The growth of telemedicine fueled by the COVID-19 pandemic has been astonishing. After decades of being touted as the future of healthcare, telehealth quickly became commonplace as social distancing and stay-at-home orders took effect. Now, although its growth has stabilized for the time being, it's achieving utilization rates that are 38 times higher than before the pandemic.
Providers and patients adopted new technology against a backdrop of sweeping regulatory changes across the healthcare industry. As a result, new hybrid care models emerged with many wondering whether telehealth services are truly here to stay. This article discusses current telehealth regulations and where we may be headed next after the conclusion of the public health emergency (PHE).
What is telehealth?
Telehealth is the use of technology to receive healthcare services that don’t require an in-person office visit. For example, patients can talk to their doctor live over the phone or video chat; send and receive messages using secure messaging, email, or secure file exchange; or use remote monitoring so their provider can keep tabs on their health.
Why is telehealth regulated?
A few things in healthcare surprisingly remain unregulated, but telemedicine has never been one of them. In fact, before the pandemic, telehealth regulations were incredibly complex, making it difficult for healthcare providers to fully embrace the technology and offer it to patients on a broad scale. There was always at least one regulatory barrier that made it difficult to implement, and most providers faced multiple barriers. These regulations included:
- Medicare payment policies
- Federal agency regulations
- State policies, including parity laws, licensing, and credentialing board regulations
- State-specific Medicaid rules
- Private insurance rules and regulations
During the pandemic, though, the typically slow-moving landscape of healthcare shifted at once: Medicare, states, and private insurers made numerous changes to encourage providers and patients to use telemedicine. With these changes came the ability to make care convenient and more accessible. However, with this ease also came the potential for excessive use of care that increases costs without improving health. This is one reason why telehealth services are regulated—to prevent fraud and abuse.
Who regulates telemedicine?
The same state-specific institutions that establish standards for in-person clinical treatment create standards for telemedicine visits. These institutions must comply with all federal telehealth regulations, including the Health Insurance Portability and Accountability Act, or HIPAA (with enforcement discretion during the PHE). Although the healthcare industry saw greater regulatory flexibility on a federal level during the PHE, individual states continue to determine many aspects of telehealth regulation.
What are the requirements for telehealth services?
The regulatory parameters for delivering telehealth services are numerous, and include:
- Provider licensing and credentialing requirements
- Documentation rules
- Privacy-related mandates
- Medical coding requirements
The Federation of State Medical Boards publishes a state-specific summary of telemedicine laws 2021, created in response to the COVID-19 pandemic. The Center for Connected Health Policy also provides a state-by-state comparison for telehealth laws in 2021. Finally, the Centers for Medicare & Medicaid Services (CMS) published a telehealth toolkit that includes federal and state policies, including coding and documentation tips to ensure revenue integrity.
Note that private payers may also have their own unique requirements for billing telehealth services. Healthcare providers rendering telehealth services must comply with all state and federal telehealth laws as well as payer-specific requirements and federal regulations affecting credentialing and privileging.
How did requirements for telehealth services change during the PHE?
On a federal level, CMS expanded telehealth coverage to include more than 80 additional services. The agency also permitted other changes, such as being able to bill telehealth visits at the same rate as in-person visits, removing geographic and originating site limitations, and providing temporary provider licenses to practice across state lines. Likewise, on a state level, there were requirements for payment and coverage parity among private payers, loosening of location and modality requirements for telehealth services, and more.
The federal government, many state governments, and several private payers also allowed healthcare providers to use telephone and other audio-only technologies to deliver telehealth services that do not require a physical or visual exam. Telehealth regulations continue to change frequently, which is why it’s important for healthcare providers to stay abreast of new developments and credentialing requirements.
What entities monitor telehealth compliance?
In addition to Medicare and commercial payers that conduct audits of telehealth services, the Department of Health and Human Services’ Office of Inspector General (OIG) has also taken a closer look at telehealth, especially in light of its increased utilization during the pandemic. The goal? To ensure “telehealth delivers quality, convenient care for patients and is not compromised by fraud.” In fact, the OIG is currently undertaking seven different national telemedicine audits of telemedicine services under the Medicare and Medicaid programs. These audits will also review remote patient monitoring, virtual check-ins, and e-visits. Telehealth fraud and abuse is not new. The OIG previously issued a report in 2018 that found a 31% error rate among telehealth claims. Specifically, these claims did not meet Medicare requirements for payment.
What are telehealth parity laws?
There are two types of parity laws:
- Coverage parity requires payers to cover telehealth services just as they would cover in-person services.
