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Previously, Medicare’s rules and requirements for reimbursement of healthcare providers for services delivered through telemedicine were very stringent and only limited to a few types of health services.

During the last few years, owing to the expansion of telemedicine, Medicare has extended the list of telemedicine services that they reimburse; however, there are still many rules for how these services need to be provided, in order to meet their criteria for reimbursement.

The following are a few key points of information regarding Medicare and Telemedicine.

Rules for determining Originating and Distant Sites. Medicare provides reimbursement for telehealth services that providers offer from a Distant Site to patients at an Originating Site.

As per the law, Originating Sites can be any of the following:
Hospitals
Offices of physicians or healthcare practitioners
Critical Access Hospitals (CAH)
Rural Health Clinics
Federally Qualified Health Centers
Skilled Nursing Facilities (SNF)
Hospital-based or CAH-based Renal Dialysis Centers
Community Mental Health Centers (CMHC).

The patient needs to be located in an HPSA. According to Medicare’s rules for reimbursement, not only must the beneficiary receive care virtually at one of the Originating Sites specified above, but this setting must also be situated in a Health Professional Shortage Area (HPSA).

Facility fee eligibility. Along with reimbursing services provided via telemedicine, Medicare also pays a facility fee to the originating site. For instance, primary care providers who are dealing with a patient in person, and decide to conduct a telemedicine consultation with a physician present in another location, can submit two separate bills for reimbursement – one for the telemedicine service they provided, and the other for a facility fee (for hosting the virtual visit).

Eligible healthcare providers.
As per the rules of Medicare, only the following providers may offer care through telemedicine:
Physicians
Physician Assistants
Nurse Practitioners
Nurse Midwives
Clinical nurse specialists
Clinical Social Workers
Clinical Psychologists
Registered dietitians or nutritionists.
Telehealth types.

Medicare provides reimbursement solely for live telemedicine, which involves real-time interaction between a healthcare provider and a medical beneficiary (patient) through a protected, private video chat. This sort of virtual visit serves as a substitute for an in-person consultation.

A recent study published in Medical Decision Making outlined a detailed comparison of telemedicine (usage of telecommunications technology for remote consultation, diagnosis, and treatment of patients) with consultation via telephone for pediatric cases in remote-area hospitals. The findings of the study, conducted by researchers at UC Davis in Sacramento, revealed that telemedicine saves upwards of $4,500 per case, which more than makes up for any expenditures on the technology.

Previous studies have already established the advantages of telemedicine for children and their families, as well as doctors – telemedicine is known to decrease errors in medication, and increases satisfaction on part of both patients and parents. However, little research has been done on finding out whether it cuts costs for any of the parties involved.

The study was conducted by researchers belonging to UC Davis’ Pediatric Critical Care Telemedicine Program, and its sample included consultations offered by healthcare providers at UC Davis to 8 emergency departments in rural areas, between 2003 to 2009. Within this duration, the researchers delimited their study to five conditions – dehydration, fever, pneumonia, asthma, and bronchitis.

These conditions were chosen because they can be treated in remote hospitals and do not require the aid of telemedicine.

The researchers compared each rural clinic’s expenses for installation of equipment required for telemedicine to the costs of transport and on-call specialists – the findings revealed that each cost around $3,640 but also saved $4,660 on average. The cost of telemedicine consultations, in fact, reduced patient transfers (and costly transfers via air ambulance) by 31%.

Physicians based in California are paid for consultations via telemedicine but providers in various other states do not enjoy the same advantage. James Marcin, interim head of pediatric critical care medicine at UC Davis, stated that owing to the varied benefits of telemedicine, it is prudent to work on creating incentives for physicians to adopt this model, by ensuring that they are paid for implementing and utilizing this technology.

The savings that can be obtained via telehealth are not solely limited to a decrease in healthcare costs. The implementation of telehealth in the workplace also leads to minimal time wastage, decreased nonattendance rates, and increased productivity among workers.

As with all other forms of technology used in the sphere of healthcare, telemedicine also needs to ensure compliance with HIPAA, for the purpose of protecting the privacy of patients. Apps such as Skype might provide a platform which doctors can use to provide virtual sessions to patients, but employing the app for this purpose is not an HIPAA-compliant practice. Any form of technology employed for the purpose of telemedicine must provide fool-proof security and guarantee the safety and privacy of patients’ personal information.

