Home Health & Hospice Week

Direct reimbursement for telehealth visits is not in the rule.

The future of home care telehealth is murky, thanks to provisions in the new home health payment proposed rule that fall far short of home care providers’ expectations.

In the proposed rule for 2021 published in the June 30 Federal Register, the Centers for Medicare & Medicaid Services proposes to make permanent some of its COVID-19 Public Health Emergency flexibilities regarding telehealth.

Specifically: The home health plan of care must include any telehealth visits, “must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment,” the proposed regulatory change reads.

Also, the POC must include a “description of how the use of such technology will help to achieve the goals outlined on the plan of care,” according to the proposed rule.

If finalized, the change “would mean that home health agencies … can continue to utilize telecommunications technologies in providing care to beneficiaries under the Medicare home health benefit beyond the COVID-19 PHE, as long as the telecommunications technology is related to the skilled services being furnished, is outlined on the plan of care, and is tied to a specific goal indicating how such use would facilitate treatment outcomes,” CMS says in a release about the rule.

Reassuring: “Because stakeholders have identified sig­nificant up-front costs in incorporating and evaluating various forms of telecommunications systems into home health care, this would allow HHAs to confidently plan for the continued inclusion of telecommunications systems under the Medicare home health benefit and increase the tools available to promote patient involvement and autonomy and potentially more efficient home health care,” CMS says in the rule.

CMS included these changes in its first COVID-19 interim final rule released back in March (see Eli’s HCW, Vol. XXIX, No. 12-13).

“This change will help to increase access to technologies, such as telemedicine and remote patient monitoring,” CMS says in the 2021 home health proposed rule.

The CARES Act also encourages Medicare’s use of telehealth, CMS notes in the rule. “The policies finalized on an interim basis meet the requirements of … the CARES Act,” CMS believes.

Is Furnishing Telehealth Visits Worth The Risks?

While CMS touts its increased flexibility on the topic, HHAs think the changes don’t go far enough.

“Although CMS intends to promote the use of telehealth/ remote monitoring for home health patients, there is no reimbursement to HHAs for visits conducted via telecom­munications,” the National Association for Home Care & Hospice notes in its rule analysis.

“The telehealth part is seriously not what the industry wanted to see,” observes consultant and physical therapist Cindy Krafft with Kornetti and Krafft Health Care Solutions. “It says we can use it but not as a visit substitute, and continue to report costs but don’t get reimbursed," she says.

“It’s frustrating that HHAs are still not getting credit for billable units of service,” says finance expert Mark Sharp with BKD in Springfield, Missouri.

The rule “doesn’t do what many providers and reps have been advocating for — furnish direct reimbursement for telehealth visits,” criticizes consultant J’non Griffin with Home Care Solutions in Carbon Hills, Alabama.

The telehealth changes are “not very helpful at all,” judges consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. They are “very shortsighted on behalf of CMS,” Warmack says.

“This continues to put many agencies into a quandary,” notes Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan. “Telehealth can be implemented, and if done so is clearly part of the plan of care and orders, but without reimbursement. It can really only be an ‘add on’ benefit since it is not to replace any onsite visits ordered and needed,” Osentoski says.

Telehealth can have many benefits, CMS notes in the rule. Telecommunications “technology can … improve patient care, better leverage advanced practice clinicians, and improve outcomes while potentially making the provision of home health care more efficient,” the regulation says. “Telemedicine … has the potential to play a large role in enhancing the delivery of healthcare in the home.” And of course, it helps contain the spread of infection.

Using telehealth to stay “in contact with the patient most days of the week” can lead to improving patient outcomes, agency outcomes, CAHPS patient satisfaction scores, and care coordination overall, says Sharon Litwin with 5 Star Consultants in Camdenton, Missouri.

Plus: “Patients’ emergent care and hospitalizations may decrease because they are being seen both onsite and remotely by agencies more frequently,” Litwin adds. “Clinicians can therefore identify issues quickly and contact the physician to prevent exacerbations” or other negative developments.

But under current regulations, HHAs will have to weigh whether furnishing telemedicine visits is worth the risk on both the reimbursement and compliance fronts.

Watch out: “Use of telehealth may reduce the number of visits to [Low Utilization Payment Adjustment] thresholds that result in reductions in reimbursement,” cautions Washington, D.C.-based healthcare attorney Elizabeth Hogue. “Agencies must walk a very fine line if they undertake this strategy” of implementing more telehealth visits, Hogue advises.

