Providing Telehealth in this Time of Crisis: Removing Barriers
Author Carolyn Rutledge, PhD, FNP-BC
Co-Author Tina Gustin, DNP, CNS
Editor Elizabeth Moran, MSN, RN, CPNP-PC
During this unprecedented time in our nation, healthcare delivery is rapidly changing to address the health and well-being of our nation while decreasing the transmission of COVID-19. Issues that have come to the forefront require new strategies and the swift implementation of telehealth. Provider sites are actively implementing technology-driven programs to address the needs of patients while maintaining physical distance wherever possible.
New populations of patients who receive telehealth include people quarantined at home, vulnerable populations (elderly, immunocompromised, or with multiple comorbidities), acute and chronic patients that are trying to limit their exposure, those who have symptoms or have been diagnosed with COVID-19, and those with new behavioral concerns, including struggles to adjust to the current crisis. While telehealth seeks to protect patients, it also can protect healthcare providers. Conducting routine and primary care visits via telemedicine reduces exposure for healthcare providers to patients who may have contracted the virus. It also reduces the risk for or patients who could be exposed to from healthcare workers that while asymptomatic, maybe unknowingly carriers have the COVID-19. Telemedicine is also being used for provider-to-provider consultation.
As a result of COVID-19, there have been many changes in the rules and regulations that have historically limited the use of telehealth. As it currently stands, such changes are only in place during this state of emergency. As such, providers are encouraged to stay abreast of which waivers are removed in the future and which remain.
With Medicare (1135 Waiver), patients can be at any location, including home, and be suffering from any medical condition, where previously the guidelines were more limited. Additionally, the requirement to use HIPAA-Compliant Platforms has been waived. However, providers should use a HIPAA-Compliant Platform whenever possible in order to minimize potential confidentiality lapses. Telehealth services must still be provided using live video conferencing connections. The requirement for patients to have an established relationship with the provider prior to a telehealth visit has also been waived.
Copays may be reduced or waived, however, practices are not required to waive the copay. Medicare beneficiaries can receive various services through telehealth including common office visits, mental health counseling, and preventive health screenings. This can help ensure that Medicare beneficiaries, who are at a higher risk for COVID-19 given their age, can visit with their provider doctor from the safety of their home, without having to go to the clinic or hospital doctor’s office or hospital which puts themselves or others at risk.. The requirement for patients to have an established relationship with the provider prior to a telehealth visit has also been waived.
Furthermore, out-of-state licensing requirements for providers are temporarily waived which allows providers to cross state lines when providing telehealth. Providers must realize that regulations do not apply to all types of providers and do their research to ensure they are following guidelines. Currently, Medicare is providing reimbursement to:
- Nurse Practitioners
- Physician Assistants
- Certified Nurse-Midwives
- Certified Nurse Anesthetists
- Licensed Clinical Social Workers
- Clinical Psychologists
- Registered Dieticians and Nutrition Professionals
Medicaid programs, which are regulated at the state level, are also being asked by the Centers for Medicare and Medicaid Services (CMS) to waive current telehealth restrictions. Many states have responded and removed some of the existing barriers to telemedicine, however, each state has responded differently. Thus, providers should check with the Medicaid program in their state in order to remain compliant with their state’s Medicaid telehealth waivers..
Commercial Payers can set their own rules regarding coverage for telehealth. The American Medical Association is requesting that commercial providers also remove barriers to providing telehealth services. Providers should check with the payers that cover their patients in order to understand coverage and abide by guidelines.
The Ryan Haight Act addresses the prescribing of controlled substances. The Drug Enforcement Administration (DEA) has released guidance allowing DEA-registered practitioners to issue prescriptions for controlled substances without an initial in-person medical evaluation for the duration of the public health emergency. The prescription must be issued for a legitimate medical purpose in accordance with the provider’s usual course of practice. In prescribing the controlled substances, telehealth must be provided using audio-visual, real-time two-way communication. The practitioner must be acting in accordance with applicable Federal and State law.
Billing codes have also been addressed as a result of this public health emergency. Under the current waiver, CMS is not requiring additional or different modifiers to be associated with telehealth services. The Medicare Telehealth Fact Sheet provides codes that are used for telehealth, telephone consultation, and visits..
Telehealth has become the go-to method for delivering healthcare during the COVID-19 crisis. Many prior barriers to widespread telehealth use have been addressed in order to allow for its rapid implementation. Providers must stay abreast of the changes that have been implemented, realizing that many of the waivers may be removed once the crisis is over. However, what is certain is that this will most likely change the way we deliver healthcare forever. Many providers, as well as patients, find telehealth practical and convenient and may choose to continue its use.
In order to learn more about telehealth in your region, Health and Human Services funded the development of 12 Telehealth Resources Centers that provide information and support for telehealth providers in the varying regions in our nation. Go to https://www.telehealthresourcecenter.org/ to find the Resource Center for your region.
- “President Trump Expands Telehealth Benefits for Medica Beneficiaries During COVID-19 Outbreak”. CMS.gov,https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak
- CMS expands Medicare telehealth services to fight COVID-19. https://www.modernhealthcare.com/medicare/cms-expands-medicare-telehealth-services-fight-covid-19
- CMS shares specifics on sweeping Medicare telehealth expansion. https://medcitynews.com/2020/03/cms-shares-specifics-on-sweeping-medicare-telehealth-expansion/?rf=
- The National Resource Center with links to the regional center. https://www.telehealthresourcecenter.org/
is Professor and Associate Chair of the School of Nursing at Old Dominion University (ODU). Dr. Rutledge has published over 55 articles and served as an investigator on 28 successful grant applications totaling over $18 million with a primary focus on utilizing new models of care such as telehealth to provide care to rural and underserved populations. Since 2010, Dr. Rutledge has focused on improving the way healthcare is delivered in remote areas using telehealth to enhance patient care and communication. She was the lead in developing the NONPF position paper on educating Nurse Practitioners in telehealth. She is a sought-after national consultant in the area of telehealth education and has a book, “Telehealth Essentials for Advanced Practice Nursing” in press. She is currently serving as the Academic Director of the Center for Telehealth Innovation, Education, and Research (C-TIER) at ODU. In 2014, Dr. Rutledge received the SCHEV Outstanding Faculty Award, the highest honor provided to faculty in Virginia.