Telehealth Webinar Series Session Two Making the Right Call on Telemedicine

Transcription

1 Telehealth Webinar Series Session Two Making the Right Call on Telemedicine Event ID: Event Started: 7/12/2017 1:53:06 PM ET Welcome Welcome to the atom Alliance Quality and Innovation Network (QIN) Learning and Action Network, Telehealth Series, titled Making the Right Call on Telemedicine. This is session number two. My name is Jennifer Ride and I will be your event moderator. We will take one minute to go over the agenda. We have a few housekeeping items we will cover and then have opening remarks by Wanda McKnight from THIMA. We will also have Mr. Yarnell Beatty from the Tennessee Medical Association and will have time for questions and answers and closing remarks. atom Alliance is a five-year five-state initiative to ignite powerful and we welcome participants from Alabama, Mississippi, Indiana, Kentucky, Tennessee, as well as other states that may be participating. We appreciate all you do to improve quality to achieve better outcomes in health and healthcare at lower cost for the patient in the communities we serve. The objectives for today, after today you will be able to see if telehealth is a good fit, know the regulatory and legal aspects and requirements to practice telehealth, find out common barriers that we have seen in telehealth and delivery for providers and look and discover what trends you might see within the telehealth industry. Housekeeping There are some housekeeping items that I would like to go over. First, all the phone lines have been muted so that we have better sound quality during the presentation. We encourage your participation throughout the event through the chat participation. You can select to send your question or comments to all the participants or to just certain individuals from the drop-down, as you see. A few of us from atom alliance will be monitoring the chat box for any information you might like to share. We will respond to you, so a link to download the slides from this presentation will also be posted in the chat box for your convenience. Another thing we are going to be doing, if you want to ask panelist questions directly or privately, you can use the Q&A function to direct your questions to certain individuals. Also, during today's presentation we will be using some polling questions. We are aiming for 100% participation of these questions, so please do not be afraid to answer. Answer are anonymous and they would come up on the side of your screen at the end it will be part of the WebEx polling feature area. Right after you select your answer and submit button so we can capture your answer.

2 Introduction At this time, I would like to introduce you to Wanda McKnight, who is a board member with the atom Alliance and for Qsource. She is also a fixture here in the Tennessee Healthcare Community, the Executive Director of the Tennessee Health Information Management Association. Thank you, Jennifer. On behalf of the Tennessee Health Information Management Association, I want to express gratitude to atom Alliance in allowing us to be a part of this important project. THIMA is devoted to quality healthcare through quality information and we are happy to partner with our friends at this another organization to explore and promote discussion about health information exchange, telehealth, and other advances to improve the health of Tennesseans and everyone in atom Alliance and across the country. It is now my pleasure to introduce our speaker for today. Thank you so much Wanda. I appreciate that and welcome to Making the Right Call on Telemedicine. I would like to start out by thanking all the folks in the host organization atom Alliance for putting the series together and inviting me to be here today. We are all friends and we appreciate them hosting today. You have been very supportive. Agenda My colleagues would have a big chuckle if they knew I was presenting on a topic even remotely related to technology. I am the least common denominator when it comes to using and understanding technology. It just doesn't like me, but here's a quick list of what I plan to go over today. This presentation is geared to the novice in exploring the possibility of using telehealth and I have from divided the presentation into five modules. In Module 1, I will define telehealth for you and give you an overview of its capabilities. If you don't know what it can do, how can you make an informed decision on whether to use it. In Module 2, I will address licensure requirements that a doctor has to have in order to use telemedicine. Module 3, will have us look at state and federal regulations as to how telehealth is delivered in Tennessee. Questions, such as what conditions have to exist before an encounter is considered telemedicine, and what if the technology used is inadequate for your provider to make a diagnosis. What can you do and can you prescribe? In Module 4, we will look at whether and how your provider will be reimbursed for telemedicine and what is the good in investing in the technology if you don t get paid. How do you bill and code for telemedicine? In Module 5, we will have to decide whether telemedicine is right for your practice and that we will look at barriers to telehealth delivery. I will predict future trends and provide you with

