Reimbursement Panel

Department of Medical Assistance Services

Mid-Atlantic Telehealth Resource Summit
“Reimbursement Panel”, March 15, 2012
Charlottesville, Virginia
Jeff Nelson, Policy Analyst Senior
Virginia Department of Medical
Assistance Services

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

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Telemedicine Reimbursement- General
• Report- “Telemedicine Reimbursement: A National Scan of
Current Policies and Emerging Initiatives” (2009) by the
California Telemedicine and eHealth Center
• Key Findings:

– No Single, Comprehensive Resource
– Number of Players and Rules Adds Complexity and
Confusion
– New Laws do not Ensure Practice
dmasva.dmas.virginia.gov Proactively Tackle the Challenges
– States can

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Telemedicine Reimbursement- General
– States can Act Proactively and Tackle Challenges

– Limited Impetus to Change Status Quo
– T he Gordian Knot of Reimbursement


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Virginia Medicaid at a Glance
• While Medicare coverage is consistent across the country,
Medicaid programs vary state to state as to eligible
persons, services covered, and service reimbursement
• Virginia Medicaid enrollment in 2011 was 804,186. About
56 percent children, 6 percent in long term care
• Virginia expenditures in 2011 were $7,166,169. Medical
services were 49 percent, long term care services 31
percent


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• About 63.5 percent of Virginia Medicaid recipients are under
managed care coverage, which consists of 6 plans including
a plan recently added.
• About 36.5 percent under fee-for-service coverage


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• Among the services covered by Virginia Medicaid are:
•Inpatient and Outpatient hospital
services
• Physician and nurse midwife
services
• Laboratories and x-ray services
• Transportation-emergency and
non-emergency
• Nursing facility services
• Home health
• Early and Periodic Screening,
Diagnosis and Treatment program

•Dental care for persons
under age 21
•Prescription drugs
•Occupational and other
rehab services
•Hospice
•Some mental health
services
•Some substance abuse
services
•Waiver programs for
persons with AIDS, other
conditions
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Virginia Medicaid Telemedicine Reimbursement
• Virginia Medicaid received inquiries from providers in the
1990s about adding telemedicine to our services coverage

• Medicaid programs have had difficulties retaining providers
due to low reimbursement
• Virginia Medicaid saw telemedicine as a win-win situation in
the potential to retain providers to strengthen our provider
capacity. Also benefits in improving access to services, cost
savings potential, and a sense that telemedicine can help
address medical conditions at an earlier stage of disease
• Credit to our agency leadership over the years for seeing
the value of telemedicine

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• Virginia Medicaid telemedicine coverage started as a pilot
project in 1995.

– Some consultations
– One psychotherapy service
– A few clinical services such as in cardiology
• Only physicians recognized as providers for both ends of
telemedicine encounter

• Reimbursement is according to the Virginia Medicaid fee
schedule and is the same as when the service is delivered
conventionally. No telemedicine equipment reimbursed

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• Virginia Medicaid expanded telemedicine coverage July 1,
2003 from a pilot to statewide. Governor Mark Warner
announced the coverage at a community health event
• Telemedicine definition as the real-time transfer of medical
data and information using an interactive audio/video
connection for the purposes of diagnosis and treatment
• Additional services covered
– Evaluation and management, office visits
– Range of individual psychotherapies
– Select clinical services such as in cardiology
– Mental health and substance abuse crisis intervention

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• 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


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

– Certified Outpatient
Rehabilitation Facilities
– Community Services
Boards
– Dialysis Centers
– Federally Qualified
Health Centers
– Health Department Clinics
– Hospitals


– Nursing Homes
– Rural Health Centers
– Program for AllInclusive Care for the
Elderly
– Plus physicians and
other providers on
previous page

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• 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. No telemedicine equipment is
reimbursed


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• 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

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• Additional services Virginia Medicaid 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

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• 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


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• 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.
Providers with 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


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• 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


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• Virginia Medicaid 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
jeff.nelson@dmas.virginia.gov


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