Exploring Telehealth Delivery Methods for Substance Use Disorder Treatment

Medicaid Innovation Accelerator Program Reducing Substance Use Disorders

Exploring Telehealth Delivery Methods for Substance Use Disorder Treatment
September 10, 2019 3:30 PM– 4:30 PM ET

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Roxanne Dupert-Frank Medicaid
Innovation Accelerator Program
Center for Medicaid and CHIP Services (CMCS)
Centers for Medicare & Medicaid
Services (CMS)

Lisa Patton, PhD
Behavioral Health and Disparities Development
Lead IBM® Watson HealthTM

• Participants will learn about why the use of telehealth delivery methods are increasing and how they
can be used for substance use disorder (SUD) treatment
• Barriers to and facilitators of telehealth delivery methods implementation will be discussed
• Speakers from New York will share information around the telehealth delivery methods in their state
under Medicaid and how telehealth has been implemented in the state’s SUD treatment delivery system

Jonathan Lang, MPA
New York State Department of Health

Mary Zelazny
Chief Executive Officer of Finger
Lakes Community Health

• Telehealth delivery methods are increasingly used to deliver care
• Evidence of effectiveness in comparison to in-person care

• Potential to lower health care costs
• Ability to expand access to care
• Increasing acceptability among providers, patients, payers, and policymakers

Source: Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state
of telehealth evidence: a rapid review. Health Affairs, 2018;37(12):1975-1982.

• More than 160 telehealth bills were introduced in 44 states in 2018
• CMS released a proposed rule in 2018 providing guidance on and expanding access to telehealth for Medicare
beneficiaries

• Barriers for implementing telehealth delivery methods include:
• Costs associated with implementation
• Lack of reimbursement for telemedicine delivery methods
• Providers’ unfamiliarity with technology
• Lack of implementation models
• Confidentiality regulations

• Facilitators for implementing telehealth delivery methods include:
• Funding available to pay for the telemedicine delivery method
• Local examples of success
• Influential champions at the payer and treatment agencies
• Meeting a pressing need

• Goal: Increasing availability (i.e., quantity) of behavioral health care
• Allows providers to make services available in areas where in-person services are not readily available or accessible
• Provides a bridge to traditional barriers related to behavioral health services, in particular:
• Geographic separation
• Language barriers
• Stigma related to accessing behavioral health care

• Live video conferencing
• Two way, real time video conferences between the patient and health care provider
• Store and forward
• Patients healthcare documents are stored and shared electronically for use and analysis by a healthcare provider

• Remote patient monitoring
• Patients healthcare data collected at one site and shared with a healthcare provider at another site for monitoring and review

• Mobile health
• Mobile applications that support continued monitoring of a patients health

• Telehealth delivery methods are increasingly used in substance use treatment:
• Removes barriers of time and distance
• Has potential for enhancing treatment and recovery for people with SUDs
• Offers clinicians ways to increase contact with SUD patients during and after treatment
• Recent legislative and regulatory changes could increase the use of telehealth delivery methods to furnish services and expand access to SUD care, particularly in rural areas
Sources: Molfenter T, Boyle M, Holloway D, Zwick J. Trends in telemedicine use in addiction treatment. Addiction Science & Clinical Practice. 2015;10(1):14.
Huskamp HA, Busch AB, Souza J, et al. How is telemedicine being used in opioid and other

• Is your state using telehealth delivery methods as a way to increase SUD treatment services in your Medicaid program?
• Yes
• No, but we are planning to do so
• No, and we do not have any current plans to do so

StatePerspective: NewYork
Jonathan Lang, MPA
New York State Department of Health

NYS Medicaid Coverage of Telehealth
TelehealthExpansion
Telehealth: Defined as the use of electronic information and communication technologies to deliver health care to patients at a distance
Originating site: Where the member is located at the time health care services are delivered
Distant site: Any secure location where the telehealth provider is located while delivering health care services by means of telehealth

TelehealthExpansion
• A Special Edition Medicaid Update was issued in February 2019
• The expanded telehealth policy is effective January 1, 2019, for Medicaid fee-for-service (FFS) and March 1, 2019, for Medicaid managed care (MMC)
• Nothing precludes implementation by the MMC plans prior to January 1, 2019

NYSInteragency TelehealthGuidance

• Interagency guidance document in development
• Department of Health (DOH)
• Office of Mental Health (OMH)
• Office of Alcoholism and Substance Abuse Services (OASAS)
• Office for People With Developmental Disabilities (OPWDD)
• Full NYS license/certification and current registration are required for telehealth practitioners
• All laws, rules, regulations, standards, and competencies apply:
• State Education Department (SED) professional scope of practice
• Privacy and confidentiality
• Patient consent and record-keeping

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Source

State Education Dept.