3 resources to help you incorporate telemedicine into your practices, if that is what you choose to do. I will then take questions from the audience, so if you would please reserve the questions to the end. Many will be answered during the presentation. What I will not get into is specific questions about technology. As I have previously stated, I am technologically challenged lawyer, so please consult your vendors for that type of consultation. Polling Question 1 We will have a polling question. And the first question, what is the status of telehealth at your organization? We will pull up that poll. Choose A, not planning to participate in telehealth; B, in the beginning stages of planning for telehealth services; C, we have been providing telehealth services for less than one year; or D, we have been providing telehealth services for more than one year. Please do not forget to click submit. A, not planning to participate; or B, in beginning stages; or C, for less than one year; and D, for more than one year. There we go. It looks like a bit of a mix, but I would say that the majority have less than one year. There are some in the beginning stages. Thank you. Back to you Yarnell. Very good. That is about what I predicted. I figured a lot of people are probably in the exploratory stages, so that looks like that is where we are. Section 1: Overview of Telehealth Let's go on to Module 1, which is an overview of telehealth. What is it and what is it not? I will give you a couple of basic understandings of definitions. What is Telemedicine To help better understand what is meant by telemedicine, let's first start with what is not telemedicine. Under Tennessee law, telehealth and telemedicine do not include audio only conversations or telephone calls. s and fax are not telemedicine. There are two definitions of telemedicine under Tennessee law. One is in the licensure section of the State Code, the professional licensure section. The one is in the State Insurance Code and that addresses when health plans have cover and pay for how telehealth services. Both of these definitions are very similar and contain the same basic elements that I have listed on this slide. We will dig in deeper into each of these elements in this module and talk about capabilities of telemedicine. Creating Physician-Patient Relationships The first question I will answer is when is the physician-patient relationship created under the concept of telemedicine. There are three concepts that will paint this picture for you. Keep in mind, that it really isn't much different than when the physician/patient relationship is created in an in-person relationship. First of all, one of two things have to happen. Either a doctor affirmatively undertakes to diagnose and treat the patient or the doctor is brought in for consultation. That is the threshold. Secondly, unless there is an emergency, the patient has to know that the doctor is participating in their care. Obviously, if the patient is having a stroke and

4 unable to consent, his consent is implied, when the healthcare provider is treating or advising for the care of a stroke patient, via telemedicine. A physician-patient relationship does exist, because it is an emergency, and as an aside, treating strokes through telemedicine is very common these days. Third, say you are conversing with an out-of-state doctor who is providing you information about a possible patient referral. No patient relationship exists. This is not a consultation, you are just considering whether to take the patient on. In that instance, no physician/patient relationship exists. Standard of Care What does this law say about standard of care when telemedicine is used? The bottom line of the statue creates parity in the standard of care between telemedicine and the provision of the same service in-person. This is important. If your physician is a dermatologist and is trying to diagnose a rash via telemedicine, she is held to the same standard of care as if the patient is in the room with the doctor. The doctor doesn't get any liability slack, because she cannot touch the rash or see if the color on the screen is skewed by technology, there is still the same level of risk. Capabilities Let's get into capabilities of telemedicine. There are three broad categories describing capabilities for telemedicine. The first one is called store and forward. The best way to explain it is by example. Imaging will illustrate this very well. Let's say you have a technologist in a rural west Tennessee hospital and the technologist takes an x-ray of an injured patient at 10:00 at night, with no radiologist at the hospital. For afterhours x-ray interpretation, the hospital has a contract with the radiology staffing company in California. The Tennessee x-ray technician loads the image and sends it electronically through a secure portal in California. The radiologist is available in California and logs in and views the x-ray. Thirty minutes later, an interpretation is dictated by the radiologist, who has the x-ray report sent back electronically back to the hospital in Tennessee. The image was stored in Tennessee and forward electronically to California where it was read, interpreted and a report was generated and then sent back to Tennessee. We have store and forward technology. There was never any direct doctor to doctor or doctor to patient interaction. We can differentiate that scenario from real time. Now, we will go to the interactive, the second category. This is your traditional virtual visit. Think Skype, only with better technology. An example would be a psych evaluation over telehealth, where the provider and patient have a discussion back and forth, so it is interactive. The third is monitoring. Sleep test combine both the store and forward and monitoring. The sleep technologist can monitor the patient on the screen, in real time, and remotely can capture those vital signs and readings and store them for review by the sleep medicine doctors at a later time.

