Morning Plenary Session

1 www.vita.virginia.gov

Cindi Jones, Director Virginia Department of Medical Assistance Services and Virginia Health Reform Initiative

dmasva.dmas.virginia.gov 1

Department of Medical Assistance Services

Mid-Atlantic Telehealth Resource Summit

“Morning Plenary”, March 16, 2012 Charlottesville, Virginia

2 www.vita.virginia.gov dmasva.dmas.virginia.gov 2


VHRI Advisory Council

Technology Task Force

Capacity Task Force

Delivery/ Payment Reform

Insurance Reform

Task Force

Medicaid Reform

Task Force

Purchasers Task Force



Status Report on VHRI Advisory Council Recommendations by Task Forces

Service Delivery and Payment Reform • Through the Virginia Chamber of Commerce, created a

private, non-profit Innovation Center to promote and spread best practices in service delivery and payment reform

Technology • Completed Broadband survey of health care providers • Continue Health Information Technology efforts,

including implementing HIT, including behavioral health • Continue the expansion of telemedicine • Continue work on the one stop electronic gateway to our

health and human services



Work Continues on Advisory Council Recommendations by Task Forces

Capacity Through the Board of Health Professions, conducted a research

project to identify barriers to safe healthcare access and effective team practice.

Other professional groups are meeting to discuss similar issues.

Medicaid Continue to expand Medicaid funded care coordination models

as laid out in 2011 Budget language 297.1, MMMM Continue to implement and plan for changes to the Medicaid

program as the result of federal health care reform. Work with other State Leaders and Congress on Potential

Changes to the Current and Future Medicaid program


Department of Medical Assistance Services Work Continues on Advisory Council Recommendations by Task Forces

Purchaser • Conducted focus groups and a survey to gain employers’

perspective on the Exchange and health care reform in general.

• Virginia Health Care conferences June 2011 and June 2012, sponsored by the Virginia Chamber of Commerce

Insurance Reform • Bureau of Insurance developed regulations to implement the

insurance market legislation. • Virginia Plans for Health Benefit Exchange.



High Level Timeline for Exchange

7

35 States Provide Medicaid Reimbursement for Telemedicine (2009)

• States With Medicaid Reimbursement

www.vita.virginia.gov dmasva.dmas.virginia.gov 7


States with coverage

8

States’ Telemedicine Policies Vary Widely, But Commonalities Exist

• Medical and psychological consultations/treatments are the most prevalent services

• Fee-for-service reimbursement is generally provided to

both the originating site (where the Medicaid recipient is located) and remote site where the physician or other provider is located

• Primarily physicians but also other providers are eligible for reimbursement, depending on the state

• Coverage and coding/billing inconsistencies across the states makes it difficult to track telemedicine utilization and impact



9

Virginia Medicaid’s Interests in Telemedicine Coverage

• Improved patient access to medical services

• Improved patient compliance with treatment

• Medical services rendered at an earlier stage of disease, improving long-term patient outcomes

• Reduction in service expenditures such as hospitalizations and transportation

• Allows for an opportunity to work proactively with

physicians and other providers; has potential to be a “win-win” situation



10

Virginia Medicaid Telemedicine Coverage, Early Years

• Virginia Medicaid started with a telemedicine pilot project in 1995. Services covered were: – Some consultations – One psychotherapy service – A few clinical services such as in cardiology

• Used Virginia defined billing codes

• Only physicians recognized as providers



11

Virginia Medicaid Telemedicine Coverage, Early Years, continued

• Reimbursed providers at originating and remote site, using the existing fee schedule

• Pilot project was limited to three Virginia localities; one was for psychiatric care and the other two were for medical consultations

• Virginia Medicaid was one of the first states with telemedicine coverage



12

Virginia Medicaid Telemedicine Coverage Expansion, 2003

• Virginia Medicaid expanded telemedicine coverage July 1, 2003 from a pilot to statewide.

• Additional services covered – Evaluation and management, office visits – Range of individual psychotherapies – Full range of consultations – Select clinical services such as in cardiology – Mental health and substance abuse crisis intervention



13

Virginia Medicaid Telemedicine Coverage Expansion, 2003, continued

• Providers recognized by Virginia Medicaid for telemedicine:

– Physicians – Nurse practitioners – Clinical nurse specialists – Clinical psychologists – Clinical social workers – Licensed professional counselors – Licensed marriage and family therapists – Licensed substance abuse practitioners



http://www.comstock.com/web/search/loupe.asp?Image=KS137398.jpg&Type=RF&CatID=&LightboxID=&NoPopUP=T

14

Virginia Medicaid Current Telemedicine Coverage

• Originating sites (where the recipient is located) were expanded in October 2009 to include:



– Nursing Homes – Rural Health Centers – Program for All-

Inclusive Care for the Elderly

– Plus physicians and other providers on previous page

– Certified Outpatient Rehabilitation Facilities

– Community Services Boards – Dialysis Centers – Federally Qualified

Health Centers – Health Department Clinics – Hospitals Homes

15

Virginia Medicaid Current Telemedicine Coverage

• Under fee-for-service, billing telemedicine to DMAS involves: – Originating site (where the patient is located) typically

bills a Q3014 code for presenting patient – Remote practitioner bills for services such as an

evaluation and management code – Reimbursement is according to the Virginia Medicaid fee

schedule and is the same as when the service is delivered conventionally

– A procedure modifier for telemedicine is to be entered on the claim form

– No telemedicine equipment costs recognized in reimbursement



16

Virginia Medicaid Current Telemedicine Coverage, continued

• Providers of telemedicine services are expected to fully

comply with service documentation and other coverage and billing requirements described in the Virginia Medicaid provider manuals