Dept. of Health

Office of Mental Health
Office of Alcoholism and Substance Abuse Services

Office for People With Developmental
Disabilities

Regulations Title VIII provides licensure
requirements for practitioners

None 14 NYCRR Part 596 establishes standards and parameters for use of
telemental health in Article 31 clinics

14 NYCRR Part 830 establishes standards and
parameters for use of telepractice in OASAS-
certified sites

14 NYCRR Part 679 will allow for services and
clinic visits to be delivered in person/face to
face or via telehealth

Guidance • Practitioners providing services via
telehealth must conform to SED regulations according to their scope of practice, etc.
• Although there are no DOH regulations
specific to telehealth, all health care
services delivered via telehealth must
conform to the same governing statutes
and regulations for the setting in which the
service would have been provided in
person
• OMH, OASAS, and OPWDD have regulations that allow for services to be delivered via
telehealth

Abbreviations: DOH, Department of Health; OASAS, Office of Alcoholism and Substance Abuse Services; OMH, Office of Mental
Health; OPWDD, Office for People With Developmental Disabilities; NYCRR, New York Codes, Rules and Regulations.
Category

Medicaid Reimbursement Policy as of March 2015

Modalities, Originating Sites, and Distant Sites
Have Been Expanded and Include the Following (in addition to those listed
in Column One)

Modalities and Sites

Column One Column Two

Eligible Modalities • Telemedicine (live, interactive audio- visual communication)

• Store-and-forward (asynchronous transmission)
• Remote patient monitoring (RPM)

Eligible “Originating” Sites (location of patient)

• Article 28 hospitals
• Article 28 Diagnostic & Treatment Centers
• Article 28 facilities providing dental services
• All Federally Qualified Health Centers (FQHCs)
• Non-FQHC school-based health centers
• Practitioner offices

• Facilities licensed under Article 40 of Public
Health Law (hospices)
• Facilities as defined in subdivision six of
section 1.03 of the Mental Hygiene Law
(includes Article 16, Article 31, Article 32
clinics)
• Certified and noncertified day and residential programs funded or operated
by Office for People With Developmental
Disabilities

• Any type of adult care facility licensed under
title two of Article 7 of the Social Services
Law
• Public, private, and charter elementary and
secondary schools located in New York State (NYS)
• Child daycare centers and school-aged child-care programs located in NYS
• The patient’s place of residence located within NYS or other temporary location
within or outside of NYS

Eligible “Distant” Sites (location of consulting
practitioner)

• Article 28 hospitals
• Article 28 Diagnostic & Treatment Centers
• Article 28 facilities providing dental services
• FQHCs that had “opted into” Ambulatory Patient Groups
• Practitioner offices

• Any secure location where the telehealth
provider is located while delivering health care services by means of telehealth. Services
must comply with the Health Insurance
Portability and Accountability Act

Category State Education Dept.

Dept. of Health Office of Mental Health

Office of Alcoholism and Substance Abuse
Services

Office for People With Developmental
Disabilities

Recognized telehealth modalities

Static transmission of data or interactive
teleconferencing telepractice applications

• Telemedicine

• Store-and- forward technology
• Remote patient monitoring

Telemental health

Telepractice • Telemedicine

• Store-and- forward technology
• Remote patient monitoring

Guidance • Practitioners providing services via
telehealth must conform to SED regulations according to their scope of practice, etc.
• Although there are no DOH regulations specific to telehealth, all health care services delivered via telehealth must conform to the
same governing statutes and regulations for the setting in which the service would have been provided in person
• OMH, OASAS, and OPWDD have regulations that allow for services to be delivered via
telehealth

Abbreviations: OASAS, Office of Alcoholism and Substance Abuse Services; OMH, Office of Mental Health; OPWDD, Office for People
With Developmental Disabilities.
Telehealth Practitioner Requirements
• Practitioners providing services via telehealth must be licensed or certified, currently registered in accordance with NYS Education Law or other applicable law, and enrolled in NYS Medicaid
• Telehealth services must be delivered by providers acting within their scope of practice
• Reimbursement will be made according to existing Medicaid policy related to supervision and billing rules and requirements