5 Telehealth vs. Telemedicine Another question I often get is whether there is a difference between the terms telemedicine and telehealth. You hear both. Whether it is telemedicine or telehealth depends upon who is providing the healthcare service to the patient. If is being provided by a medical doctor, osteopathic physician or a physician s assistant, it is telemedicine. If it is being performed by some other type of healthcare professional, it is telehealth and that is it. We will use those terms interchangeably for the purposes of this presentation. Section 2: Licensure Requirements That concludes Module 1 and we will now go on to Module 2. That will deal with the licensure requirements. Our goals are to know when a Tennessee Medical license is required in order to provide telemedicine services and which state license the physician has to have in order to deliver telemedicine. If the patients are going to be treated via telemedicine and are located in Tennessee, the rule is that the treating physician must have a Tennessee license, unless there is an exception that applies. There are two types of Tennessee licenses available. You either have to have a full Tennessee license or a Tennessee telemedicine license to practice telemedicine. Tennessee Telemedicine licenses are only issued to out-of-state doctors and are extremely limited in scope. In fact, beginning next October, October 31, 2018, the Board of Medical Examiners will no longer be issuing telemedicine licenses. Physicians who currently have a telemedicine license will have some options. They can transfer the telemedicine license to a full medical license or they can keep the telemedicine license. About telemedicine licenses. There is only a few certain physicians that would want to retain a telemedicine license, and those would be the first of all the physician has to maintain a current ABMS specialty certification. The physician has to limit the telemedicine practice to a provision of medical interpretation services in his or her area of specialty of board certification services and the doctor cannot prescribe (not at all), unless an out-of-state provider, or a radiologist or pathologist, or someone else who just practices medical interpretive services, the provider out-of-state provider needs to have a full Tennessee license, again that transition has to be done by next October. There are exceptions where no license is required at all and all of you are probably familiar with most of them. If there is a second opinion requested by a Tennessee physician and there is no payment for the second opinion, that can be delivered by telemedicine without a license. If there is a US military physician practicing within a VA hospital, there is no licensure requirement. If the information is just used for determination to see if the patients is covered by insurance, then there is no license. There are other exceptions of the law, but those are the main ones.

6 Polling Question 2 Okay and we have another polling question. This one is asking, what type of services is your organization providing? A, none; B, if you have a pediatric specialty; C, neurology; and D, behavioral health. Do not forget to hit submit and again, choose A which is none; B, pediatric specialty; C, is a neurology; or D. which is behavioral health. We will give you just a moment for that to compute. Okay, I don't see and was still waiting for that to compute? Okay. There we go. It looks like neurology and behavioral health and other. I would say neurology is the leading answer. Yarnell? Very interesting. I would have thought that the behavioral health would have had a higher percentage. I think that is a growing area and certainly in the rural areas, where access is challenging. That is very interesting. Section 3: Delivering Telemedicine in Tennessee Let's now press on to the third module, which is Delivery of Telemedicine in Tennessee. Our goal is to provide an overview of the regulatory conditions for telemedicine in Tennessee. This particular Module is limited in scope to telemedicine by a physician. The reason for that is because I am going to go over the rule that the Board of Medical Examiners has come out with for physicians that were effective in October Regulatory Conditions on Telemedicine There are several regulatory conditions on the telemedicine and they depend upon whether a facilitator is present. A facilitator is someone who is with the patient when the patient is being seen by a telemedicine. A facilitator is required to be present when a patient is under 18 years of age, except as otherwise authorized by law. Otherwise authorized by law would include situations where the minor patient can lawfully consent to treatment. For example, an emancipated minor. An emancipated minor in the state of Tennessee is someone who is 16 years of age and married, they can consent to the treatment without a parental consent. If a facilitator is not present, what has to happen? Well number one, the patient has to utilize adequately sophisticated technology to enable the physician to verify the patient s identity and location with an appropriate level of confidence. Number two, the patient must transmit all relevant health information at least at the level of store and forward technology or secure videoconferencing, and we talked about interactive versus store and forward. Third, the physician has to comply with the state title identification law, which many of you are well familiar with, and the provider providing the service has to disclose what type of provider they are. Are they a doctor, or nurse, or a practitioner and what they are recognized specialty is, and that would be either a name tag or a sign in the office. The same applies in telemedicine.

