With healthcare organizations making so much use of telehealth now, how does one assess the quality of care provided through this technology? How can one ensure the facility is in compliance with the relevant requirements for coding and reimbursement?
The answers involve a mixture of holding telehealth to the same standards one would apply to in-person care, but also recognizing the use of this technology carries limitations and risks.
The healthcare community rapidly expanded its use of telehealth because of the restrictions necessary during the COVID-19 pandemic. HHS loosened restrictions to allow the use of commonly available meeting apps rather than dedicated telehealth platforms that previously were necessary to meet government requirements.1
To assess the quality of telehealth, leaders must apply a similar rubric to how they have always assessed the value of face-to-face or in-person care before the pandemic, says David Dickerson, MD, vice chair of the American Society of Anesthesiologists Committee on Pain Medicine. “In pain management, like many areas of medicine, we value safety, efficacy, and cost effectiveness. Telehealth cannot fully replace prepandemic care delivery, but it can add value and help us connect with our patients and assess and triage their needs,” says Dickerson, section chief for pain medicine at NorthShore University HealthSystem in Evanston, IL. “Misapplied, it could diminish value as certain aspects of an assessment such as vital signs, key physical examination maneuvers, or specific treatments that cannot be delivered via telehealth.”
The ability to escalate to in-person care when necessary may drive value. Follow-up surveys of patient experience after encounters is a good way to track patient engagement and the experiential relationship patients are maintaining with their clinicians and their healthcare systems, according to Dickerson.
Systems already are in place for those surveys and can be adapted to include additional telehealth-specific questions, he notes.
Quality standards and performance metrics often are specialty-specific. Many intersections between compliance and quality standards were set forth through professional societies in partnership with CMS. But many standards and metrics did not anticipate a rapid adoption of telehealth, Dickerson says.
“Our workflows were developed prepandemic to optimize performance. Some of these workflows did not anticipate the need for a path to fulfill these requirements virtually or in a non-in-person encounter,” Dickerson says. “Specific to pain medicine, we have had to redefine several of our workflows to ensure patients can virtually renew or complete pain agreements or complete screening surveys that help us address risks for opioid misuse or depression. Similarly, the reporting and auditing of these processes required revamping to ensure line of sight to performance of the new workflows.”
Telehealth virtual encounters must comport with the applicable standard of care that an in-person encounter would require, says John E. Morrone, JD, partner at Frier Levitt in New York City.
“The quality standards are significantly more difficult for regulators to measure, as there is not a physical presence to inspect. Many traditional metrics, such as quality of office-based surgery, are evaluated based on the physical plant, equipment, staffing, and training,” he says. “Telehealth is dependent only on the assessment of the physician-patient encounter.”
Compliance programs should focus on patient satisfaction and chart review to determine the level of care provided. Morrone cautions that telehealth must be limited to that which is appropriate for a virtual encounter.
“The most significant pitfall involves provider deviation from the standard of care because they lack the understanding of the limitation of telehealth,” Morrone says. “Fundamentally, if the physician would need to lay hands on a patient in a face-to-face encounter to provide the appropriate standard of care, that patient cannot be treated in a virtual encounter.”
Watch Telehealth Documentation
Documentation for reimbursement can be challenging. “Compliance has many layers, but in regard to care delivery via telehealth clinical documentation for these encounters has not changed. Complexity-based billing can be challenged by the limitations we have in telehealth on conducting detailed physical examinations, a key portion required for complexity-based billing,” Dickerson says. “Time-based billing may be a more effective way to qualify the documented effort an encounter required. As is currently done, this documentation can be audited internally and externally to ensure a compliant billing practice commensurate with services rendered.”
Compliance programs for telehealth should be no different from currently existing programs that address in-person care, Dickerson says. However, he notes the COVID-19 pandemic has not affected all healthcare practices to the same extent.
“A balanced approached should seek to minimize reporting burdens on groups acutely impacted by the public health emergency while ensuring ongoing participation in compliance activities that ensure [continuous] delivery of safe, effective, and ethical care,” he says.
The proper coding of telehealth claims is the primary basis for compliance with CMS rules, says Sean Kirby, senior vice president at VisiQuate, a consulting and data analytics company in Santa Rosa, CA. Data-specific procedure codes and modifiers in their proper places provide a clear picture of whether the claim will be in compliance and result in full reimbursement or a denial from the insurance plan, he says.
“Analytics through exception-based anomaly detection can provide proactive alerts when any of these rules are not followed correctly,” Kirby says. “Mitigating this risk before the claims are billed helps reduce compliance and reimbursement issues for providers.”
