Morning Plenary Session

Department of Medical Assistance Services

Mid-Atlantic Telehealth Resource Summit
“Morning Plenary”, March 16, 2012
Charlottesville, Virginia

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

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

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Purchasers
Task Force
Medicaid
Reform
Task
Force

Insurance
Reform
Task
Force


Technology
Task Force
VHRI
Advisory
Council

Delivery/
Payment
Reform

Capacity
Task
Force
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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


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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

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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.

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High Level Timeline for Exchange


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35 States Provide Medicaid
Reimbursement for Telemedicine (2009)

• States With Medicaid Reimbursement

States with
coverage


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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


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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

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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


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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


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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


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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


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Virginia Medicaid
Current Telemedicine Coverage
• 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
Homes


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

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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

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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

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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

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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


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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


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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)

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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)
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• mco itemsxxxxxxxxx


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)


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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


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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

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• 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


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• 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


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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
jeff.nelson@dmas.virginia.gov


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