Telemedicine Coding and Reimbursement - Current and Future Trends

Health Insurance Payment for Telehealth Services: Scoping Review and Narrative Synthesis

BACKGROUND

As telehealth services have demonstrated significant advantages in providing qualified and accessible care, health insurance payments for telehealth services have been issued by various countries. However, the optimization of health insurance payments for telehealth services remains uncertain.

OBJECTIVE

We conducted a scoping review of the current situation regarding health insurance payments for telehealth services, with the aim of providing evidence to enhance policies related to health insurance payments for such services.

METHODS

This scoping review was conducted by comprehensively retrieving data from 6 electronic bibliographic databases from inception to October 2023. The databases included China National Knowledge Infrastructure, Wan Fang, Weipu, Web of Science, PubMed, and Embase, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Two authors independently assessed search results, extracted data, and evaluated the quality of the included studies using the Critical Appraisal Skills Programme checklist. After the initial screening of titles and abstracts, full texts were obtained and examined. The data regarding the first author, date of publication, country, type of telehealth services introduced in health insurance, health insurance reimbursement providers, reimbursement standards for telehealth (eg, the condition for the reimbursement and reimbursement rate), and key findings of studies were extracted and analyzed. Moreover, we also conducted a narrative synthesis to summarize and report the findings.

RESULTS

A total of 7232 papers were retrieved. Following quality assessment, 23 papers were finally included, with the covered countries including China, the United States, Australia, France, Japan, the United Kingdom, and Germany. The forms of the services vary across different regions, mainly including consultation services, medical monitoring services, mental health services, health education services, and other services. Payment standards are generally categorized into fee-for-service and global budget payment, with clear health insurance payment quotas or proportions and certain restrictions (eg, specifying the location of medical visits and setting the limitation on distance from home to hospitals). The paying entities for health insurance payment include national health insurance and commercial health insurance. In addition, there are 2 kinds of reimbursement rates-a comparable rate for both telehealth and in-person health care services, and a lower rate for telehealth services compared to in-person health care services.

CONCLUSIONS

To enhance the accessibility of telehealth services through health insurance payment, it is crucial to further refine the design of health insurance payment for telehealth and strengthen the supervision of services quality, bridging the gap between telehealth and in-person health care services. Additionally, this review did not include studies from all countries, and we recommend that future reviews should include a broader range of countries to provide a more comprehensive view of global telehealth insurance systems.

Reimbursement in the age of generalist radiology artificial intelligence

We argue that generalist radiology artificial intelligence (GRAI) challenges current healthcare reimbursement frameworks. Unlike narrow AI tools, GRAI's multi-task capabilities render existing pathways inadequate. This perspective examines key questions surrounding GRAI reimbursement, including issues of coding, valuation, and coverage policies. We aim to catalyze dialogue among stakeholders about how reimbursement might evolve to accommodate GRAI, potentially influencing AI reimbursement strategies in radiology and beyond.

Mobile Patient-Provider Communication and Lifestyle Improvement: Examining the Role of Mobile Technology Identity and Health Empowerment

In the span of a decade, smartphones have gained popularity and acceptance among both patients and physicians thanks to their advantages in health care delivery. However, research investigating mobile patient-provider communication (MPPC) and its impact on patients' lifestyles is only just beginning. Drawing on the pathway model of health communication and mobile technology (MTI) theory, we developed a research model to explore the effect of MPPC on lifestyle improvement, using health empowerment as a mediator and MTI as a moderator. The findings from 432 participants (Mage = 32.5 years old, female = 212) suggested that after controlling for respondents' age, gender, education, income, and general health status, having greater communication with healthcare providers through mobile devices was positively related to lifestyle improvement and that health empowerment mediated this relationship. Moreover, MTI-emotional energy (MTIE) moderated the direct relationship between MPPC and lifestyle improvement, while MTI-dependency (MTID) moderated the indirect impact of MPPC. Individuals who hold a greater MTIE/MTID were more likely to benefit from MPPC such that they are more likely to be empowered for self-care and maintain healthy lifestyles. This study not only contributes to the growing literature on mobile health communication but also plays a reference role for interventions in patient empowerment and health promotion. Theoretical and practical implications were discussed.

Predicting Peak Productivity in Urologic Medicare Practice via Work-Relative Value Units

OBJECTIVE

To explore factors associated with productivity in urologic practice. Work-relative value units (wRVUs), the basis for Center for Medicare & Medicaid Services (CMS) and private payer reimbursements, commonly serve to estimate physician productivity. Limited data describes which practice factors predict increased wRVU productivity.