7 If the facilitator is present with the patient, the facilitator must personally verify the identity of the patient and be able to transmit all of the relevant information about the patient and again uses store and forward technology and have that interactive conversation. The facilitator has to identify himself to not only the patient, but also the remote physician that is practicing telemedicine. The physician again, whether the facilitator is present or not, still has to comply with the identification law. Tell who they are. Regulatory Conditions: Medical Records What kind of medical records and documentation is required for a telemedicine encounter? Frankly, it is just not that much different than an in-person visit. The physician has to have the appropriate patient medical records or to be able to obtain information during the telemedicine encounter to be able to adequately treat the patient. The same as in-person. All of the pertinent data and information from the telemedicine encounter has to be documented in the patient's record. Again, you can do that during the face-to-face visit and be cognizant of the fact that the rules require that the technology used must be entered into the medical record. I don't know what that means? I don't know how specific that has to be? I think, that at a minimum, the physician would need to document that it was an interactive telemedicine encounter or something to indicate that it was a telemedicine visit. I don't think they have to go to the brand of technology used and so forth. Regulatory Conditions: Quality of Transmission The extent to which a physician can prescribe using telemedicine, excuse me, I got ahead of myself. Anytime technology is used, things can go wrong. It could cause the examining physician not to be able to make a diagnosis. So, what has to happen if that is the case? Let's say that the transmission is just not a good quality and something goes wrong. The physician is required by the rules to declare that he or she cannot form an opinion to form a diagnosis. You have to tell the patient what is wrong and why they can't make a diagnosis. They also have to tell the patient that they need to either directly refer the patient for an actual physical examination and request additional information and recommended that the patient be seen by their primary care or someone local in their area. I want to mention also that the rules are silent as to whether a physician can charge a patient if the physician has to declare the diagnosis cannot be made. Presumably they can, because at least some evaluation has been conducted, but that is not directly addressed in the rules. Regulatory Conditions: Prescribing The extent to which a physician can prescribe depends upon the type of license that the physician has. If the physician just has the telemedicine license, prescribing is not allowed at all. It doesn't matter if it is scheduled drugs, controlled, or whatever, they cannot do it at all. If the physician has a full license and that is what we are talking about of prescribing is allowed that there are some limitations and again most of the limitations are identical to the limitations that apply to an in-person visit.

8 You have to perform the appropriate history and physical examination. You have to make the diagnosis based upon all of the diagnostic and appropriate lab test that are required. You have to formulate and discuss therapeutic plans with the patient through informed consent. You have to go over the risks and benefits of the various treatment options. Number four, you have to ensure the availability of the physician for appropriate follow-up care, whether it is a physician practicing by telemedicine or someone in the patient area. They have to have follow-up care, have somebody available for follow-up care. The prescriber cannot prescribe a drug based solely on answers to a set of questions posted online. This was a huge problem when telemedicine started. Technology really outpaced the regulations, so you have these online questionnaires to answer a few questions about pain or something and then get mail order opioids, and that is a bad idea. It has certainly been banned by the Board of Medical examiners, and at the federal level as well. Prescribing controlled substances is governed by the State Chronic Pain guidelines, which does not allow chronic pain to be treated by via telemedicine. I interpret this to be refills, as well, and the rule of thumb here is that if it is a chronic pain patient, they need to be seen in-person. Regulatory Conditions: Controlled Substances Must an in-person encounter take place before a physician can prescribe controlled substances? Being the typical lawyer, the answer is, it depends. An in-person encounter is not absolutely required to take place, in order for a prescriber or physician to issue a controlled substance via telemedicine. There might be instances in which the in-person s physical examination should be performed. Certain medical conditions may necessitate in-person encounters. The Board of Medical Examiners rules provides a list of exceptions for physicians who can absolutely prescribe without doing the history. Some of those are, you issue admission orders for a prescription for a newly hospitalized patient or for a patient's you are taking call for, short-term medications for a new patient prior to the first appointment and for an established patient where the physician just doesn't feel that there needs to be a physical examination, for the treatment of chlamydia is carved out in the law. Controlled substances can be prescribed and governed by federal law at 21 USC 829. Remember again, this is non-chronic pain prescribing of controlled substances only. Federal law allows a covering practitioner to issue a prescription via telemedicine without any physical examination under federal law a covering practitioner or is someone who is conducting a medical evaluation using telemedicine at the request of another practitioner or who has conducted an in-person evaluation at least within the last 24 months. If you are covering you would not necessarily have to have an in-person visit before that. Note please that the federal law disallows partial fills of schedule II controlled substances by a practitioner engaged in telemedicine. Continuing with the discussion of whether a practitioner can prescribe controlled substances via telemedicine, TMA believes that the federal controlled substance acts has a broader use of the term electronically. So, if a prescriber intends to prescribe a controlled substance based upon the set of questions on the Internet that I talked about, such and encounter would require the in-

