Episode 080: When Healthcare Goes Virtual

Speaker 1: You are listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals. Brought to you by SVMIC.

Brian: Hello. Thanks for joining us today. My name is Brian Fortenberry and on this episode of Our podcast we are delighted to have an individual that is going to speak with us about telemedicine, telehealth, and the risk associated with it and we're very fortunate to have Dr. Richard Moses. Dr. Moses, thank you so much for joining us today.

Dr. Moses: Oh, thank you, Brian. Thank you for having me.

Brian: Well, before we get started in our discussion, Dr. Moses, why don't you tell our listeners and subscribers a little bit about yourself, your background and the work you do?

Dr. Moses: Sure. It'd be my pleasure. I'm a practicing physician in a 10 provider gastroenterology group in the city of Philadelphia in Pennsylvania. I've been in practice for 36 and a half years and counting. I also hold a law degree, which I received about 10 years after I went into practice. I don't actively practice law per se. I do teach at Temple University School of Law, the Beasley School of Law and I also act to train some of the residents at Temple University Medical School where one of the hospitals that I'm affiliated with is a part of that system. So I'm an adjunct professor at both the law school and medical school. 

I also am chairman and medicine at Jeanes Hospital, which is the Temple Health system affiliate and I'm currently the president of the Pennsylvania Society of Gastroenterology. So I try to keep my feet in a number of different places if you will. I actively publish, my areas of expertise in health law are healthcare law obviously with special attention to medical professional liability, keeping physicians out of trouble. I'm 100% defense oriented. I also publish actively and right on compliance issues, healthcare fraud and the like. If there's anything that the defense of physicians and for patient safety and patient protection, patient advocacy, I'm touching it.

Brian: Well, Dr. Moses, you are deeply involved in a lot of issues and some that are very valuable to our conversation today for certain. I tell you, when it comes to telemedicine, it seems to be a rapidly changing environment within healthcare. What is telemedicine from your perspective? Does that really differ from telehealth? You hear a lot of these different names given to these things and sometimes they have different meanings. Could you enlighten us a little on that?

Dr. Moses: Sure, absolutely. So, as with anything, telemedicine, telehealth has really undergone somewhat of a consolidation. When you think of telemedicine, you have to think of it as remote delivery. It's remote delivery of healthcare services and clinical information using some type of telecommunication technology. And that's important from a definition standpoint from all providers. So when we talk about telemedicine and telecommunication technology, this includes things like the Internet, computers, monitors and apps, wireless products, satellite, and telephone technology.

Many providers think that it's talking to a patient over the telephone, but indeed you need to involve these other modems, if you will, in order to really practice true telemedicine. So, you know, turning attention to your question about telemedicine and telehealth and the difference, they've essentially become synonymous. When you hear telemedicine and you hear telehealth, think that you're talking about the same thing. Both terms refer to the use of remote healthcare technology like I outlined to deliver clinical services. As you alluded to, telemedicine is growing rapidly in the United States. There are currently 200 telemedicine networks, believe it or not.

Brian: Wow.

Dr. Moses: It's unbelievable the way it's growing and there are probably about a million Americans using remote cardiac monitors, so the easiest thing for physicians, nurse practitioners, physician's assistants, and other healthcare providers to get their head around is think of cardiac monitors and think of the old days when the patient had to walk into the cardiologist's office and have a magnet put over their cardiac pacemaker or over their pacemaker-defibrillator. Nowadays, that information is transmitted over a telephone or over a Bluetooth connection to a device while the patient sleeps. It's really remarkable.

Brian: It is phenomenal and I continue to read different articles and see snippets and interviews of how much it is changing. 

Dr. Moses: Absolutely. I just want to digress a minute and I want to give two extremely important definitions for everything else that we're going to say for the rest of this podcast. 

Brian: Okay.

Dr. Moses: All right, so there's an originating site and there's a distance site. This is important from a liability standpoint. An originating site is the location where an eligible beneficiary or the patient at the time of service has furnished a telecommunications interaction. 

The provider's location, the doc, the PA, the nurse practitioner there, whoever who's providing the service is the distant site. Reimbursement is based on the location of the originating site, so it depends on where the patient is, not where the provider is, and providers always get this confused. They think it's where they are. It's not, it's where that patient is. That's the originating site. That's what's going to determine where reimbursement is going to be made and where it's tied to. Let me give an easy example.

