Alex Krouse, JD, MHA Christine Wernert, MBA, CPMA Understanding
the Implementation and Compliance Issues Concerning Telemedicine
What Legal and Regulatory Issues Should We Know?
Slide 2
Telehealth vs. Telemedicine vs. Telecommuting What do these
terms mean? Differences between services Differences in provider
contracts, equipment, EPs Differences in payments
Slide 3
Licensure of Professionals Are patients located in the State?
Are all practitioners located in the same State? Licensing
requirements must be met in the State in which services are
provided Location of Patient Be aware of licensure issues for
border providers
Slide 4
Credentialing of Professionals Originating Site Hospital can
rely on Distant Site for credentialing matters. Written Agreement
Confidentiality Ownership of Records Distant Site Requirements
Medicare Participating Hospital or Ensures Medicare Compliance
Practitioner is Privileged at Distant Site Distant Site Provides
Current list of All Privileges
Slide 5
Prescribing A documented patient evaluation, including history
and physical evaluation adequate to establish diagnoses and
identify underlying conditions or contraindications to the
treatment recommended or provided, must be obtained prior to
providing treatment, including issuing prescriptions,
electronically or otherwise. 844 IAC 5-3-2
Slide 6
Prescribing Except in institutional settings, on-call
situations, cross-coverage situations, and situations involving
advanced practice nurses with prescriptive authority practicing in
accordance with standard care arrangements, as described in
subsection (d), a physician shall not prescribe, dispense, or
otherwise provide, or cause to be provided, any controlled
substance to a person who the physician has never personally
physically examined and diagnosed... unless the physician is
providing care in consultation with another physician who has an
ongoing professional relationship with the patient, and who has
agreed to supervise... 844 IAC 5-4-1
Slide 7
Malpractice Concerns Malpractice Still an Issue! Physician
Patient Relationship What are the requirements? Multiple
Physicians? Patient Abandonment Informed Consent Provide Choice of
Traditional vs. Telemedicine Practitioners coverage online Hub site
coverage
Slide 8
Non-Physician Providers 180,233 Nurse Practitioners 3,000+ in
Indiana 83,466 Physician Assistants 397,130 Primary Care Physicians
Pediatrics 70,967 OBGYN 45,043 Family Medicine 116,933 Internal
Medicine - 164,187 2020: Shortage of 91,500 Physicians Including
45,000 Primary Care Physicians Source: Assoc. of American Medical
Colleges
Slide 9
Non-Physician Providers Nurse Practitioners/PAs Supervision or
Collaboration? NP = Collaboration PA = Supervision Scope of
Practice Incident to billing Who are we billing under?
Slide 10
Anti-Kickback Risks Under the Anti-kickback Statute it is
illegal to knowingly or willfully: offer, pay, solicit, or receive
remuneration; directly or indirectly; in cash or in kind; In
exchange for; referring an individual; or furnishing or arranging
for a good or service; and for which payment may be made under
Medicare or Medicaid.
Slide 11
Is the Government Focused on Telemedicine? Office of Inspector
General Guidance Case Law United States vs. Greber United States v.
Polin Safe Harbors EHR Donations Anti-Kickback Risks
Slide 12
Stark Law Risks The Stark Law prohibits a physician from making
a Referral To an entity For the furnishing of a designated health
service For which payment may be made under Medicare If the
physician (or an immediate family member) Has a financial
relationship with the entity
Slide 13
Stark Law Risks Strict Liability Stark Law Applies to ANYTHING
of VALUE NOT $$$ Only How does the Stark Law impact telemedicine?
EHR Exceptions Rural Exception Analyze Every Arrangement!
Slide 14
False Claims Act Risks Generally a false/fraudulent
claim/statement made or caused to be made for payment to the United
States, 31 U.S.C. 3729(a) Includes conspiracy and reverse false
claims provisions Claim must be submitted knowingly Actual
knowledge Deliberate ignorance Reckless disregard No specific
intent to defraud required
Slide 15
Indiana Medicaid Medical necessity in every clarification of
reimbursed services Behavioral Health rapid expansion 15 states
require tele-health reimbursement to be same as face-to- face (IN
not one of them) IHCP does reimburse for consultations, outpatient
E/M, behavioral health, MTM, and end stage renal disease services
20 miles from hub and spoke No home care reimbursement
Slide 16
Implementation Concerns Area serving a HPSA? Security and HIPAA
Who and where is the patient and how am I sure? Reimbursement for
interactive services Modifier codes Reporting with documentation!
EHR concerns and things to watch out for
Take-awayson Indiana What to tell health care professional
looking to implement a tele-health plan Legislature to watch for on
state/federal level Access of care and patient services in remote
areas increase quality and access PQRS! New technologies and
policies for implementation to be on look out for Ensure there are
processes in place for licensure and credentialing of professionals
Educate providers on the practical concerns related to malpractice
Analyze every new telemedicine arrangement, from the onset, from a
fraud and abuse perspective
Slide 19
Christine Wernert, MBA, CPMA President Practice Management
Solutions, LLC 317-410-2010 [email protected] Christine
Wernert, MBA, CPMA President Practice Management Solutions, LLC
317-410-2010 [email protected] Alex T. Krouse, JD, MHA
Attorney Krieg DeVault LLP 574-485-2003 [email protected] Alex T.
Krouse, JD, MHA Attorney Krieg DeVault LLP 574-485-2003
[email protected]