9 person visits with the physical before it takes place. Otherwise, to reiterate this important this distinction, the Board of Medical Examiners rule requires that a physician before prescribing or dispensing any drugs, by any means, telemedicine or whatever, has to perform an appropriate history and physical examination. That can be in-person or it can be via telemedicine. There may be adequate examinations through telemedicine. You may be able to get at the diagnosis by asking for appropriate questions of the patient so the treating physician is the one who makes that determination. It really boils down to standards of care, with no hard and fast rule but, prescribing for acute pain for example. It is hard enough to evaluate pain in and in-person visits, but evaluating it over electronic means can be very tough and that might be an instance where you need to have it in person. On the other hand, if you are dealing with a psychiatry patient, where the interaction can be through a question on how the patient feels, typically those examinations if the patient is not touched by the doctor, telemedicine may be appropriate without any prior in-person visit. Section 4: Telemedicine and Health Insurance Reimbursement Going on to Module 4. This is where we will talk about the elements that that are necessary for a health provider to be reimbursed from a health insurance company or Medicare for telemedicine. This is where I think you get telemedicine and it gets trickier. Polling Question 3 All right. Now we will go ahead and have our third and final polling question and that is what are the major concerns that your organization has regarding telehealth? A, getting paid for telehealth services; or B, technology functioning correctly; C, patient privacy security compliance concerns; or D, documentation in the medical record? Don't forget to hit submit and again, what are your major concerns regarding telehealth? Letter A, getting paid for services? B, technology functioning correctly? C, patient privacy and security compliance concerns? Or, D documentation in the medical record. It might be difficult to choose just one, but let's see what we get. Don't forget to click submit. It looks like A, getting paid for telehealth services is the greatest concern, followed by documentation issues. Health Insurance There you go, that is a legitimate concern as I'm about to get into right now that is an excellent segway into discussing reimbursement. It is very confusing. Tennessee law-we will talk about a particular provision, TCA , which is located in the state insurance code and this is statute addresses a telehealth in terms of how it is treated by the health insurance industry. As I stated before it defines telehealth. This law is what we call a parity law and the intent is to make telemedicine coverage by health plans on par with coverage of the same service delivered in person. So, telemedicine is subject to terms that are set out in your network provider agreement and health plans payment policy, just like any other reimbursement for service.

10 The law does make several requirements of health insurance entity itself and I want to go over. As I read the statute to there is a requirement to make telehealth coverage healthcare policies. This is a separate from acquiring payment for it or from dictating how much of a plan is required to pay. A health plan cannot have coverage requirements or reimbursement policies for telehealth services that vary with a qualified site location, where the patient is located, such as a physician office versus a hospital versus a school clinic, where ever the patient is located. I don't think it means that health insurance is required to reimburse for telehealth services at whatever geographic location the patient happens to be. What are the Tennessee state law requirements placed on health insurance companies, as far as reimbursement is concerned? First, the health insurance company cannot exclude a service from coverage solely because it is provided through telehealth, instead of in-person. Billing for Telemedicine Services: Commercial Next, a health insurance company is required to reimburse healthcare service providers who are out-of-network for telehealth under the same reimbursement policy with physical out-of-network healthcare service providers, in-person. Health insurance companies are not required to pay total reimbursement, including the use of the telehealth equipment. They could pay more for telehealth, but they don't have to. They can pay the same as an in-person service, so you would not be able to charge an add-on for to towards the payment of the technology. In order to qualify for reimbursement under Tennessee law, the encounters have to meet requirements as to where the patient is located and where the treating provider is located. Both have to align. This slide lists the qualified sites for the healthcare provider must be located in order to qualify for reimbursement. If the teledoc is not at one of these specific locations, they are not eligible for the reimbursement. They are not eligible. It also has to align with where the patient is located and you have to have where the patient is located in order for the provider to be eligible for reimbursement. You can read it, I won't go over it, but let me point out that noticeably absent from this list is it the patient's home. You would think that would be a very desirable place to want to initiate and encounter. You have got a sick child and to be able to call in and be able to have that interaction over the Internet would be very desirable. However, since home is not on the list of qualified sites, there is not insurance reimbursement for that. Consequently, if the patient is at home and they treat patients at home, these are cash only businesses right now. It is our understanding that there is a new modifier for telehealth services for patients under commercial health plans. Modifier 95 would be appended to E&M codes and for new patients and and for established patients. You have a modifier GT for Medicare and that is services delivered to buyer interactive video systems. The bottom line, you need to check each insurer's reimbursement rules and policies for the services that are covered and the applicable billing procedures. You will need to clarify with each of the health plans what modifiers you are using and whether the list of codes is the same as Medicare or has a broader coverage.

