Tag Archives: Medicaid

2016 Is Ramping Up For Telemedicine Developments

Two months in and this year has already seen significant movement in regulatory action across the country to expand the ability to provide telemedicine services. Below please find some of the more significant items that have already gone into effect in 2016 or are under consideration, including commercial payor and Medicaid reimbursement coverage for telemedicine services, reciprocal licenses for out-of-state providers and the ability to prescribe without an in-person evaluation.

Parity Laws in New York and Connecticut

Effective January 1, 2016, New York passed a Chapter Amendment clarifying last year’s telemedicine commercial coverage statute.  Under the 2016 Chapter Amendment, private insurers are required to cover services via telemedicine if provided by hospitals, home care and hospice agencies, licensed physicians, physician assistants, dentists, nurses, midwives, podiatrists, optometrists, ophthalmic dispensers, psychologists, social workers, speech language pathologists and audiologists.  The parity law prohibits an insurer from excluding from coverage a service provided via telehealth if that service is otherwise covered in-person.

The law also provides for Medicaid reimbursement to providers for telehealth services, which is defined broadly to include real-time two-way electronic audio visual communications, asynchronous store and forward technology and remote patient monitoring. However, with the exception of remote patient monitoring, telehealth will not be reimbursed by Medicaid when the patient is located in their home.  The New York Department of Health is expected to release telemedicine regulations later this year.

Similarly, Connecticut also recently passed a new telemedicine parity law that went into effect January 1, 2016. Under Connecticut’s parity law, commercial insurers must provide coverage for services rendered via telemedicine under the same terms and conditions as would apply if that service was provided in-person.  Connecticut broadly defines telehealth to include services performed by a telehealth provider at a distant site as well as synchronous interactions, asynchronous store and forward transfers and remote patient monitoring.

Notably, Connecticut went even farther than New York in its telehealth parity law by expressly preventing a health plan from excluding a service from coverage solely because the service is provided through telehealth and not in-person. In this way, a health plan cannot exclude a telehealth service, such as remote patient monitoring, simply because it does not lend itself to an in-person professional service.

Florida’s Controlled Substance Teleprescription Law

Florida recently implemented a new rule to permit physicians to prescribe controlled substances via telemedicine exclusively for the treatment of psychiatric disorders, effective March 4, 2016. Specifically, the amended regulation provides that controlled substances may not be prescribed through the use of telemedicine, “except for the treatment of psychiatric disorders.”

However, after passing this new rule, the Florida Board of Medicine recognized that it is still restricted by the Federal Ryan Haight Online Pharmacy Consumer Protection Act of 2008.  The Ryan Haight Act narrowly permits the remote prescription of controlled substances for patients without an in-person evaluation so long as the patient is: (1) physically located in a hospital or clinic with a valid DEA registration; and (2) treated by a DEA registered practitioner in the usual course of professional practice and in accordance with state law.  Accordingly, while Florida is expanding its telemedicine laws, the prescription of controlled substances via telemedicine will only be broadly permissible if the American Telemedicine Association, or other organizations, are successful in amending the Ryan Haight Act.

Newly Introduced Telemedicine Bills in New Jersey and Ohio

Various other states are also in the process of trying to pass telemedicine bills. For example, New Jersey recently introduced a bill on February 8, 2016, that would require private payors to provide coverage for telemedicine to the same extent that the services would be covered if they were provided through an in-person consultation.

Additionally, another NJ telemedicine bill was introduced on January 12, 2016, which would provide a mechanism for physicians and other health care providers to obtain reciprocal licenses to practice in New Jersey if the providers are licensed by another state in their particular specialty.  The bill would also provide a parity law for telemedicine services to be reimbursed under NJ Medicaid.  As a similar bill was proposed in 2015 and has now carried over into the 2016 session, the likelihood of its passing is even greater.

An Ohio legislative bill is also headed to the Senate that would allow patients to obtain prescriptions (for non-controlled substances) without an in-person exam or visit from a health care provider.

For more information on telehealth and telemedicine legal and regulatory considerations, continued legislative developments or related issues, please feel free to contact Daniel Meier or any member of our health care practice group for a further discussion.

