Telehealth Effectiveness from a Business Process Standpoint

Telehealth refers to the use of technology and electronic information to provide healthcare services remotely. Telehealth utilizes the internet, video conferencing, streaming video, imaging, telephone calls and other electronic communications.

Due to the advent of COVID-19, telehealth has become the predominant method to diagnose and monitor patients who are otherwise unable to receive in-person medical care. In many areas, routine healthcare services are currently only available through telehealth, and many patients enjoy the flexibility and safety that telehealth provides.

Many providers have adapted to effectively utilize telehealth from a patient care perspective; however, they are now having difficulties determining whether they are effectively managing the business processes to ensure proper billing and to validate that they are being paid appropriately for all services rendered.

Some of the common issues that have arisen include lost charges and lower than expected payments, in addition to denials for untimely filing, incompatible services, coding errors, and lack of coverage. It is also expected that providers will be subject to retroactive audits of coding and medical record documentation for telehealth services.

As telehealth is expected to remain a significant method of healthcare delivery, it is critical for providers to analyze the effectiveness of their telehealth policies, procedures, systems, and controls in order to maximize financial opportunities and to reduce risks related to compliance exposures and compromised Protected Health Information (PHI).

ACCELERATED IMPLEMENTATION OF TELEHEALTH

Many healthcare providers rushed to rapidly expand telehealth in the midst of COVID-19. In an effort to provide services to patients as quickly as possible, some providers were forced to cut logistics corners in the implementation of telehealth. Many providers didn’t invest the time and resources required to develop the proper workflow, policies, procedures, and controls necessary to sustain telehealth for an extended period of time.

Moreover, even providers who took additional time to implement telehealth are also struggling to fully understand how they can improve the business operations/functions related to telehealth.

POLICIES, PROCEDURES, AND CONTROLS

Policies, procedures, and controls are the foundation for an effective telehealth program. It is important to develop comprehensive policies, procedures and controls that are specifically designed for telehealth rather than to utilize those designed for traditional office visits.

For instance, policies should require the verification of coverage with the patient’s payer before the first telehealth visit in order to ensure that the patient’s insurance covers telehealth services, as the denials rate has been high for certain services provided.

Formal monitoring controls should also be implemented to ensure the accuracy of billing codes; timely billing of all services, timely remittances, and follow-up for claims where the amounts received are lower than expected reimbursement.

CHARGE CAPTURE

Controls should be implemented to ensure that all services provided have been billed. There should be reconciliations of the number of scheduled telehealth sessions to the number of sessions actually billed with explanations for cancelled, no-show, or unbilled sessions.

Management should develop tools to analyze unbilled visits on a regular basis. Such review is important to ensure that all unbilled charges are captured and resolved timely, in order to avoid denials due to untimely billing.

In addition, systems should be designed to accurately estimate the amount of reimbursement expected from each payer for each telehealth session. The expected payment amounts should be monitored and adjusted frequently, as many payers have telehealth rates in effect for relatively short periods of time. Discrepancies in the amounts received and estimated reimbursements should be investigated.

Providers should also utilize benchmarks to develop expectations regarding reimbursement for telehealth services and an understanding of the reasons why average reimbursement may be inconsistent with the relevant benchmarks.

BILLING AND CODING

Many payers’ telehealth billing requirements have been changing frequently and will continue to evolve over time. Therefore, it is important to closely monitor these requirements by frequently visiting the payers’ websites for updates and to remain current with the correspondence received from the payers.

It should also be noted that commercial payers often have different requirements for submitting bills for telehealth services than for traditional office visits.

Medicare and commercial payers frequently require the use of different Common Procedural Terminology (CPT) Codes for the same telehealth services provided. Medicare maintains a large list of eligible CPT codes, in contrast to some private payers that prefer the use of a single telehealth code instead. As a result, knowledge of each payer’s specific requirements is necessary in order to avoid denials and to receive reimbursement at the appropriate rates. The place of service codes and billing modifiers is important to ensure that a claim will be paid.

The documentation of medical necessity is critical for telehealth claims, as is documentation under the principles of evaluation and management (E/M) coding.

Quality control audits of coding should be performed from both a corporate compliance standpoint and a lost revenue perspective, as there have been many instances where bills have been “under-coded” based on a lack of understanding of the guidelines.

DENIALS MANAGEMENT PROGRAM FOCUSED ON TELEHEALTH

Providers should establish a formal denials management program that separately focuses on denied telehealth claims. Such a program should accumulate telehealth denials, track denial trends, remediate specific denial reasons through process improvement or education, track results of claim recovery by denial rate and turnover rate, and report claims recovery results with prospective prevention results. The goal of such a program is not only to recover bills that have already been denied, but to also identify the root causes of denials in order to prevent similar denials from occurring in future periods.

HIPAA & CYBERSECURITY RISKS

With the rapid shift to telehealth and the increase in the number of providers working remotely on personal networks, there are increased risks related to cybersecurity breaches, as well as Health Insurance Portability and Accountability Act (HIPAA) violations. Providers should ensure that they are working with their information technology professionals to enhance PHI security, in order to avoid costly breaches and violations.

CONCLUSION

Providers will be required to efficiently provide telehealth services and to effectively bill and collect for these services in order for telehealth to become a financially viable delivery method. If properly implemented, telehealth can also be a useful tool to facilitate value-based care initiatives, which are the focus of many payers and have a direct correlation to the reimbursement paid to providers.

Marcum is currently performing a number of provider telehealth assessments to determine the effectiveness of our client’s telehealth programs and is experienced in developing business strategies to help implement best practices.