“Without being reimbursed for the visits, it may end up being more cost than benefit, even in a PHE environment,” Osentoski rues.

In addition to short-range reimbursement risks, there are also long-range ones. Being unable to count telehealth encounters as billable units will leave data unreported. That means likely rate reductions in future years, experts fear.

Compliance with the CoPs is also paramount. “It may … pose a plan of care compliance risk during surveys,” Osentoski highlights.

Do this: “Providers need to make sure that requirements for the use of telehealth are met,” Hogue emphasizes. In other words, such visits must be “related to skilled services being furnished, outlined in PoCs, and tied to a specific goal indicating how such use facilitates treatment outcomes,” she advises.

Bottom line: “The use of telehealth is not a ‘free for all’” Hogue stresses.

CMS also includes some basic nondiscrimination reminders for telehealth services. “Access to telecommunications technology must be inclusive, especially for those patients who may have disabilities where the use of technology may be more challenging,” CMS says in the proposed rule. “Section 504 of the Rehabilitation Act and the Americans with Disabilities Act protect qualified individuals with disabilities from discrimination on the basis of disability in the provision of benefits and services.”

And “the home health CoPs at § 484.50(f )(1) require that information must be provided to persons with disabilities in plain language and in a manner that is accessible and timely, including accessible websites and the provision of auxiliary aids and services at no cost to the individual,” CMS continues. “This means that the HHA must meet these requirements to ensure access to and use of telecommunications as required by law. Appendix B of the State Operations Manual (regarding Home Health services) provides detailed examples of ‘auxiliary aids and services.’”

Plus: You are prohibited from turning down patients because they can’t or won’t do telemedicine visits. An “HHA cannot discriminate against any individual who is unable or unwilling to receive home health services that could be provided via telecommunications technology. In those circumstances, the HHA must provide such services through in-person visits as the intent of the Medicare home health benefit.”

One good point is that “since it is not being reimbursed, it cannot be denied upon resumption of home health medical review,” Osentoski adds.

What Lies Ahead

HHAs have a chance to give CMS their two cents on telehealth in comments on the rule, which are due Aug. 31. “I am sure there will be comments about that section,” Krafft predicts.

But it’s looking more like a legislative solution will be required to give HHAs equity with telehealth visits. “The definition of a visit would have to be changed in the regulations,” Griffin expects.

Newly released survey results from NAHC ranked “the inability to fully utilize telehealth services as an adjunct to in-person care that is reimbursed by Medicare” as one of respondents’ top three concerns about operating in the PHE.

“Even without direct reimbursement for telehealth services,” participants surveyed in June about May practices indicated “a slight uptick in telehealth use by HHAs. In [a] March-focused survey, 39.5 percent of HHAs reported using one or more modalities of telehealth. The May survey shows a slight rise to 43.6 percent,” NAHC reports.

Key: Congress and the Trump administration should allow “Medicare-certified home health clinicians to deliver care through telehealth and telephonic virtual visits. This is smart, efficient and essential to ensuring that millions of Medicare beneficiaries impacted by COVID-19 are able to be monitored and assessed at home,” says trade group The Partnership for Quality Home Healthcare. “Allowing flexibility for home health clinicians to treat patients in virtual visits will help to alleviate pressure on other parts of the healthcare system, including hospitals, physician offices and clinics. It also helps to ensure that patients in need of monitoring are able to be safely maintained at home,” PQHH says.

A bipartisan group of 30 U.S. senators have called for the “expansion of access to telehealth services during the COVID-19 pandemic to be made permanent,” according to a letter sent to Senate Majority Leader Mitch McConnell (R-Kentucky) and Senate Minority Leader Chuck Schumer (D-New York). “We have long advocated for increasing access to telehealth because of its potential to expand access to health care, reduce costs, and improve health outcomes,” says the June 15 letter headed by Sens. Brian Schatz (D-Hawaii) and Roger Wicker (R-Mississippi). But the letter stops short of specifically asking for direct home health telehealth visit reimbursement.

Stay tuned: CMS needs to include some more specifics about the rule’s new requirements. For example, Medicare needs to specify “what telecommunication technologies will be acceptable as part of the home health POC,” NAHC says in its rule analysis.

Note: See the senators’ letter at www.schatz.senate.gov/press-releases/schatz-wicker-lead-bipartisan-group-of-30-senators-in-calling-for-permanent-expansion-of-telehealth-following-covid-19-pandemic.