Dickerson is cautious about one potential problem seen in other areas of healthcare, related to technology integration at the point of care. Overleveraging telehealth may contribute to healthcare disparities. Access to such engagement may be limited for patients with technology literacy issues or with limited access to the necessary video-capable devices.
“Maintaining fair market reimbursement for providers, creating a streamlined experience, and ensuring equity for patients of different socioeconomic status is important as we continue to utilize these platforms and workflows. Additionally, privacy and security must be ensured for patients,” Dickerson says. “Patients should trust their clinicians when they request the patient come to the office for a medically necessary exam, lab, test, or procedure that telehealth just cannot provide.”
Technology Provider’s Quality Program
The requirements for a clinical quality management program in telehealth are mostly similar to those other healthcare organizations use, notes Martha Garcia, vice president of clinical quality and compliance for SOC Telemed, the largest provider of acute care telehealth services in the United States, based in Reston, VA. (There are multiple other companies providing telehealth technology services.)
“The care is virtual because of the element of technology, but it is still healthcare. Real, live physicians are providing it,” Garcia says. “Those physicians have degrees, certifications, and training that is documented and vetted before they ever see a patient through a video camera for SOC.”
Garcia suggests the same quality program used by the technology provider can be applied on the other side of the telehealth experience at the hospital. For her company, Garcia says quality assurance starts with earning accreditation from The Joint Commission.
Like brick-and-mortar hospitals, the telehealth provider has dedicated quality and clinical leadership, led by a chief medical officer. It also has dedicated chiefs for each medical specialty service line who are actively engaged in clinical practice.
Also, each specialty service has an active quality committee comprised of members of the practice. This committee is responsible for assessing clinical quality and ensuring current clinical practice guidelines, Garcia explains.
Regarding compliance, Garcia says SOC’s revenue cycle management department focuses intently on the CMS rules for reimbursement.2
“Since we deliver eligible services by eligible providers to eligible originating sites, there are only two major restrictions in the CMS pre-COVID rules that SOC needs to navigate: geographic eligibility of the originating site and exemption for telestroke services,” she says. “SOC sets billing rules in its systems to designate geographically eligible sites, codes telestroke consults appropriately, and audits paid CMS claims to ensure that ineligible services were not billed.”
Track Outcome Measures
Since March 2020 and until the end of the national health emergency, CMS is reimbursing all SOC services, Garcia notes. The company’s intensivist, neurology, and psychiatry groups regularly review changing standards. When appropriate, those groups institute immediate changes.
As new practice standards develop, physicians review and adapt them to a national telehealth practice. When these standards change, SOC Telemed works to assure client hospitals are aware of these changes and can implement them effectively.
The company’s telehealth platform tracks performance on numerous factors on both sides of the telehealth visit, allowing it to measure performance and work to improve processes, Garcia says.
“For any quality program to be effective, key indicators of patient and staff safety and organizational performance need to be measured and managed. They must be statistically valid performance measures of care, treatment, and services,” she says. “For example, at SOC, we look at patient outcome measures such as hemorrhagic conversion in thrombolytic cases, reversal of commitment in psychiatry, and length of stay and complication rates for ICU.”
The company follows the same requirements for focused professional practice evaluation and ongoing professional practice evaluation as hospitals, including a formal peer review process.3,4
Garcia believes following accreditation standards means she works for a company that strives for continuous quality and patient safety improvements. “That doesn’t change because the care is virtual in nature,” Garcia notes.
- Department of Health and Human Services. Telehealth: Delivering care safely during COVID-19. Content last reviewed July 15, 2020.
- Centers for Medicare & Medicaid Services. COVID-19 frequently asked questions (FAQs) on Medicare Fee-for-Service (FFS) billing. Updated Aug. 26, 2020.
- The Joint Commission. Focused professional practice evaluation (FPPE) - Understanding the requirements. Last updated Aug. 17, 2020.
- The Joint Commission. Ongoing professional practice evaluation (OPPE) - Understanding the requirements. Last updated Aug. 17, 2020.
- David Dickerson, MD, Vice Chair, American Society of Anesthesiologists Committee on Pain Medicine, Schaumberg, IL. Phone: (847) 825-5586.
- Martha Garcia, Vice President, Clinical Quality and Compliance, SOC Telemed, Reston, VA. Phone: (866) 483-9690.
- Sean Kirby, Senior Vice President, VisiQuate, Santa Rosa, CA.
- John E. Morrone, JD, Partner, Frier Levitt, New York City. Phone: (646) 970-4017. Email: email@example.com.