Speaker 1: You are listening to Your Practice Made Perfect, support, protection and advice for practicing medical professionals brought to you by SVMIC.


J. Baugh: Hello everyone, and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh and I'll be your host for today. Today we're going to be talking about telemedicine. The full extent of the liability associated with telemedicine has yet to be determined. Should a claim be filed against the physician, it is likely to be filed in the state in which the patient resides. Physicians should fully investigate state licensure requirements and restrictions along with the applicability of their professional liability coverage. And to help us talk about this very important and timely topic is Michael Cash. Michael, welcome.


Michael: Thanks Jay, it's a pleasure to be here today.


J. Baugh: Well, we're glad that you're taking the time to talk to us about an important issue like telemedicine. Before we get started, could you give us a little brief introduction of yourself?


Michael: Sure. I work in the Medical Practice Service department of SVMIC. We help our policyholders from the beginning of their practice to the end. We work with residents all the way to physicians considering retirement, and we handle the business side of their practice. We help with HR related issues, financial assessments, strategic planning, governance, technology implementation, and really anything in between. We just try to be a resource for practices and look at ourselves as an extension of their management team.


J. Baugh: Well, I know that the Medical Practice Services department at SVMIC plays a very important role for the business development of our policyholders, and I thank you for taking the time to talk to us today about telemedicine. So let me start with this question, what is the biggest difference between telemedicine prior to COVID-19 and after COVID-19?


Michael: Well, the biggest difference is that payers cover telemedicine during the public health emergency. Prior to COVID, many payers had a site restriction requiring the patient to be in a physician office or hospital setting. There were a few exceptions. Some payers offered a telemedicine benefit to their members via a corporate platform, but it was not open access, and a few physicians implemented telemedicine as a self-pay service as it was considered a non-covered service prior to COVID. Some patients also access telemedicine as a self-pay service to a corporate vendor. While it's important to research state laws, since medicine is regulated at both the state and federal levels, most states have revised laws allowing patients to be treated via telemedicine. In other words, we have the infrastructure in place to continue telemedicine beyond COVID, we'll have to see how payers respond.


One argument for telemedicine is that it improves access, decreases cost and improves the patient experience. On the other hand, some are concerned about increased utilization and quality associated with telemedicine. Prior to COVID, I thought payers were testing telemedicine via limited access. There are legislative efforts at the state and national levels to implement payment parody and require payment payer coverage after the public health emergency.


The other big difference between telemedicine prior and post COVID is that The Department of Health and Human Services and The Office of Civil Rights provide enforcement, discretion and non-secure applications like FaceTime and Skype. Normally, state and federal laws require the physician to utilize a secure encrypted platform, this prevents others from interfering with the patient visit. However, The Department of Health and Human Services realized that they're trying to keep patients at home during the emergency period, so they provided some flexibility to allow physicians to utilize non-secure platforms. The key is that it cannot be public facing. If you are using one of those platforms, I would encourage you to look at The Department of Health and Human Services website for a list of secure applications; it will protect you from others interfering with your visit.


J. Baugh: So what do you see as the biggest challenge moving forward with telemedicine?


Michael: Well, I mentioned in the previous question, payer reimbursement will be a challenge. Tennessee BlueCross announced that they're making telemedicine permanent, however, other payers are not as quick to jump on board. After the emergency period, I can see a situation where we have some payers covering and some not covering telemedicine. And then we'll create some scheduling challenges. If a physician is contracted with the payer, most require the office to bill for covered services, unless the patient refers to pay out of pocket. It all depends on the insurance contract.


Another thing, providing care across state lines is another issue. Many states require the physician to be licensed in the state where the patient is located at the time of service. During the public health emergency, many states have implemented a temporary waiver, allowing physicians to treat patients in other states. However, many states still require the physician to submit a temporary application.


The Federation of State Medical Boards lists the requirements for each state during the COVID emergency. Malpractice coverage is another issue to consider. Currently, there's very little claims history to write premiums for telemedicine. SVMIC covers telemedicine under the physician's existing policy and coverage area. We encourage physicians to notify us if they're seeing patients in other states to make sure that they're covered in that state.


Other malpractice carriers may have a separate policy for telemedicine or may have limitations on the telemedicine modalities, advanced practitioner supervision or scope of service. Furthermore, laws regarding the standard of care may be different across state lines. Some states adapt to national standards, other states have a regional standard.


Finally, prescribing controlled substances across state lines should be considered. Physicians are required to have a DEA in each state for prescribing controlled substances. Those federal and state guidelines apply. There are some restrictions for prescribing controlled substances via telemedicine. There is flexibility during the public health emergency, but that's likely to change after the emergency period.


J. Baugh: So what changes in telemedicine do you see after the public health emergency?


Michael: I think we'll see changes in audio-only telemedicine coverage. Prior to the public health emergency, most payers considered audio-only visit a non-covered service. However, many payers cover the service to keep patients at home since many did not have the ability to communicate with an audio-visual visit. Also, many of the payers increase reimbursement to reflect similar office visit codes. I think it's likely we'll see some retraction of audio-only coverage and reimbursement.