If the provider is licensed to practice medicine in state A by providing telemedicine services to a patient originating in state B, that doctor, that provider is providing medicine without a license in state B. So extremely important concept. It's where the patient is so that if your patient is in Tennessee but you are licensed in Pennsylvania and you are providing services to that patient in Tennessee, you are providing services without a license. You're practicing medicine without a license. You can get in major league trouble for that.

Brian: It's what you're saying that if you are going to be providing these services in multiple locations and particular multiple states to make sure you are licensed in each of those states. Correct?

Dr. Moses: Absolutely. You are exactly on point. One of the top telemedicine legal issues concern state licensure and this has been something that states have been grappling with for over five years now so that if you're licensed to practice medicine in Tennessee, you're limited to treating patients in Tennessee. You can practice telemedicine across the state of Tennessee. You can be taking care of a patient on the western part of the state even though you're on the eastern part of the state, but you can't step into Nebraska for example.

Brian: Sure. And if we're looking at this, is it just a normal license or are there telemedicine license and is it difficult to get a medical license in a different state to practice telemedicine? Do you have to go through the exact same types of procedures to get a license or have they revamped that at all?

Dr. Moses: That's a great question. In my experience, applying for a medical license in any state is cumbersome and involved. Where I live in Philadelphia, the states are a lot smaller and it's a tighter geographic area, so I can tell you that historically I have a license in Delaware, New Jersey, and Pennsylvania. It's called the tri-state area. 

Brian: Okay.

Dr. Moses: It was really cumbersome to get licenses in those states, and I did this now decades ago. I've just kept them up to par. Although reapplying for licensure really is a hassle because you have to get all of these records. 

It's been made easier when we talk about telemedicine, okay, because most states require that you obtain all of these individual documents that you need in order to get licensures, and it's really extremely oppressive. Licensing requirements have been identified as the major barrier to the expansion of telemedicine, and there's actually been a solution, you know,  which has really addressed this.

Brian: Okay. Is there anything in the works where there may be like a compact or anything amongst many states to take out the hassle of having to go state to state?

Dr. Moses: Yes, so the Federation of State Licensure Boards, which is really kind of a trade organization for each individual state's licensure board, because remember that each state licensure board is responsible for licensing providers in that particular state, they formed a communication's committee of the Interstate Medical Licensure Compact Commission. 

Brian: Okay.

Dr. Moses: That's called the IMLC. Basically, what it's done is expedited a pathway for licensure for qualified providers, physicians, if you will, you know,  because that's really what we're speaking about, who wish to practice in multiple states, and the mission of that commission is to increase access to healthcare for patients in underserved and rural areas by allowing them more easily to connect with medical experts through the use of telemedicine technologies.

So the IMLC is essentially a legal agreement among states, so it makes it easier for physicians to obtain licenses to practice in multiple states by strengthening public protection and enhancing the ability of states to share investigative and disciplinary information. What it basically does is make the application process expedited. It leverages existing information that was previously submitted to your principles state of licensure. So if you were a physician that originally applied for a medical license in Tennessee, that would be your principle state of licensure if you will. 

So, Pennsylvania Licensure Board is holding your databank information, your certificate from medical school, all of your certificates from all your training. They're holding that. Through the licensure compact, okay, and through the state principal licensure program, another state that participates in this compact, because not all 50 states participate, more are applying and more and more every year are starting to jump on board. But for the states that participate, they can now contact your SPL, your state of principal licensure; they would contact Tennessee in the case of our discussion and they would actually, Tennessee would share all of those documents with the state that you're applying for your licensure; so you no longer have to go out and do this and waste time. You still need to go through the usual licensure process and the state that you're applying to will verify everything, okay, but you don't have to go out and do that now, so it'll save time.

Brian: Yeah, and a lot of hassle, I would imagine.

Dr. Moses: A lot of hassle.

Brian: One of the other parts that is interesting when it comes to telemedicine that a lot of people, certainly physicians, are going to be interested in is reimbursement for these telemedicine services. How does that work? I'm sure they're reimbursable, but how?