NYS Identifies $496 Million in Medicaid Home Health Erroneous Payments

On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid erroneous payments related to home care recipients who are dually eligible for both Medicare and Medicaid funds.  On October 1, 2013, the New York State Department of Health’s Fiscal Group received the $211 million payment through the action of OMIG, which was the largest single monetary recovery in OMIG’s history.

These payments were recovered by New York State as part of a federal project, the Third-Party Liability Home Health Care Demonstration Project, which is reviewing home health care involving dual eligible recipients, and is being conducted in conjunction with the University of Massachusetts Medical School.  Continue reading

Circuit Court Upholds Immediate Jeopardy for Failure to Notify of Significant Change in Patient’s Condition

The U.S. 6th Circuit Court recently upheld a DHHS Departmental Appeals Board decision that found a skilled nursing facility’s (“SNF”) deficiencies were at an “immediate jeopardy” level relating to a failure to notify a physician or family member of a significant change in a patient’s condition. See, Claiborne-Hughes Health Center v. Sebelius, 6th Cir. No 09-3239, 6/25/10.

The Claiborne-Hughes Health Center is a SNF in Franklin, TN. The decision was based upon surveyors findings that the facility failed to comply with 42 C.F.R. §483.10(b)(11). Section 483.10(b)(11) requires a facility to immediately consult with a resident’s physician and notify the resident’s family members or legal representation when there is a significant change in a resident’s physical, mental, or psychosocial status.

The failure to comply with the applicable regulation related to Claiborne-Hughes’ policy on recording patient fluid-intake. Surveys completed in August and September of 2006 revealed that the facility was not sufficiently monitoring patient fluid intake in accordance with its own policies.

A copy of the decision can be found at – http://caselaw.findlaw.com/us-6th-circuit/1529702.html

CMS to Share Terminated Provider and Supplier Information with States

In order to implement requirements in the the Patient Protection and Affordable Care Act of 2010 (“PPACA” or the “Health Reform Bill”), CMS is starting to share information with the states about providers who are terminated from participation in Medicare.  CMS is going to start sharing the information via e-mail while it works on developing an electronic database.

Section 6401(b)(2) of the PPACA requires CMS to establish a process to make available to State Medicaid and CHIP agencies certain information on Medicare providers and suppliers that are terminated from participation in the Medicare program or CHIP. Additionally, Section 6501 of the PPACA requires state Medicaid programs to terminate any Medicaid provider that has been terminated from Medicare.

See this recent CMS Program Integrity memorandum from the CMS Center for Program Integrity.

Health Reform Includes Face to Face Practitioner Encounters for HHAs and DME

The Patient Protection and Affordable Care Act of 2010, H.R. 3590 (the “Health Reform Bill”) includes statutory provisions requiring face to face practitioner encounter requirements for home health certifications and prior to the provision of orders for durable medical equipment.

In the home health context, Title VI, Subtitle E, Section §6407(a) of the Health Reform Bill amends 42 U.S.C. §1395f(a)(2)(c). The amendment adds a condition to the existing conditions for payment.  The new condition provides that prior to making a certification that a patient meets the criteria for Medicare-covered home health services,  the physician “must document that the physician himself or herself has had a face-to-face encounter with the [patient] within a reasonable timeframe as determined by the Secretary’’. At some point in the near future, CMS will likely publish regulations defining “reasonable timeframe”.

In the durable medical equipment context, Title VI, Subtitle E, Section §6407(b) of the Health Reform Bill amends 42 U.S.C. §1395m(a)(11)(B). The amendment adds a condition to the existing conditions for payment.  The new condition provides that prior to providing an order for durable medical equipment under the Medicare program, “a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist [must have] had a face-to-face encounter with the [patient] during the 6-month period preceding such written order, or other reasonable timeframe as determined by the Secretary.’’ To the extent that CMS wants to redefine the timeframe, it will likely publish regulations in the future.

Additionally, Title VI, Subtitle E, Section §6407(d) of the Health Reform Bill provides that the encounter requirements shall apply to similar home health certifications or orders for durable medical equipment in the Medicaid program.