Credentialing and Privileging
• The Article 28 hospital acting as an originating site may rely on the credentialing and privileging decisions of the distant site hospital when granting or renewing privileges to a health care practitioner who is a member of the clinical staff at the distant site hospital
• The distant site hospital collects and evaluates all credentialing information and performs all required verification activities, and it acts on behalf of the originating site hospital for such credentialing purposes

Credentialing and Privileging
• The distant site reviews (at least every 2 years) the credentials, privileges, physical and mental capacity, and competence of the telehealth provider and reports the results of the review to the originating site
• The originating site also reviews (at least every 2 years) the performance of these privileges and provides the distant site hospital with the performance evaluation for use in the distant site’s periodic appraisal of the telemedicine practitioner

Confidentiality
• All services must be performed on dedicated secure transmission linkages that meet the minimum federal and state requirements
• The Health Insurance Portability and Accountability Act (HIPAA) requires that a written business associate agreement (BAA) or contract that provides for privacy and security of protected health information be in place between the telehealth provider and the supporting telehealth vendor
• All confidentiality requirements that apply to medical records apply to services delivered by means of telehealth

Consent
• Providers must document in the medical record that the Medicaid member has consented to the six questions under Part E of the February 2019 Medicaid Update on telehealth
• Providers must have written protocols and procedures on how practitioners shall provide the Medicaid member with basic information about the services that the member will be receiving via telehealth, and the member shall provide their consent to participate in services using this technology

Failure of Transmission
• All telehealth providers must have a written procedure detailing a contingency plan in the case of a failure of transmission or other technical difficulty that renders the service undeliverable via telehealth
• Policies and procedures must be available upon audit
• If the service is undelivered because of a failure of transmission or other technical difficulty, a claim should not be submitted to Medicaid

Modifiers To Be Used When Billing for Telehealth Services
Modifier Description Note/Example

95

Synchronous telemedicine service rendered via real- time interactive audio and video telecommunication system

Note: Modifier 95 only may be appended to the specific services covered by Medicaid and listed in Appendix P of the American Medical Association’s Current Procedural Terminology (CPT®) Professional Edition 2018 Codebook.

The CPT codes listed in Appendix P are for
services that typically are performed face to face but may be rendered via a real-time
(synchronous) interactive audio-visual
telecommunication system.

GT

Via interactive audio and video telecommunication systems

Note: Modifier GT is only for use with those
services provided via synchronous telemedicine for which modifier 95 cannot
be used.

GQ

Via asynchronous telecommunication system

Note: Modifier GQ is for use with store-and-forward technology.

25

Significant, separately identifiable evaluation & management (E&M) service by the same physician or other qualified health care
professional on the same day as a procedure or other service

Example: The member has a psychiatric consultation via telemedicine on the same day as a primary care E&M service at the
originating site. The E&M service should be
appended with the 25 modifier.

Place of Service Code
To Be Used When Billing for Telehealth Services

Place of Service Code Description

The location where health services and health-related services are provided or
received through telehealth telecommunication technology. When billing 02 telehealth services, providers must bill with
place of service code 02 and continue to bill
modifier 95, GT, or GQ.

Fee-for-Service
Billing Rules for Telehealth Services
Medicare/Medicaid Dually Eligible Beneficiaries
• If Medicare covers the telehealth encounter, Medicaid will reimburse the Part B coinsurance and deductible to the extent permitted by state law
• If the service is outside of the geographic region recognized by Medicare and Medicare denies coverage of the telehealth encounter, Medicaid will not cover such services
• If the service provided is one that is not within the scope of services covered by Medicare (e.g., CASACs, dental, store and forward) but is an eligible telehealth service under Medicaid, the telehealth encounter may be billed to Medicaid

Medicaid Managed Care
Medicaid Managed Care Considerations
• MMC plans are required to cover, at a minimum, services that are covered by Medicaid FFS in addition to services included in the MMC benefit package, when determined medically necessary
• Questions regarding MMC reimbursement and/or billing requirements should be directed to the member's MMC plan

Questions
• Questions regarding Medicaid FFS billing should be directed to eMedNY Provider Services at (800) 343–9000
• Policy questions regarding Medicaid FFS may be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473–2160
• Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan

Current issues in providing health- related services:
• A lack of access to care
• Workforce shortages
• Cost of care
• Patients/clients needing interpretation
• Geographic barriers (transportation)

• Chronic disease management
• Provider burnout
• Stigma
Why Use Telehealth?