Dr. Moses: All right, so anyone listening to this podcast will freely admit that we do a number of things, talk to patients on the telephone, speak with families. We do all kind of meetings and we don't get reimbursed and that's just part of the job. When it to telemedicine services, however, we're actually providing a medical service and CMS has recognized this and they will reimburse telemedicine services, but they'll only reimburse it Brian, for a limited number of services provided at originating sites and they've actually defined this.

Brian: Okay.

Dr. Moses: The current head of CMS has come out and said that they are interested in expanding the number of services that are reimbursable, so this is a really hot area. 

Brian: Okay.

Dr. Moses: We are going to see more services reimbursed for remote monitoring. CMS actually came out and said that they're going to come out with a document and they're going to tell us how they're going to expand these services and how they're going to reimburse us. Now when it comes to the states, that's not CMS. In the different states, there are private healthcare insurers, private healthcare insurers with their own health plans. Some of them, and by the way, many of them are jumping on board, are actually jumping on and they will reimburse for telemedicine services and they'll actually do, at least what CMS does or more. In other words, do more services, broader services.

Brian: This is such a growing industry. Now with all of this advancement, you see this making licensure easier and the services and the reimbursements are getting broader. That probably means that there could potentially be some areas of risk that are broadening as well. As we talk to practitioners and providers out there, what are some of these areas of risk of telemedicine that they should really be focused on?

Dr. Moses: Right. Very important risk. So there are really two main areas of risk. There's the area of risk that we as providers are most familiar with, medical professional liability or medical malpractice as we say. So that's one main area of risks. The other one is fraud and abuse claims. When it comes to telemedicine, the provider is held at the exact same standard of care as if they were treating a patient in their office physically there. So it's the same standard of care whether you're through an electronic platform doing telemedicine or they're in your office.

The other big area of risk which providers do not think about, but it is there, is the fraud and abuse arena. And there are really three potential fraud and abuse triggers that will get the federal government on you that can really get you into trouble and you can actually lose your license for some of this stuff. So it's really important.

Improper coding; so we're all familiar which how important it is not to upcode things, upcode our visits, that's probably the number one. Offering patients free technology so they can do telemedicine with you, okay, and also kickback concerns where the government would look at offering something like an iPhone for example, so a patient could communicate with you as offering them something so that they will then let you provide a service so then you can build, in other words, prevented kickback. It gets a little confusing, but just keep in mind that those are the two main areas of risk.

Brian: Those are very good points to point out and make sense as well. Dr. Moses, as we get ready to start wrapping up, what could we leave as some of the steps or even precautions that some of our providers should take before really jumping into this arena of telemedicine? Because it's going to be tempting to go there, but you probably need to be prepared before you make the jump. What are some steps that they may want to think about?

Dr. Moses: Very important. So let me try to bullet this a bit. Telemedicine is an evolving and complex area and is not only here to stay, but it may be a big part of the way we deliver healthcare. The first step if you're going to step into this arena is to consult with a healthcare attorney who's specifically versed in telemedicine in your particular state or the state that you're going to be applying for a license to provide telemedicine. Never practice telemedicine across state lines unless you are properly licensed in the state that originates the visit where the patient is communicating with you. 

It's important to stay abreast with the developing federal laws regarding telemedicine also. Old telemedicine communication interactions must be documented in the chart. So you have to have electronic records that can either do this directly or you have to be able to create a document and scan it in. I personally would recommend standardizing all patient encounters regardless of telemedicine. So the best thing to do is to develop a standard script for interviewing the patient and documenting that assessment in the chart.

You should also establish a disclaimer that explains the limitations of telemedicine and it's used with all patient encounters and you may be able to reach out to your medical malpractice insurance carrier. They may actually have some template language for you or help you to draft language that they find, you know, would be the best way to protect you.

Brian: Absolutely, yeah. I would encourage those SVMIC policyholders to reach out to SVMIC and they should be able to help you through that as well. We've been speaking with Dr. Richard Moses.

Dr. Moses, I can't thank you enough for taking the time out of your busy day to join us and enlighten us in this ever-changing world of telemedicine and all the things that you have to do to make sure that you're practicing and practicing to the best of your ability when it comes to telemedicine. Thanks for joining us.

Dr. Moses: Thank you very much, Brian.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host Brian Fortenberry. Listen to more episodes. Subscribe to the podcast and find show notes svmic.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.