- Payment parity, though, requires the same payment rate.
Currently, 43 states and the District of Columbia have implemented a coverage parity law. However, not all of these state laws are created equally in terms of ensuring that providers can deliver telehealth and patients can access virtual care. Only 14 states require payment parity for telehealth. Payment parity laws are critical because they forbid health plans from paying for telehealth services at only a fraction of what they would pay for the same exact service rendered in-person. This step makes it easier for healthcare providers to justify investing in telehealth solutions.
What are the infrastructure requirements for telehealth?
Nearly all telehealth programs require broadband Internet to transmit audio and video data. They also need HIPAA-compliant telehealth software, devices compatible with that telehealth software, and access to technical support to prevent interruptions in care.
What’s the best way to train healthcare providers on telehealth technology?
Many telehealth software vendors offer healthcare provider training. This is a great place to start. It may also be helpful to identify a “super user” within the organization, who can undergo more in-depth training and become the resident expert for all things telehealth. Another helpful training-related step is to create a frequently asked questions document that providers can reference at their convenience. Don’t forget to give physicians actual hands-on training in a simulated environment so they can get used to using the technology before going live with patients. Finally, plan for refresher training as telehealth software enhancements or other updates occur.
Once physicians become comfortable with the technology, organizations can take their training to the next level to help providers improve their telehealth technique. This can include everything from making eye contact to wearing colors that translate well on camera to improving lighting in the room and more.
What are the benefits of telehealth?
There are many benefits of using telehealth for all healthcare participants. One obvious example is that during COVID-19, telehealth helped reduce the spread of infectious disease. But its benefits for patients, providers, and health systems go so much further. For example, telehealth allows providers to:
- Increase continuity of care
- Extend access beyond normal clinic hours
- Reduce or eliminate patients’ travel burden
- Overcome clinician shortages
- Manage patients’ chronic conditions more effectively
- Enhance patient experience, wellness, and satisfaction
- Improve efficiency
The use of telehealth can also help attract and retain patients. For example, many organizations view telehealth as part of a larger digital health strategy that includes a retail-like experience for patients. Not only can patients video chat with a provider within minutes, they can also self-schedule clinic and virtual appointments based on real-time availability, compare wait times at urgent care facilities, and check symptoms using a chatbot. Many of these functions are available directly from a mobile app that also allows patients to perform additional tasks, such as accessing their health information, contacting their provider, and paying their bill.
What is telehealth nursing?
Telehealth nursing is the use of telecommunication technology (i.e., videoconferencing, image sharing, remote monitoring devices, and more) to provide clinical healthcare, patient and professional health-related education, public health information, and healthcare administration. For example, a telehealth nurse can monitor a patient’s oxygen levels, heart rate, respiration rate, and blood glucose remotely. They can teach patients how to dress a wound or treat a minor burn via a video call. They can collect medical history information and reconcile a patient’s medication list before the patient sees a physician. Telehealth nursing improves patient access to care (especially in rural communities), saves time and money, and helps balance nurse workloads.
What are the biggest opportunities in telehealth?
There are many opportunities. For example, providers can use telehealth to provide front-line care, monitor discharged patients, address behavioral health, treat chronic conditions, and more. However, with opportunities often come challenges. For remote patient monitoring, for example, organizations must be able to manage supply chain logistics for wearable technology, establish escalation points for intervention, and work with community leaders to tackle lack of access to broadband Internet. They must also address health literacy and other social determinants of health.
What is the future of telehealth?
Many healthcare organizations have continued to forge ahead with delivering safe care via telemedicine as part of a larger strategy to reduce costs and improve outcomes under value-based payment models. These organizations also know this fact: Consumers want this technology. Eight out of 10 consumers say COVID-19 has made telehealth an “indispensable part of the healthcare system,” while three out of every four consumers say, “telehealth is the future of medicine.”
However, other organizations are more conservative and prefer to delay long-term telehealth investments until it becomes clearer whether flexibilities regarding telehealth regulations will stick, and whether payers will continue to pay for telehealth services as they currently do during the PHE.
Telehealth continues to improve patient access to healthcare services during the COVID-19 pandemic. Will payers and regulators continue to promote and cover telehealth once the PHE ends? This question has yet to be answered and it is front and center for healthcare organizations nationwide. Telehealth regulations play an important role in preventing fraud and abuse, but the danger with regulations may be a tendency to over-regulate and prevent progress toward lower-cost, equally as effective care models. How will the story unfold? Only time will tell.
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