11 Medicare Conditions for Payment We have been talking about the Tennessee commercial health insurance and now I want to shift to Medicare. This is governed by the Medicare Conditions for Payment. The first condition is that the service provided by telehealth has to be on the Medicare's list. You need to check online for the Medicare list of covered services. The additional condition is the technology requirement. Telehealth service has it to be furnished to be an interactive telecommunication system to be eligible for Medicare reimbursement. It has to be an eligible service and again there is a list of codes that you need to check that would include things such as office visits, office psychiatry services and I will say again that the list of codes is evaluated each year by the Secretary of Health and Human Services. There are some changes, typically there are additions to the list. This is something that needs to be reviewed every year. A tele-presenter at the original site is not required. That would be similar to what I talked about earlier in Tennessee law regarding the facilitator. The facilitator, this is not required in order to be reimbursed. And like Tennessee use of the term qualifying site, Medicare paid for element telemedicine services and they call the originating sites. That means only specific consisted sites at which the patient is located are eligible. There are some site requirements as well. They are very narrow and it has to be in an area that is designated as a rural health professional shortage area. It can be a County not included within a metropolitan statistics area or from an entity that participates in federal telemedicine demonstration project. Again, it is very narrow and I think eventually this will broaden and expand beyond the rural realm. That is in the future. The eligible originating sites are the traditional physician's office, hospital, Federally Qualified Health Center, skilled nursing facility, there is a long list of qualifying sites. If all conditions are met, then the provider and the facility are paid by Medicare for the telemedicine services. CMS pays a facility fee to the originating site and that is reported as HCPCS Q3014, and also a professional fee is based upon the E&M and began you have to appended that with the GT modifier for Medicare. The Medicare payments for a physician in telemedicine have to be an amount that is equal if it had been delivered in-person. Medicare has parity as well. Section 5: Wrap Up Barriers to Telehealth Delivery We are now in Module 5, which is the wrap-up. I will start by going over some of the barriers to telehealth delivery. I know that a lot of you have said that the practice of exploring of taking the plunge in telemedicine and you need to know in order to do that what are some of the barriers? Future Trends: ACA There is an uncertain national healthcare climate, is the ACA going to be repealed and if so, is medical technology companies able to make the investment in improved tele-technology, in all this uncertainty. What will be covered and incentivized and we are taking a pause on the national level.