A number of states in America have laws of this sort, which make it mandatory for parties such as developers of telehealth apps to ensure their compliance with various rules for security and privacy, regardless of whether or not their company is subject to HIPAA.

Some laws in California decree that apps must have the “do not track” feature. Florida completely revamped its law for reporting data security breaches the previous year and passed a law this summer which requires that detailed contact information is made available on websites and digital services online.

It is vital for present health apps, telehealth apps, and developers of consumer-targeted tools for health to take these laws into account. States are working on extending the scope of laws for ensuring privacy and security, and developers of health apps need to comprehend these laws and adhere to them.

However, as pointed out by the National Policy Telehealth Resource Center, “Compliance with the Health Insurance Portability and Accountability Act (HIPAA) is more complex than simply using products that claim to be ‘HIPAA-compliant.” It is not enough for the platform being used for telemedicine services to be compliant – the patients, providers, and staff members utilizing the tool also need to make sure that they are HIPAA-compliant.

For example, in addition to creating a product that guarantees security, telemedicine software designers will also need to make sure that their companies are in compliance with HIPAA.
Compliance with HIPAA involves a structured set of safe practices which include stringent documentation and monitoring, between parties whose privacy is ensured.

Products in themselves cannot guarantee compliance – however, certain products might have components which permit users to employ them in a way that is in accordance with the HIPAA.

The HRSA’s “Telehealth Network Grant Progam” www.hrsa.gov/ruralhealth/telehealth has awarded $6,286,264 in grants to 21 community health organizations. Each organization will receive an annual fund of $300,000 for about three years, with the goal of targeting medically underprivileged areas for the creation and implementation of viable telehealth programs and networks.

Organizations can utilize this funding to augment and extend healthcare providers’ training, in addition to raising the quality of health that is accessible to healthcare providers and subsequently to patients and their families. The program places specific emphasis on establishing teleconnections to School-Based Health Centers (SBHC); as such, it is mandatory for grantee networks to include a minimum of one SBHC.

Another grant for telehealth, the USDA Rural Development Distance Learning, and Telemedicine (DLT), was awarded to organizations working in rural areas of America. The California Telehealth Network www.caltelehealth.org, for instance, was awarded a grant of $405,917 for a three-year duration.

This funding is to be targeted toward using telehealth training and equipment for the purpose of improving the access of rural underprivileged communities in central, northern, and southern California to telemedicine specialty physician services and distance learning. The project comprises one central hub and a total of 48 end user sites.

The DLT granted to the Center for Telehealth is geared toward the provision of specialty care to nine StrikeForce counties designated by the USDA. In addition, two mobile Health Wagons will cover six counties, granting primary care on-site, as well as access to specialty doctors and clinicians via telemedicine video conferencing.

Rural Development DLT funds worth $375,000 will go toward the expansion of Alaska’s current telemedicine program. The grant will benefit the rural patients in 24 villages by enabling them to connect with and consult medical specialists. The mental, behavioral, and lifestyle healthcare requirements of rural patients will also be catered to.

In addition, another $494,518 grant will fund Avera Health www.avera.org in South Dakota, Minnesota, Nebraska, and Iowa for the purpose of using Avera’s ePharmacy network to provide aid and assistance to struggling hospitals that are low on staff. A total of 18 rural hospitals that are short on staff will be provided a live pharmacist who will offer round-the-clock pharmacy support and prescription review. Each hospital will also be equipped with an automated dispensing machine.

There are many positive signs that point to a bright future for telemedicine. Given the exponential increase in technological advancements, telemedicine is likely to become more widespread and easier to implement and use in the future. There are already a number of ground-breaking tech products which are assisting healthcare providers, such as smart glasses (e.g. Google Glass) and smartwatches (such as the Apple Watch) – these aid in the monitoring of health data for patients, and can send real-time information on a patient’s health to doctors and professionals. Programs such as clmtrackr, which gauge people’s emotional states via their facial expressions, can also be employed for the monitoring of mental health.

The healthcare system currently displays a rising trend for shifting to a fee-for-value payment structure. Owing to this, healthcare delivery is now focused on achieving increasingly high-quality care results, rather than simply emphasizing on increasing the volume of visits.

