ORLANDO -- What is the best-kept secret in the telemedicine industry? The fact that payers legally cannot discriminate against clinicians who provide services via telemedicine, according to healthcare attorney Alexis Gilroy, JD. "This is massive leverage," Gilroy, a partner at Jones Day in Washington, said Wednesday during a session at the annual meeting of the Healthcare Information and Management Systems Society (HIMSS). "Use it." In her presentation, Gilroy discussed the three types of telemedicine: Provider to provider. This is the form of telemedicine "most talked about, and most often reimbursed." Remote monitoring. Chronic care is part of this model, and the Centers for Medicare & Medicaid Services (CMS) is paying for new services in this area, Gilroy said. "This involves a variety of healthcare providers generally working in concert with each other; they are all getting data from the patient." Direct to consumer. This type of telemedicine "has given the most consternation to the regulators, and it's probably the most disruptive of the various models," she said. With regard to the latter, said Gilroy, "Some people are referring to this as 'consumer-initiated care' -- you have a clinician who is in a remote location from a patient and directly engaging with the patient or consumer," including providing wellness or educational services. This often involves serving the patients "where they are, in their home or in a work environment, not a traditional brick-and-mortar healthcare setting. That piece has made regulators stop and think, 'This is a really different engagement between the healthcare provider and a patient." No matter which type of telemedicine is employed, the regulations for it are based on the state in which the patient is located -- that includes things such as licensure rules, practice standards, and certification for allied health professionals like genetic counselors, Gilroy noted. In addition, in terms of reimbursement from commercial payers, at least 32 states have adopted some form of legislation that "advances the ball" for private-payer reimbursement, she said. "Basically, these are anti-discrimination [rules]; that is, a service can't be discriminated against because it was performed via telemedicine." Some states, such as California, have very strong "telemedicine parity" laws that include several types of telemedicine, such as asynchronous consultations -- in which the patient side and the physician side of the encounter occur at different times, not in real time -- as well as remote monitoring. Other states, like Texas and Louisiana, have more narrow definitions and just limit telemedicine to real-time audio or video, said Gilroy. Knowing those differences can be very helpful when it comes to billing, she added. "If you educate yourself on state rules, you can have a very productive conversation with your payer. [You can ask whether] there are any particular modifiers or specifics you want incorporated as part of [telemedicine] claims" to make sure they're in agreement with state law. Some states, like Florida, require providers to meet the same standard of care in telemedicine as they would if they saw the patient in person, "but audio-only, email-only, or fax-only encounters are not [considered] telemedicine," she said. So telemedicine advocates will often point out that clinicians will combine audio-only telemedicine with store-and-forward technology to give the clinician access to medical records, pharmacy records, and other data to enrich the patient encounter. "That's a great point," said Gilroy. "That would be the conversation that [telemedicine providers] want to have with a regulator. You have to understand what the rules say, and then think what your model will do to go beyond the audio-only encounter." Although most telemedicine regulations focus on physicians, a lot of non-physician provider groups, such as those for nurse practitioners and physician assistants, are starting to think about how to approach the issue. "Although [physicians] may be able to appropriately supervise a non-physician provider, some of the language in the state rules and the payer rules hasn't been updated to enable that remote supervision, so it's important to understand whether in-person supervision is required." "We've been successful in some cases going to talk to the regulators and saying, 'Look, here's the model we want to put out; here's how we will deal with supervision -- frankly it may be even better supervision than supervision down the hall because we'll have somebody who's actually watching and intimately engaged' ... Just go have those conversations because sometimes the rules have not been updated to deal with that." As with many other areas of medicine, telemedicine is not immune from turf issues, particularly when it comes to eye care, Gilroy said. "We're starting to see some state rules saying 'Telemedicine is great ... except for providing services for ocular health.' Just watch out for that. Not all disease states and conditions you might look to treat via telemedicine are treated equal." Why is that particular area a problem? "Unfortunately, I think some in the ocular health space view telemedicine as a threat," Gilroy told MedPage Today. She noted that South Carolina had passed telemedicine legislation last year that excluded ocular health, including prescribing eyewear remotely; the governor's veto of the bill was overridden by the legislature. And eye care specialists weren't the only ones. "Until 2014, telemedicine was technically unethical under AMA [American Medical Association] standards," said Gilroy. "That's pretty remarkable, but thankfully that changed; I think that shows young physicians are embracing this. They [see it as] a new tool to engage with their patients." To help providers sort through all the new regulations, several professional societies and policy organizations, such as the American Telemedicine Association, have developed guidelines and other information on providing services via telemedicine, Gilroy said. One question providers need to ask themselves if they are considering providing telemedicine services is when do they need to use real-time video and audio. "Regardless of what regulators say, from a clinical perspective, [they need to decide] what's appropriate and what's not appropriate -- involve clinical teams in evaluating that [question] and build it into your protocol."
Telemedicine is making advances in state law, helped by anti-discrimination rules that make it clear that the service has parity with other healthcare offerings. Telemedicine services can be divided into At least 32 separate types: provider to provider, remote monitoring and direct to consumer. The second is most easily reimbursed, and the first is supported by MedPage Today reimbursement for chronic care and other similar services. The last is referred to as “consumer-initiated care”, where clinicians interact directly with patients via telemedicine. This type of telemedicine is potentially the most disruptive. three states have advanced legislation that will clear the path from private payer reimbursement for the latter option, enforcing the rule that telemedicine cannot be discriminated against. What is considered “telemedicine” varies from state to state, meaning telemedicine providers should approach regulators with their proposals and help to advance the implementation of this type of care. There are still certain areas of medicine that are resistant to the advances of telemedicine, such as ocular health. However, the progress in state legislation has led several professional groups and policy organizations to create useful guidelines on the implementation of telemedicine.