12 Future Trends: Reimbursement Reimbursement, we have talked a lot about the barriers there and talked about qualified sites, originating site under federal law. There are limitations where a provider and/or a patient has to be. There are legal barriers. For instance, there is a lawsuit in the state of Texas where a Tele- Doc, a major telemedicine company nationwide, has filed an antitrust lawsuit against the Texas Medical Board that came up with rules prohibiting prescribing without the prerequisite of the face-to-face encounter, which damages the Tele-Doc model, which no in-person requirement before the telemedicine encounter. The Federal Trade Commission decided with Tele-Docagainst the board and that lawsuit will be settled soon and it is my understanding that the medical board in Texas is going to back off of its requirements of the face-to-face encounter before prescribing. Future Trends: Liability Was unable to find any Tennessee malpractice cases. I think that professional liability coverage is going to evolve. Most telemedicine is covered under existing policies, if there are subsequent lawsuits and liability payments and will liability risks will be forced into riders. We will cover the in-person visit but if you are going to branch out into telemedicine costs based on a rider. That has not happened yet, but that is something you might want to think about in the future. Heightened protection if you are engaged in psychiatry, behavioral health records which there is heighted scrutiny over protecting those records. There is a business associate agreement that you will have a vendor with your technology and those have to be in place. If you are really technologically savvy and venture into mobile health apps, that is the platform for a diagnostic fix or treatment, that is regulated by the Federal Trade Commission and so there are additional federal regulations. If the apps are used for prescribing, maybe the FDA weighs in. The wireless network that is regulated by the federal communications commission. If fraud and abuse might occur, a claim that is falsely filed. As you see there are just not as clear-cut as just the license. Future Trends: Other Legal Barriers There are many other regulatory legal barriers that you have to be aware of. Competition from out-of-state providers. I hear that a lot. No longer is your competition the clinic across the street or even in the same town of the same state. Now, with telemedicine your competition is nationwide. Continuity of care. If you are going to have a patient seen through telemedicine on an acute basis, are the results of that going to be reported to primary care physician. So that they are aware of the treatment. Privacy and security and the hacking concerns and again Tennessee borders eight different states so if you are going to enter into telemedicine and you see a patient out-of-state, you have to comply with each of the other states. A lot to consider in terms of the barriers and they can certainly be overcome. Future Trends: Growth of Telemedicine Future trends telemedicine will grow because both consumers, employers that offer healthcare, they are demanding it. Looking in my crystal ball, what do I see for telemedicine? I think for one

13 thing there was going to be more emphasis placed on it in the Tennessee General Assembly, there is perception that there is a shortage of healthcare providers, especially in rural areas and our regulators will look at that and see that telemedicine might be a solution to be able to provide services in those areas. It most certainly will ramp up to be used in schools and by employers. In the last two years in the General Assembly, there is an amendment to the laws to add schools, so in the legal arena, I think there will be gaps that will be addressed expansion of qualified site requirements and things like that and hopefully there will be faster clarification of technology and especially with respect to what delivery modalities are most secure. Some of these things that are adequate security barriers in place to make sure that it is safe. The technology is only going to get better, but there has to be nimbleness in regulations. Key Take Home Concepts My take-home concepts, and here is a punch list of things to keep in mind. What telemedicine is not? The rule of thumb to be licensed for the patient that you are treating and understanding that qualified and originating sites have state and federal laws in order to be in reimbursed and under state law the roles of facilitators for what the doctor and patient are response for. I won't spend a lot of time on preconditions to prescribing, but be able to understand that and Medicare conditions for payment and the bottom line is the fact that a patient's home is not a qualified site, so there is no insurance reimbursement for that. It is cash only. Resources And I put together a couple of slides of resources for you and I will direct your attention to the Board of Medical Examiners FAQs. If you have questions about telemedicine, it might be a good idea to submit the question to the Board of Medical Examiners and then the TMA online log guide. They will add more within the next few days, so everything in these slides and much more will be included. I encourage that if you are providers an excellent source for anything is the AMA. It will help you prepare for steps you must take to do telemedicine in your practice. This slide has my particular contact information on it and if you have any particular questions that come up later on, please contact me and I would be more than happy to respond. Just tell me you were on this presentation and I will get back to you as soon as possible. So that is it. I will now take any questions. Questions and Answers Question: Impact of Regulations on Adoption We had one question coming in via the chat. Is there a sense of how the regulatory conditions in the states have impacted the adoption rate of telehealth in Tennessee? As I think, adoption has been slow because legislation and regulation has been very slow to come. It took the Board of Medical Examiners almost 2 years to come up with their rules addressing telemedicine. I think a lot of providers are looking at that and waiting to see what are these rules going to look like and will I be able to afford to adopt. There have been some

