Healthy Adult Opportunity
State program directors face many complex considerations as they evaluate the Healthy Adult Opportunity 1115 waiver option.
New flexibility for telehealth, virtual visits, and remote patient assessment and monitoring under MSSP ACO and PFS proposed rules
This 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 and other non-face-to-face services, as well as care coordination using enabling telecommunications technologies. Together, the changes proposed in the calendar year (CY) 2019 Medicare Physician Fee Schedule (PFS) and the Medicare Shared Savings Program (MSSP) proposed rules have the potential to enable new provider interventions that strengthen care access and coordination for a much broader set of both patients.1,2 In this paper we will describe these changes in detail, as well as the possible implications for providers and MSSP ACOs in particular. This paper is the fourth in a series of white papers Milliman is writing on the MSSP proposed rule.
“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:
Originating sites must be located in a health professional shortage area that is either outside of a Metropolitan Statistical Area (MSA) or within a rural census tract. Originating sites are limited to a practitioner’s office, critical access hospital (CAH), rural health clinic (RHC), federally qualified health center (FQHC), hospital, hospital-based or CAH-based renal dialysis center (including satellites), skilled nursing facility (SNF), or community mental health center (CMHC).
Some inherently non-face-to-face services not listed among the Medicare-approved telehealth services may still be eligible for separate FFS payment. For example, as discussed further below, remote patient monitoring (CPT 99091), which is the “collection and interpretation of physiological data,” may be paid separately, provided that other conditions established by CMS are met (e.g., initial face-to-face visit with the practitioner for a new patient or patient not seen within one year by that practitioner prior to the remote monitoring service; beneficiary consent documented in the medical record).
Current waivers of Medicare telehealth rules
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 ACOs do not have such flexibility because no telehealth waivers are currently available to them.
For 2020, CMS proposes:
The Bipartisan Budget Act of 2018 provides certain ACOs the ability to expand the use of telehealth. Under CMS’s proposal, beneficiaries in urban locations may be served through telehealth. The beneficiary’s place of residence may also be an originating site. According to CMS, “This new flexibility will expand access to high-quality services in a manner that is convenient for patients.”4
More specifically, CMS proposes to make these telehealth flexibilities available to practitioners billing though the tax identification number (TIN) of an ACO under performance-based risk (i.e., ACOs in levels C, D, and E of the BASIC track and ACOs in the ENHANCED track) that has selected prospective assignment. CMS does not believe that ACOs that participate under the preliminary prospective assignment with retrospective reconciliation method meet the definition of an applicable ACO as specified in the statute, although it requests comments on its interpretation of this provision.
CMS also proposes to provide a 90-day grace period that functionally acts as an extension of beneficiary eligibility to receive telehealth services after a beneficiary loses assignment to the ACO. This 90-day coverage provides additional time for the ACO to receive quarterly exclusion lists from CMS and communicate beneficiary exclusions to its ACO participants and providers/suppliers. The ACO may not charge beneficiaries for whom telehealth services are not paid because the beneficiary was not prospectively assigned to the ACO or was not in the 90-day grace period. CMS expects that the ACO should have had procedures in place to confirm that the requirements for providing telehealth services were satisfied before the telehealth service was provided.
CMS does not propose to allow payment of telehealth services delivered through asynchronous technologies.
Virtual check-in visits
For the 2019 PFS, CMS proposes to provide a $14 payment for a brief virtual check-in by phone with a patient to determine if a visit to the office is necessary in order increase efficiency for practitioners and convenience for beneficiaries. If an office visit is required, CMS will not make a separate payment for the virtual visit.
CMS proposes to create a new Health Care Common Procedure Coding System (HCPCS) code to bill for virtual check-in visits to established patients. Payment for these phone assessments (which CMS does not consider telehealth services) would be bundled when the virtual visit originates from a related evaluation and management (E/M) service provided within the previous seven days by the same physician. Similarly, where the “check-in” leads to an E/M in-person visit with the same physician, the virtual visit would be bundled into payment for the E/M visit. The rule notes that certain components of medication-assisted therapy (MAT) for opioid use disorders could be carried out virtually and states that these new virtual check-in visits can allow a practitioner to assess the patient’s condition and determine whether an office visit is required. The virtual visit payment of $14 in the first year would be substantially lower than the proposed $92 payment for E/M in-person visits. CMS seeks comment on whether audio-only telephone interactions are sufficient compared with interactions that are enhanced with video or other kinds of data transmission.
Chronic care remote physiologic monitoring
For the 2019 PFS, CMS proposes to provide separate payment for certain remote physiologic monitoring services to further promote care management activities.
The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel created three new codes for 2019 to report services for remote monitoring of physiologic parameters (e.g., weight or blood pressure): initial set-up and patient education on the use of the equipment, a 30-day supply of the monitoring device including daily recordings or programmed alert transmissions, and 20 minutes or more per month of treatment management of the remote physiologic management services by physicians or clinical staff that requires interactive communication with the patient or caregiver.
For the 2019 PFS, CMS proposes to provide separate payment for interprofessional or “peer-to-peer” internet consultations (sometimes also called “e-consults”) as part of its efforts to reflect medical practice trends in primary care and patient-centered care management within the PFS.
