores the role that emerging trends will play in the future of health care."

Participants who enroll in the study will receive IBD specialty medical home care through either a team-based or tech-based approach.

The team-based approach is a personalized service design that includes gastroenterologists, behavioral health specialists, registered nurses, and health coaches who provide intensive, in-person support and resources. The tech-based approach leverages a digital platform using remote monitoring, digital behavioral interventions, and telehealth to deliver team-based care at the patient's convenience, at home and in the community, with the guidance of health coaches.

“By examining the effectiveness of a 'team vs. tech' approach, we expect that this research will provide insight on the most effective methods to provide both physical and behavioral health care to individuals with IBD and most importantly, a better quality of life for patients both now and into the future,"  principal investigator for the study, Dr. Eva Szigethy, professor of psychiatry at the University of Pittsburgh and senior faculty at the UPMC Center for High-Value Health Care, said in a statement.

Co-investigators of the study include clinical experts from the UPMC Center for High-Value Health Care, the University of Pittsburgh, Mount Sinai Health System in New York, and Brigham and Women's Hospital in Boston.

This marks the fifth PCORI contract awarded to the UPMC Center for High-Value Health Care over the past five years.

 

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Senate Passes Opioid Response Bill with Substantial Health IT Elements

September 18, 2018
by Rajiv Leventhal, Managing Editor
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The U.S. Senate yesterday passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions, by a vote of 99-1.

The bill was originally sponsored by Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), and includes proposals from five Senate committees and over 70 senators. The House passed its version of the legislation in June and now it’s expected that a committee will be convened to reconcile the differences between the two.

The legislation’s core purpose is to improve the ability of various health departments and agencies—such as the Department of Health and Human Services (HHS), including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Departments of Education and Labor—to address the opioid crisis, including the ripple effects of the crisis on children, families, and communities, help states implement updates to their plans of safe care, and improve data sharing between states.

There are several key health IT provisions in the legislation, including: enabling the Centers for Medicare & Medicaid Services (CMS) to test various models that provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record (EHR) technology to improve the quality and coordination of care through the electronic documentation and exchange of health information; requiring the use of electronic prescribing for controlled substances within Medicare Part D; facilitating the use of electronic prior authorization within Medicare Part D; and expanding access to telehealth services for substance use disorders.

Regarding telehealth specifically, the Senate version of the bill will allow for payment for substance use disorder treatment services, via telehealth, to Medicare beneficiaries at originating sites, including a beneficiary’s home, regardless of geographic location. It also requires guidance to cover state options for federal reimbursement for substance use disorder services and treatment using telehealth including, services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

Health IT Now's Opioid Safety Alliance—a working group of prescribers, health systems, technology companies, pharmacies and pharmacists, professional societies, and patients advocating for the use of technology to fight illegitimate opioid use—supported the Senate’s passing of the bill. Said Joel White, HITN Opioid Safety Alliance executive director, “We are especially encouraged by the inclusion of commonsense Opioid Safety Alliance-endorsed language in this bill that will remove bureaucratic barriers to vital telehealth services for those suffering from addiction, modernize prescribing practices for controlled substances, and streamline prior authorization claims to improve efficiency while bolstering patient safety. These solutions can make a world of difference both in dollars saved and, more importantly, lives spared."

White did add, however, as Congress convenes a committee to reconcile the differences in the House and Senate-passed bills, lawmakers ought to include the House-passed OPPS Act (H.R. 6082) as part of any final conference agreement, “thereby ensuring that addiction treatment records are no longer needlessly isolated from the rest of a patient's medical history—a practice that has hindered informed decision making and threatened patient safety for too long.”

Indeed, the Senate version of the bill requires HHS “to develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient.”

White also noted, “Additionally, OSA remains concerned about the lack of real-time, actionable data provided to clinicians by states' prescription drug monitoring programs (PDMPs). With lawmakers poised to devote additional resources toward these programs, we should know if taxpayers are getting a return on their investment. We support the inclusion of language that would require an objective study and report on states' use of PDMP technology." 

As stated in the bill, states and localities would be provided with support to improve their PDMPs and "implement other evidence-based prevention strategies.” The bill also “encourages data sharing between states, and supports other prevention and research activities related to controlled substances."

What’s more, another section of the bill reauthorizes an HHS grant program “to allow states to develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology.”

Sen. Alexander, meanwhile, said yesterday he is “already working to combine the Senate and House-passed bills into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly.”

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