Peter Kilbridge, an Advisory Board analyst, offered an opinion recently on the fact that there has been a rise in provider-to-provider use of telemedicine and suggested that this could be a promising development for population health management. The Advisory Board stated:

“Telehealth eye exams are popular among diabetic patients, have been shown to be highly effective, and are increasing in use. A Canadian study reported the successful use of image and email-based telemedicine for orthopedic consultation for 1,000 patients for mild-to-moderately severe fractures, saving patients thousands of miles of travel. Other uses include remote eye screening for retinopathy of prematurity, support for pediatric transport, the conduct of remote sleep studies, remote support for pediatric asthma, and others.”

In order to remain at par with the rapid advancements in technology, telemedicine will have to resolve issues at the administrative level; these issues include limits and constraints imposed by state laws on telemedicine, the licensing criteria set out by medical boards which is specific to each state, and uncertain policies on reimbursement which determine whether payers reimburse healthcare providers and patients do not pay out-of-pocket.

However, keeping in view the prediction that the industry of telemedicine will be worth around $36.3 billion by 2020, the 50+ bills in the 113th Congress pertaining to telehealth, and the survey which found 75% patients to be interested in telemedicine, it appears that telemedicine’s future is promising, and increasing demand is likely to help the industry rise above these obstacles.

Telemedicine platforms, like all other innovative technological solutions, require proper training and the purchase of appropriate equipment. The extent of the training and the types of equipment required to depend on the sort of solution that is needed.

For example, a more detailed and widespread inpatient telemedicine program which is designed for use between primary healthcare providers and specialists for consultation will obviously require in-depth training and the purchase of equipment such as a telemedicine cart and several types of mobile health devices.

Detractors of telemedicine maintain that virtual visits lack a necessary personal touch, and do not allow for physical exams which are essential for a complete diagnosis. If there is an increase in providers and patients resorting to online consultations rather than face-to-face in-person visits, what could be the possible ramifications of this?

There is no denying the effectiveness and value of in-person visits between patients and healthcare providers – in some cases, they are essential. Telemedicine needs to be used to enhance and complement these in-person visits; doctors can use it to check-in with patients and ensure that care and treatment are proceeding smoothly.

In addition, telemedicine is also great for the treatment of small, minor conditions such as infections, in which case in-person consultations are not usually required. In such scenarios, telemedicine benefits providers, patients and the entire healthcare system as it is both time-saving and cost-effective.

Reimbursement can often be a tricky subject where telemedicine is concerned, as state policies regarding this new healthcare technology keep changing. Various states now have parity laws in place which make it mandatory for private payers to provide reimbursement for telemedicine consultations, as they would for in-person consultations.

Ultimately, the best way to figure out matters of reimbursement is to call top payers and request information on their policies. You may also find it helpful to view our guide on telemedicine reimbursement, as well as this matrix developed by ATA on state policies in this regard.

Another point to be noted is the fact that doctors and providers who are using telemedicine will include a convenience fee in their charges to patients, and these can range from $35 – $125 for each visit. This fee is charged directly to patients and is in addition to reimbursement through payers. However, despite the fact that patients have to pay this fee out-of-pocket, many providers have discovered that patients are generally willing to do so for the sake of added convenience.

The growth of telemedicine in the past couple of years has been significant; however, there are still several obstacles to widespread acceptance and adoption of this practice.
State laws are the main determinants of reimbursement policies for telemedicine services provided within that state, as well as any restrictions in this regard. If a state has passed a telemedicine parity law, for example, private payers based in that state will be required to reimburse telemedicine consultations just as they would with a traditional in-person consultation.

A large number of states have passed telemedicine parity laws – however, bringing about a change in legislation at the state level is a lengthy and often complicated process, which has major ramifications for the practice of telemedicine in that state.

Obtaining reimbursement for services provided through telemedicine is not as simple a process as the one for healthcare provided via traditional medical practice. The state policies for telemedicine are constantly changing, and this has a direct impact on the rules and regulations regarding reimbursement via state Medicaid programs and private payers.

Currently, Medicaid does offer reimbursement for the real-time provision of care through telemedicine; however, there are restrictions involving which providers meet the criteria for reimbursement, where the patient is located, the medical procedures that qualify for reimbursement, etc.

Its steady rise indicates that telemedicine now provides a larger variety of options and more cost-effective solutions. However, in the initial stages, telemedicine programs do require some investment and expenses, in the shape of purchasing and setting up new equipment, and training staff members on how to use this new technology. This means that some independent practices that operate on a small scale might find that they are unable to accommodate telemedicine in their budgets.