14 amendments in the last few years, but when you look at the history of all of this, except for telemedicine license, which has been around for a long time, other regulation and the parameters around it are very new. Again, the Board of Medical Examiners for rules were only effective in October 2016, not even one year. So, I think now that we have a little bit of a lay of the land of the regulatory scheme, practices will be able to look at those to see if telemedicine is the right way for them to go for their practice. Question: Approved Sites I have one more here. Do you think eventually a home will be considered as an approved site if a home health nurse or therapist is present and the patient has an interactive visit with the physician? Short answer would be yes. That might be the steps that the regulators take to start off by covering it if there is a facilitator present. Let's say you have an elderly patient who has a caregiver who could be a facilitator. I think that insurance companies, Medicare, regulators everyone may have a better taste about telemedicine in those situations. You might see that progression where it might be covered for certain services if a facilitator is present before they just go full on at the patient s home, will pay. Question: Telemedicine and Chronic Care Okay we just have one more that says, can you speak a bit to the difference in telemedicine for chronic care versus other conditions? Yes, for chronic care, I would say that one of the benefits of telemedicine is the behavioral health realm. I think it provides access and a lot of flexibility in terms of when encounters can take place and if it is an emergency or if you have a patient that needs to be virtually seen, then telemedicine is so much easier than saying okay I will see you Monday morning in my office. I think there is a lot of nimbleness in that area. Question: Advancing Telehealth What can a patient practice or a concerned citizen do to advance telehealth in their state? The most important thing you can do is contact your state legislator. Again, the coverage, a lot of people are very concerned about insurance coverage. That will be the emphasis for its growth and it will be a matter of a grassroots effort. I think we will see in the coming years is more pressure put on employers on insurance companies to coverage more services via telemedicine. It is quicker access and there are a lot of services that can be provided that don't need an in-person in counter so the rank and file you should just write a letter to their legislator to enact legislation to expand capability and coverage.

15 Follow-Up to Telemedicine and Chronic Care Will follow-up at about the difference for chronic care versus other conditions. Could chronic care in the future be considered for home as an originating site without the presence of a healthcare provider? As technology improves I see that happening, yes. At this time, I don't see any further questions. Question: Distance and Reimbursement Is there specific distance that you have to be outside of the servicing area for reimbursement? Not to my knowledge. The law simply says that the patient and the treating provider not be in the same location. There is no interpretive guidelines or rules that further explained what that is so that is the best. It doesn't address whether the service can be on the same campus of the hospital and there really is no distance guidance that I have been able to find. Question: Regulatory Conditions in Tennessee Is there a sense of how the regulatory conditions in the state have impacted the adoption rate in Tennessee? I don't have any early indicators that I can only think that now that everything has settled down with the rules and providers are able to review the Board of Medical Examiners rules and know what the parameters are, that it will only grow. I think a lot of providers are waiting for these rules to be promulgated and when they were originally proposed, the original set of rules, was very restrictive and the board did require an in-person visit for before a controlled drug could be prescribed. They were very restrictive to begin with and after hearing and after comment, the board back off of its narrow and restrictive parameters and has taken a middle ground and not just a Wild West show out there. There are some oversights on telemedicine's that I suspect, here we are less than one year into it, and I think we will see this poll I would not be surprised if it didn't double in terms of those either planning to use it or are already using it. Question: Coding Documentation Requirements The same documentation requirements for coding apply with telehealth. For example, level II or level III visits? I'm afraid I do not know the answer to that question. I could follow up with that person. If the person asking the question wants to me that question I will be happy to follow up. Okay and the parity law covers the patient seeing in non-rural areas for private payers? It would under state law, but under federal, Medicare Conditions of Payment, it would not at this point. Closing There are no further questions in the queue at this time.

16 This is Jennifer, if you want to advance of the slides to the next slide, there is a question that I see here about being unable to download the PowerPoint slides. You can also go to the ondemand learning area of the atomalliance.org and you may be able to download them from that area. There is going to be also a way that you can go to the list of the opportunities, so that your name and other information, and you will be able to download any of that on-demand learning sections of your choice if you go to that. Hopefully you can get those. If you cannot get them, please contact us and we will you the slides if you cannot get them from the on-demand learning session. Thank you so much everybody for joining us. Thank you, Yarnell Beatty and thank you for all your information. I know that was a lot to absorb in one setting, but thank you for putting that altogether so that we have a better understanding of the legalities and healthcare arenas. Thank you also for our disciplines for joining the call today and participating in the polls. It is appreciated and please know that we are here to help you. Please contact us if you have any questions regarding what you just heard or if you need some technical assistance or if you need any help with your chosen activities. This call was recorded today and a transcript will be posted to the atom Alliance website. Be sure to check out all our past presentations and this one as well and I do want you to please complete the survey. If you go to the next slide there is a survey question. Please be sure to provide your feedback to us. We would love to have you like us, tweet us or send us information and connect with us however you would like to get the word out about what you learned today. We would appreciate that and thank you again for your participation. Everyone have a great afternoon.