• Providers can only bill for services using telemedicine, which are services Virginia Medicaid already covers when delivered conventionally and are on a list of Virginia Medicaid approved telemedicine services

• Virginia Medicaid telemedicine coverage is similar to

Medicare coverage but is not tied to rural area definitions for the originating site



17

Virginia Medicaid Current Telemedicine Coverage, continued

• Additional services DMAS has added recently: – Cochlear implant related procedures (CPT 92601-92604,

95974) for post operative analysis and fitting of devices, measurements and adjustments

– Teledermatology, dermatology services utilizing store and forward

– “Telepractice” speech therapy services for children in special education

– Diabetic retinopathy screening, digital images of the retina are captured (stored) and forwarded to ophthalmologists for evaluation



18

DMAS Telemedicine Billing Experience

• Telemedicine “billing” has been low for Virginia Medicaid. In FY11, 3799 claims and encounters were received. This reflects approximately $183,762 of services using DMAS reimbursement amounts. Other Medicaid programs have reported low billing volume as well

• Psychiatric care was the predominant service billed. Community Services Boards, which are the point of entry in Virginia into the publicly-funded system of services for mental health, intellectual disability, and substance abuse, were the primary providers



19

DMAS Telemedicine Billing Experience, continued

• Possible explanations as to why telemedicine billing is low:

– Providers not using telemedicine billing modifiers on

claims form – Telemedicine as part of the larger bundle of services

rendered to patients with particular diagnoses – Contracts for services with hospitals/clinics do not break

out telemedicine



20

Telemedicine, Virginia Medicaid Managed Care Organizations

• Telemedicine is included in the contracts DMAS has with

Managed Care Organizations. The contract coverage parallels the DMAS coverage

• An informal DMAS survey was conducted in February of MCOs regarding telemedicine activities, with the following comments provided: – A focus is on underserved areas such as Danville for

adolescents needing psychiatric services. Also eICU is used by intensivist physicians to continuously manage remotely patients in the ICU. This has reduced ICU length of stay. (MCO A)



21

Telemedicine, Virginia Medicaid Managed Care Organizations, continued

• Currently 51 telemedicine presentation sites exist with

approximately 90% or more of these located in the western part of the Commonwealth. The specialty locations include the University of Virginia and Virginia Commonwealth University. (MCO B)

• An increasing emphasis is taking place on a telemedicine partnership with the Office of Telemedicine at the University of Virginia School of Medicine. (MCO C)

• Over the last two quarters, 30 telemedicine encounters were conducted primarily in Danville and Lynchburg. Aged, blind and disabled Medicaid recipients were the primary users. (MCO D)

• mco itemsxxxxxxxxx



22

Telemedicine, Virginia Medicaid Managed Care Organizations, continued

• The value of telemedicine is recognized and is covered

without preauthorization. Until December, telemedicine has generally focused on members in the urban and suburban areas of Virginia. As we have expanded into the southwest, and in anticipation of expansion into the far southwest, we have providers ready to provide telemedicine services. (MCO E)



23

Future Possibilities for Virginia Medicaid Telemedicine Coverage

• Adding home health services to the telemedicine coverage.

DMAS currently covers home health services when delivered conventionally

– The Medicaid recipient’s home serves as the telemedicine originating

site with an electronic connection to the home health agency office. The Medicaid recipient’s condition is monitored by the home health agency

– Studies have documented savings particularly due to fewer

hospitalizations and shorter hospital lengths of stay. Medicaid transportation is reduced



24

Future Possibilities for Virginia Medicaid Telemedicine Coverage, continued

• Home health telemedicine applications for Medicaid

recipients at home include: – post-operative care – high risk pregnancies – diabetes – congestive heart failure

• Use of telemedicine for home health patients depends on

the diagnosis, medical need, permission of the patient, and patient’s ability to use the equipment

• The telemedicine visit is not intended to substitute for needed physical visits to the home by the nurse www.vita.virginia.gov dmasva.dmas.virginia.gov 24


25


• text



•Expanding DMAS telemedicine “store and forward” coverage

•Store and forward involves electronic medical information, such as video and still images, which is stored and transmitted for review by a physician or other practitioner at a later time

•The patient is not present when the physician conducts the evaluation of the image but findings are reported back to the patient’s primary care provider

http://www.comstock.com/web/search/loupe.asp?Image=KS136092.jpg&Type=RF&CatID=&LightboxID=&NoPopUP=T

26


• Store and forward applications under consideration include:

– Tele ophthalmology

• Store and forward can be inexpensive for the originating and remote sites because the electronic medical information, such as a digital picture, simply needs to be captured and transmitted to the physician or other practitioner



27

Questions?

• DMAS Website http://dmasva.dmas.virginia.gov/ • DMAS telemedicine coverage description (“Provider Memo”,

September 30, 2009) at https://www.virginiamedicaid.dmas.virginia.gov/ECMPdfWe

b/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf • Contact DMAS staff Jeff Nelson- 804-371-8857 or

[email protected]



mailto:[email protected]

Morning Plenary Session

Health & Medicine

Transcript of Morning Plenary Session