Numerous health care providers are already strained on new budgets for technology and training of staff members for EHR systems, which has been made mandatory by the Meaningful Use program.

Currently, as per the law, healthcare providers are granted medical licenses for a particular state, which means they can practice legally in that state alone. For example, as per medical licensing rules, a doctor based in Colorado cannot legally take on a patient located in New Mexico.

This law presents an obstacle for telemedicine, the aim of which is to overcome geographical boundaries in order to allow providers to offer care to patients regardless of location.

As it is relatively new, the telehealth industry is far from having a set of standard rules and regulations for telemedicine. However, the American Telemedicine Association has compiled some guidelines for a variety of specialties, selected on the basis of a survey.

There are a variety of conditions that are not on the list but can still be treated through telemedicine. However, the following conditions are particularly well-suited to treatment through telemedicine: Allergies and asthma, Chronic bronchitis, Conjunctivitis, Diabetes, Hypertension, Low back pain, Otitis media, Rashes, Upper respiratory infections, UTIs, Mental illness/behavioral health, Prevention and wellness services.

The usage of telemedicine is not suitable for conditions where in-person visits and physical examinations are necessary, owing to extreme symptoms, forceful interventions, or in the case of procedures for which certain protocols need to be followed. In addition, in the case of a medical emergency, patients need to call 911 or visit the ER immediately.

Ultimately, providers need to use professional expertise and judgment in order to determine whether telemedicine is or is not appropriate in a particular case.

There are only a few states where the law requires providers to obtain the informed consent of patients before employing telemedicine in their cases.

However, it is always a good idea to do so, whether or not it is required by law in your state. Prior to the first virtual visit via telemedicine, providers need to give the patient a clear and simple explanation of how telemedicine works (the timings during which they can avail the service, privacy matters, scheduling appointments, etc.), the rules regarding confidentiality, what to do in case of technical failure, regulations for contact in between virtual consultations, prescription policies, and the coordination of healthcare with other providers and professionals.

Healthcare professionals need to set aside a dedicated area for practicing telemedicine. This area should be well-lit, have clear audio, ensure the privacy of the patient, and be in a place where there are no disturbances. It is also recommended that healthcare providers set their cameras on a steady and even stand, and fix the cameras so they are at eye-level.

Having a contingency plan in place in the case of emergencies and referrals is also highly important.

Lastly, it is essential for the providers to communicate with the patient in a culturally sensitive manner, via a language that the patient understands fully. If the patient is unable to comprehend the provider owing to a language barrier, the use of telemedicine is not advised.

With the advancing technology, improvements have been done on health care provision through Telemedicine. The preceding denotes the interchange of medical information via electronic communication. Notably, many insurance companies are encouraging their members to subscribe to the above because it saves time and money. Nevertheless, it is important to note that customers fail to receive the care they want.

At times, patients can contact Teledoc and fail to receive treatment. However, these doctors do not refund the money. The preceding is wrongful on the customer. Equally, it is a breach of the doctors’ professional ethics. Consequently, the client is left disadvantaged, since he or she will meet another cost of visiting a regular doctor.

CEO Jason Gorevic claims that investigation on customer satisfaction is done within 72 hours. However, this is not true. Not everybody is surveyed. Kim Guthrie of Texas called for urinary tract infection treatment but he did not receive treatment and was not refunded. Surprisingly, he was not interviewed, likewise for Mc Murrain.

Telemedicine attendants may ignore the client’s explanations. The above results in failure in fulfillment of customer’s health needs. Evidenced by symptoms, McMurrain knew she had a Sinus infection. According to her history, the infection remains on her chest if unattended. Then, she called a doctor for a prescription. Instead of helping, the doctor gave her a lecture on how people use antibiotics excessively. Subsequently, the infection got into her lungs making her sicker. Basically, physicians do not take time to listen to clients because of the rush to attend to others online. The preceding lowers the quality of service offered since caregiver do not understand the customer’s exact needs.

David Hildebrand mentions that their Telemedicine policy is founded on “performance assurances” for call duration, hold times, and affiliate gratification. However, he exempts the standards of care therein. In regard to experience and whether the physicians have credentials, David Hildebrand says they just believe in them and they are appreciated. Honestly, there is a need for assurance that physicians fit in their positions. Inexpert doctors are likely to give an incorrect diagnosis and consequently wrong medication to the sick resulting in adverse consequences.