navigating the virtual behavioral health delivery maze...long-term strategy •telehealth is here to...
TRANSCRIPT
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Navigating the Virtual Behavioral Health
Delivery Maze
Christian & Barton’s
Jonathan M. Joseph and Elizabeth S. Olcottpresent
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From the Beginning…
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First Telemental Health
• Provided over telephone
• First true telemental health—1964
Nebraska Psychiatric Institute and
Norfolk State Hospital closed-circuit
television transmission for psychiatric
consultations
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Telemental Health Defined
• Telemental Health is a subset of
telehealth that uses technology to
provide mental health services from a
distance.
• Telemental Health includes terms
such as tele-psychiatry, tele-
psychology and tele-behavioral
health.
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Categories of Telemental Health
Delivery is broken down between two
categories:
• Synchronous is real time, interactive,
two-way communications and
• Asynchronous is the transmission of
medical information that is not real
time, to a distant site for review later,
such as store and forward.
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Evidence-based Telemental Health
• Organizations such as the American
Telemedicine Association have
produced evidence-based best
practices for telemental health since
2009. State boards of medicine have
also produced guidance, generally
geared towards telehealth globally.
• Important to consider for purposes of
“standard of care.”Christian & Barton, LLP
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Commercialization of Telemental Health
• Telehealth and telemental health, in
particular, have evolved from the
experimental days of the 1960s to a
multitude of commercial ventures
today. Commercial companies now
provide telemental health on a
national basis.
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Challenges
• Medical boards
• Virginia Board of Medicine telehealth
guidelines
• Ryan Haight Act
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Reimbursement
• Telehealth growth tied to
reimbursement
• Medicare offers limited reimbursement
• Medicaid pays for telehealth
• Virginia Code §38.2-3418.16
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Ryan Haight Act
• Intended to target internet pharmacies
– Prohibited online prescribing of
controlled substances without in-person
examination
• Created a challenge for telemedicine
and prescriptions
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Then COVID Hit…
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Ryan Haight Act
• DEA publishes updated FAQ
– Exceptions to in-person examination
requirement include public health emergency
• Effective March 16, 2020 – public health
emergency remains in effect:
– No in-person medical evaluation required if:
• Rx for legitimate medical purpose in usual course
• Telemedicine conducted via audio-visual, real-time,
2-way
• Practitioner acting in accordance with federal & state
laws (VA law still also applies)Christian & Barton, LLP
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Virginia Laws - Online Prescribing
• Virginia law still applies
– Prescribing via telemedicine is permitted when
there is a bona fide practitioner-patient
relationship
• Can be established via telemedicine, in person
examination not required
• 7 conditions required by statute
– Va. Code 54.1-3303
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CMS Flexibilities Provided
• Medicare allows beneficiaries in all
areas to receive services in any
setting (including at home!)
– And all areas of the U.S., not just rural
settings
• Reimbursement for diagnosis and
treatment for most behavioral health
services
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CMS Flexibilities Provided
• Requirement for HIPAA-compliant
audio visual communication tech
relaxed; no risk of penalties
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The Commonwealth Added Flexibilities Too
• In 2019, language was added to the
Code of Virginia to mandate Medicaid
cover telemedicine services
• Confidentiality and security
requirements remain
• Providers reimbursed at same rate as
the analogous service provided face-
to-face
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The Commonwealth Added Flexibilities Too
• Relaxed requirement that provider staff must
be with patient at originating site to bill DMAS
for originating site facility fee
• Telemedicine in home is permissible, but no
site fee is paid
• DMAS allows audio-only, or telephonic
connections in addition to audio-visual
connections
– CMS allowing this for many Medicare behavioral
health services as wellChristian & Barton, LLP
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Contracting Considerations
• CSBs can choose to provide
telemental health or contract with
providers to provide telemental health
to clients of the CSBs
• If contracting for these services, must
keep a few things in mind
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Contracting Considerations
• Provider must be appropriate
– Credentialed with the CSB
• Require current Virginia license
• Check exclusions list
• Check work history and education
• Require malpractice insurance
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Other Contractual Considerations
• Technology requirements
– Minimum connectivity requirements/platform
use
– Who pays for that?
• Availability and scheduling
• Confidentiality
– HIPAA/42 CFR Part 2
• Especially important for telemental healthChristian & Barton, LLP
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Other Contractual Considerations
• Billing arrangement
– Fraud and abuse considerations
– Safe harbor rules
• Complying with DMAS requirements
• Flexibility for changes in the law
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Taking Care in Providing Care
• Ensuring that the standard of care is
met when providing services
– Board of Medicine:
• https://www.dhp.virginia.gov/medicine/guideli
nes/85-12.pdf
– Board of Social Work:
• https://www.dhp.virginia.gov/social/guideline
s/140-3.pdf
– Board of Psychology:
• https://www.dhp.virginia.gov/psychology/psy
chology_guidelines.htmChristian & Barton, LLP
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Taking Care in Providing Care
• Staff training for provision of
telehealth services
– Don’t just wing it!
• Make sure staff have proper training
in telemental health
• Develop policies and procedures for
delivery of telemental health services
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Documentation Required
• Support medical necessity for
telehealth
• Confirm patient is in Virginia
• Verify patient location
• Note provider location
• Note encounter conducted via
telemedicineChristian & Barton, LLP
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Documentation Required
• Indicate start/stop time
• Note patient consent
• Identify providers, family member or
individuals present during service
• Ensure patients sign HIPAA notices,
electronically if needed
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Are the Changes Here to Stay?
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Benefits Limitations
Continued medical care
and referrals for COVID-
symptomatic patients
Patient privacy concerns
when addressing
sensitive subjects
Continued access to
care for chronic health
conditions
Interstate licensure
challenges
An alternative to
in-patient care
Cultural acceptance for
telehealth visits by
patients and providers
Ease of follow up Liability risks
(cybersecurity) and
malpractice coverageChristian & Barton, LLP
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Short-term Observations
• COVID created urgent need
• CMS changes encourage telehealth
visits
• Widespread consumer satisfaction
• Federal funding appropriated to help
provide telehealth services during
pandemic
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• Opioid Pain Management Guide
recommends telehealth care for opioid
addiction
Gain insight into home setting
Patients are comfortable
Patient travel not necessary
In Practice
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Long-term Strategy
• Telehealth is here to stay
• Investors are interested
• Telehealth needs to be integrated with
existing tech platforms
• Properly address cybersecurity
concerns
Christian & Barton, LLP
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Legal Challenges
• Licensure
• Patient confidentiality and HIPAA
• Fraud and abuse and Stark laws
• Concerns related to payment for
medical equipment and software
• State prescribing and DEA concerns
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Legal Challenges
• Informed consent
• Fee-splitting law
• Mental health parity laws
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Thank You
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This is provided as an informational
service and does not constitute legal
counsel or advice, which can only be
rendered in the context of specific
factual situations.
If a legal issue should arise, please
retain the assistance of competent
legal counsel.
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Jonathan M. Joseph804.697.4125
Christian & Barton, LLP | 909 East Main Street, Suite 1200 | Richmond VA 23219
Elizabeth S. Olcott804.697.4136