CMS proposes to provide payment for two new CPT codes created by the AMA CPT Editorial Panel for CY 2019 and four existing CPT codes for e-consults of various durations that include “assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified healthcare professional with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or qualified healthcare professional.” The proposed rule discussion recognizes the value of team-based approaches and consultation to better manage patients with chronic or complex conditions. Instead of the current approach of generating a new specialist visit to ensure that the specialist is engaged in patient care, these new services are intended to promote more efficient communication between the treating and the consulting providers.
Remote professional evaluation of patient-transmitted information
For the 2019 PFS, CMS proposes to provide a separate payment for a physician’s use of recorded video and/or images captured by a patient in order to evaluate a patient’s condition, provided that the evaluation does not result in a subsequent E/M visit. The proposal is part of its efforts for reflect within the PFS the progression of technology and its impact on the practice of medicine in recent years and to increase access to services for Medicare beneficiaries.
CMS proposes to create a new HCPCS code for remote evaluation of for physician evaluation of patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology. When the review of the patient-submitted image and/or video results in an E/M in-person visit with the same physician, the remote service would be bundled into that office visit. Similarly, when the remote service originates from a related E/M service provided within the previous seven days by the same physician, the remote service would be bundled into that previous E/M service. CMS seeks comment as to whether these services should be limited to established patients or whether there are certain cases, like dermatological or ophthalmological services, where it would be appropriate for a new patient to receive these reviews.
Figure 1: Summary of current versus proposed policy
|Current policy||Proposed policy|
|MSSP ACOs experience geographic location restrictions for Medicare telehealth services||
|MSSP ACOs have originating site restrictions for Medicare telehealth services||
|MSSP ACOs are not paid for services provided by asynchronous technologies as Medicare telehealth services Next Generation ACOs may be paid for teledermatology and teleophalmology provided by asynchronous technologies||
|Brief communication technology-based service, e.g., virtual check-in payment is bundled into payment for related E/M visit, with no separate payment||
|Remote evaluation of pre-recorded patient information, e.g. assessment of images payment is bundled into payment for related E/M visits, with no separate payment||
|Interprofessional or peer-to-peer consultation—e.g., e-consults—payment is bundled into payment for related E/M visit by treating practitioner, with no separate payment to treating or consulting practitioner unless the patient has a separate E/M visit with the consulting practitioner||
|Remote patient monitoring (CPT 99091)—e.g., collection and interpretation of physiologic data that is digitally stored and transmitted to physician—may be separately paid; payment for supplying the monitoring device, days of recording, and monitoring treatment management services is bundled into payment for related E/M and collection/interpretation services||
ACO participants, which include providers/suppliers, are the entities that are paid. The ACOs themselves are not paid directly for services. In this table and throughout this paper, we use the term “ACOs” to refer to the ACO participants, meaning the providers/suppliers that are eligible for payment.
These proposed regulations, which both allow for flexibility for Medicare telehealth services and add new separately payable codes for non-face-to-face services, present opportunities for ACOs to leverage these services to improve efficiencies, care coordination, and care management. Consider the following examples:
While the new availability of separate payment for these services that use telecommunications technology may help to improve access and quality of care, there are legitimate concerns regarding impacts to utilization and revenue.
One concern—which is not unique to ACOs—is related to whether improved, convenient access to care (especially for lower-acuity services) may increase unnecessary utilization, rather than substitute for higher-cost services in more expensive settings. A recent study evaluating patterns of utilization and spending among patients with commercial insurance and acute respiratory illness found that a relatively small proportion (12%) of telehealth visits were substitutes for face-to-face visits, and approximately 88% of telehealth visits were new utilization, with a resulting $45 annual increase in healthcare spending per telehealth user.5 However, in terms of quality of care, there is sufficient evidence and consensus regarding effectiveness of telehealth for certain situations, including “remote monitoring, communication, and counseling for patients with chronic conditions, and psychotherapy as part of behavioral health,” according to a recent systematic review by AHRQ.6 ACOs will be well advised to leverage this new flexibility and payment opportunities and do so in a manner consistent with existing guidelines and evidence.7, 8, 9, 10 Where evidence is lacking or mixed, data collection and evaluation to assess impact on quality, access, operational efficiencies, and costs would be invaluable.
The proposed rules also raise specific questions for ACOs’ and practitioners’ consideration:
ACOs and participating providers may choose to increase their use of telehealth and other innovative non-face-to-face services in response to opportunities arising from new CMS policies and/or environmental changes. In making such a decision, ACOs would be well advised to take the opportunity to evaluate their current technology infrastructure and workflows in order to determine how these modalities can better engage patients, manage care, engage specialty care services efficiently, and support those beneficiaries in their residences who have multiple, complex, chronic health conditions. Specifically, ACOs may want to consider the role these non-face-to-face services may play in achieving the objectives of the ACO to improve the quality and reduce the cost of care for ACO-assigned beneficiaries.
Opportunities for care coordination through innovative technologies
This paper discusses how accountable care organizations (ACOs) can increase their use of telehealth and other innovative non-face-to-face services in response to opportunities arising from new CMS policies and/or environmental changes.