I also think we'll see more audits on billing and documentation. There was a lot of confusion in the beginning of the emergency regarding billing audio-only and audio-visual codes. It's important to have adequate documentation to support the visit with an appropriate diagnosis code. It's also important to mention if you're using audio-only or an audio-visual platform in your documentation. It can seem like a virtual visit is more casual, but please remember that the requirements are the same as an in-person visit.


J. Baugh: So what do you see as the opportunity for telemedicine after the public health emergency?


Michael: Well, prior to the public health emergency, I often heard there was a large segment of the population that was not comfortable with phone applications and virtual visits. The emergency forced many patients and providers to utilize telemedicine, more people are now comfortable with virtual conversations. We're in a convenience-based society, telemedicine will not replace the need for all face-to-face encounters, but it can provide another avenue for patients to access care.


I also think most providers have just touched the surface on telemedicine implementation. Most use a platform just for the virtual interaction with the patient. There are telemedicine platforms that assist with scheduling and workflow. Some telemedicine platforms can capture some of the patient recorded information asynchronously to assist the provider with documentation and time. Telemedicine can improve office efficiency and many patients like the privacy of telemedicine. Patients don't want to be exposed to other sick patients. Many patients travel long distances to see their provider, it also reduces patient time associated with an office visit.


Offices are trying to do more with less. Telemedicine can reduce the number of staff encounters with the patient, allowing them to focus on patients that need to come in for a face-to-face visit. There's also fierce competition for patients. Retail, clinics, urgent care, corporate telemedicine and others are trying to gain market share. One advantage I see for the physician community is that patients want their provider of choice and prefer to have continuity in care. Patients value the relationship with their physician, but we have to remove barriers for access.


J. Baugh: So where do you see telemedicine going as we move beyond the public health emergency?


Michael: I've been studying telemedicine and providing education for the last four years, I personally utilized telemedicine over four years ago for an eye infection. I thought it would expand more quickly, however, there tends to be a negative perception with patient documentation technology and access in healthcare. Many physicians have had negative experiences with EHRs, patient portals and payment reform. Also, there's a portion of the population that's not comfortable with technology.


COVID was the catalyst that moved the dial, and now we'll have to see if it's here to stay. Part of the public health emergency, I witnessed most states increasing flexibility for telemedicine. Many payers also expanded coverage, although it had restricted access, medical schools are implementing telemedicine in the curriculum and residents are becoming more comfortable with the service. It's not appropriate for every situation, but I think it will be an integral part of care moving forward.


J. Baugh: Do you have any recommendations on a starting point for those listeners who may not have started with telemedicine yet?


Michael: Yes. It would be good to review the state laws regarding telemedicine. There are state laws regarding licensure, informed consent, establishing the relationship, medical records and security. Telemedicine is regulated at both the federal and state level. It would also be good to research payer guidelines beyond the emergency. It's also important to visit with your malpractice carrier to make sure you're covered for telemedicine.


Beyond that, The American Medical Association and The Medical Group Management Association have an implementation guide. The American Telemedicine Association and The National Consortium of Telehealth Resource Centers have a wealth of information. I think it would be helpful to visit with telehealth vendors to explore the functionality in the practice.


J. Baugh: How about for our practice managers out there listening? With physicians now resorting to telemedicine in many cases, do you have any tips or advice for a practice manager as she or he transitions office processes and so forth?


Michael: Yes. When the pandemic started, most physicians implemented telemedicine with little planning. Instead of being strategic, implementation was for survival. Now that providers and patients are more comfortable with the service, it would be helpful to review processes to ensure success in the long-term. It starts by identifying the need. What are you trying to accomplish?


For example, are you trying to fill no-show visits, capture new patients, improve access or improve office efficiency? While all are important, it'd be helpful to have a few goals for the practice. It'd be helpful to have a small team that works together to achieve those goals. You can measure your success and adjust based on the accomplishment of those goals. The American Medical Association has a telemedicine playbook that describes some of the steps practices can use for implementing telemedicine.


J. Baugh: So Michael, as we're getting ready to wrap up this particular episode, do you have any final tips or advice that you would like to share?


Michael: Yes! If you haven't started telemedicine yet, I would encourage you to at least look into it. Start small by identifying a few services that you feel comfortable treating telemedicine. If you are established, keep in mind the changing payer guidelines and also look for ways to improve your process. As I mentioned earlier, there are some vendors that assist with some of the functionality in your practice and it can help you improve the service beyond the emergency period.


J. Baugh: Well, Michael, I want to thank you for taking the time today to talk about such an important topic as telemedicine, and I also want to let our listeners know that we will have links in the show notes for any resources that you've talked about today. So just let the listeners know they might want to check out the show notes to find links to those references. And once again, thank you Michael for your time today.


Michael: My pleasure, it's an honor to visit with you.


Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect. Listen to more episodes, subscribe to the podcast and find show notes at SVMIC.com/podcast.


The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.