Two proposed rules open up opportunities for care coordination through telehealth

Over the summer, the Centers for Medicare and Medicaid Services (CMS) issued two proposed rules that will create mechanisms for some providers to receive payment for telehealth as well as other non-face-to-face and care coordination services using telecommunications technologies. Together, the changes proposed in the calendar year 2019 Medicare Physician Fee Schedule (PFS) and the Medicare Shared Savings Program (MSSP) proposed rules have the potential to enable new interactions that strengthen care access and coordination for a much broader set of patients.

The term “telehealth” is often used to broadly refer to the use of telecommunication technologies to furnish healthcare services. However, Medicare telehealth services specifically refer to a set of Part B-covered services specified under section 1834(m) of the Social Security Act. By law, Medicare fee-for-service (FFS) telehealth services under the PFS are currently subject to the following conditions:

• Provided using real-time, interactive audio and video
• Geographic restrictions on originating site (beneficiary location)
• Setting restrictions on distant site (provider location)
• Provider restrictions (and possibly further limitations due to state licensure laws)
• Limitations on type of visits

Waivers of Medicare telehealth rules are currently available under specific CMS Center for Medicare and Medicaid Innovation models. For example, under the existing Next Generation ACO Model, CMS has waived the geographic and originating site requirements for Medicare telehealth services. In addition, beginning in 2018, the Next Generation ACO Telehealth Waiver was expanded to include asynchronous telehealth services for teledermatology and teleophthalmology, which provides physician payment for the receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation.

MSSP accountable care organizations (ACOs) do not currently have such flexibility because no telehealth waivers are available to them. However, under the MSSP proposed rule, for 2020, CMS has proposed changes for telehealth services provided by ACOs that take on two-sided risk. Specifically, CMS proposes to expand the use of telehealth by ACOs by removing the geographic and originating site restrictions on these services. This means that ACOs will be able to provide telehealth services to beneficiaries in their homes as well as for beneficiaries obtaining care in metropolitan statistical areas (MSAs).

In addition, under the PFS proposed rule, CMS proposes to provide separate payment for new non-face-to-face services, virtual check-in visits, chronic care remote physiologic monitoring, interprofessional consultation, and remote professional evaluation of patient-transmitted information.

In this paper, Milliman’s Susan Philip, Carol Bazell, and Laurie Lingefelt describe these changes in greater detail and also discuss the possible implications for providers and MSSP ACOs in particular.

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