Telehealth and the Quadruple Aim
ImprovedAccess = Better Outcomes:
• Increased access to specialists, primary care doctors, behavioral health providers, remote home monitoring
• Reduced readmissions
• Better access to clinical data more quickly (remote monitoring)
HigherPatient/ProviderSatisfaction:
• Streamlined care
• Meeting the patient where they are
• Better access to providers

Telehealth and the Quadruple Aim
Lower or Stabilized Costs:
• Remote monitoring enables patients to be monitored at home
• Lower utilization rates of ambulatory care
Workforce:
• Reduced provider burnout
•Opportunities for peer-to-peer relationships/education
• Access to Continuing Medical Education

Using Telehealth forSUD
Services
• Medicated-assisted treatment (MAT)
• Counseling services
• Case conferencing between providers/staff
• Crisis intervention
• Work force coverage

Telehealth Modalities

1. Synchronous visits (real-time video)
• Live consults
• Live treatment/follow-up appointments
• Direct to consumer

1. Asynchronous visits (store and forward)
• Remote patient monitoring
• eConsults

Telehealth = Change/Innovation

COMMITTED
INFORMATION
WORKGROUPS
TECHNOLOGY

(IT) SUPPORT
Perform an organizational assessment to determine your readiness in the adoption of telehealth technologies ...

Be sure that—
There is buy-in from your leadership team
There is a commitment to the additional work involved in developing your capabilities
You know what your state licensure allows
You have appointed a Team Leader
who understands his or her role as an agent
of change You understand that it will take time to build telehealth technologies into your clinical process Telehealth forces change ... make sure your team is on board!

The use of technology is the new normal!

Build Your Clinical/Operations Work
Group
Quality Assurance – Strategic Alignment
• Define performance measures
• Collect, analyze, and report data through Quality Improvement Committee
• Chart reviews:
• Baseline
• Throughout pilot and ongoing
• Plan Do Study Act process

• Program evaluation
• Telepresenter, patient, distant provider
• Develop policies and procedures

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Clinical/Operations Work Group
Clinical workflow:
• What is the purpose:
• Increase access (i.e., treatment for MAT)
• Decrease wait times
• Extend current workforce
• Meet quality performance measures
• Referrals:
• What is an appropriate referral?
• Develop your clinical process from both
sides of the virtual visit
• Prior authorizations, billing considerations, coding
• Scheduling/appointment management:
• Block scheduling versus next available visit
• Reserving the room/equipment
• Management done by both sites?
Patient Education: Showing patient the equipment
Registration: Consents, health history, patient documents Process to get documents to distant provider
Previsit: Previsit planning = one-stop shopping Any primary care needs?
Does distant provider have all information needed for the visit?
Testing equipment Pharmacy Considerations How will the patient get his or her
prescriptions filled?
• Your telehealth plan needs to address how to get your patients their meds
• Electronic prescribing works very well with telehealth
• Keep current federal regulations in mind:
Ryan-Haight Act (first visit must be in
person)
• Do you need to test the patient for the presence of drugs? Make that part of your plan!

IT in Telehealth

Legal/Regulatory

• Know any regulations and/or guidelines
for your organization's state licensure type
• Know the vendors and external partners with which your organization will need a BAA
• Engage in contract management with vendors/external providers that includes credentialing and privileging, reimbursement, and roles and responsibilities of both parties

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Millennials and Telehealth

• Millennials make up 25 percent of the U.S. population
• Millennials account for 27 percent of consumer discretionary purchases (more than $1 trillion)
• 37 percent of millennials state that they are willing to purchase a product or service to support a cause they believe in, even if it means paying a bit more
• Millennials are more than 2.5 times more likely to be early adopters of technology than any other generation
• 56 percent of millennials report that they are among the first group to try out new technology
• For millennials, new technology must serve a purpose in order to be considered 53

"You Don't Know What You Don't Know"
–Socrates

• Learn from others ... don't try to reinvent the wheel.

• Buyer beware! Know what you need for
equipment and, more important, what you don't need.
• Test any equipment with your clinical staff
before buying. Let them choose which
equipment they are willing to use.

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ThankYou!

Mary Zelazny, CEO Finger

Lakes Community Health
14 Maiden Lane

PO Box 423

PennYan, NY
14527 Phone:
315.531.9102

Email: maryz@flchealth.org

Web Addreess:
www.localcommunityhealth.org

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• Telehealth delivery methods are becoming more widely used to improve SUD treatment access
• Patient-provider interactions allow for increased quantity of SUD providers
• Important points to consider for implementing telehealth delivery methods:
• Clinical and leadership champions needed
• Clinical/operations workflows need to be considered
• Patients need to be educated
• Know the legal/regulatory issues

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