METHODS

The 2017 and 2018 CMS databases were retrospectively queried for urologic Medicare provider demographics and procedural/service details. Medical school graduation year was used to estimate years in practice and generation (Millennial, Gen X, Baby Boomer, or Post-War). Treated patients' demographics were obtained. Adjusted and unadjusted linear mixed models were performed to predict wRVU production.

RESULTS

Included were 6773 Medicare-participating urologists across the United States. Millennials produced 1115 wRVUs per year, while Gen X and Baby Boomers produced significantly more (1997 and 2104, respectively, P <.01). Post-War urologists produced numerically more (1287, P = .88). In adjusted analyses, predictors of Medicare wRVU productivity included female and pelvic medicine and reconstructive surgery (exponentiated beta estimate (β) 1.46, 95% CI 1.32-1.60), men's health (β 1.22, 95% CI 1.13-1.32), and oncologic subspecialization (β 1.08, 95% CI 1.02-1.14), female gender (β 0.87, 95% CI 0.82-0.92), wRVUs generated from inpatient procedures (β 1.08, 95% CI 1.06-1.09) and office visits (β 0.88, 95% CI 0.87-0.89), and the level of education (β 1.10, 95% CI 1.07-1.14) and percent impoverished patients (β 0.85, 95% CI 0.83-0.88) in provider's practice zip code.

CONCLUSION

Urologic experience, specialization, demographics, practice patterns, and patient demographics are significantly associated with wRVU productivity in Medicare settings. Further work should incorporate quality metrics into wRVUs and ensure patient demographics do not affect reimbursement.

Strengthening Support for Community Mental Health Programs Through Partnership and Collective Impact

Effective partnerships can profoundly impact outcomes for youth with behavioral health concerns. Partnerships occur at multiple levels - at the individual, organizational, state, and national levels. The Systems of Care (SOC) framework helps to conceptualize and articulate the skills necessary for forming partnerships in youth's mental health. This article explores values in the SOC framework and makes the case that the framework can help develop a "road map" to develop the skills needed to achieve successful partnerships. Impediments to effective partnerships are also discussed. Several case examples are given to illustrate the principles and impediments to partnership formation.

MEMS Technology in Cardiology: Advancements and Applications in Heart Failure Management Focusing on the CardioMEMS Device

Heart failure (HF) is a complex clinical syndrome associated with significant morbidity, mortality, and healthcare costs. It is characterized by various structural and/or functional abnormalities of the heart, resulting in elevated intracardiac pressure and/or inadequate cardiac output at rest and/or during exercise. These dysfunctions can originate from a variety of conditions, including coronary artery disease, hypertension, cardiomyopathies, heart valve disorders, arrhythmias, and other lifestyle or systemic factors. Identifying the underlying cause is crucial for detecting reversible or treatable forms of HF. Recent epidemiological studies indicate that there has not been an increase in the incidence of the disease. Instead, patients seem to experience a chronic trajectory marked by frequent hospitalizations and stagnant mortality rates. Managing these patients requires a multidisciplinary approach that focuses on preventing disease progression, controlling symptoms, and preventing acute decompensations. In the outpatient setting, patient self-care plays a vital role in achieving these goals. This involves implementing necessary lifestyle changes and promptly recognizing symptoms/signs such as dyspnea, lower limb edema, or unexpected weight gain over a few days, to alert the healthcare team for evaluation of medication adjustments. Traditional methods of HF monitoring, such as symptom assessment and periodic clinic visits, may not capture subtle changes in hemodynamics. Sensor-based technologies offer a promising solution for remote monitoring of HF patients, enabling early detection of fluid overload and optimization of medical therapy. In this review, we provide an overview of the CardioMEMS device, a novel sensor-based system for pulmonary artery pressure monitoring in HF patients. We discuss the technical aspects, clinical evidence, and future directions of CardioMEMS in HF management.

The COVID-19 pandemic's impact on sleep medicine fellowship telemedicine training: a follow-up survey of program directors

STUDY OBJECTIVES

Our 2019 survey of sleep medicine fellowship program directors (PDs) indicated that fellows' contact with telemedicine was limited. Within months, the coronavirus disease 2019 (COVID-19) pandemic significantly impacted the field. This survey describes fellows' telemedicine exposure, their PDs' attitudes toward it, and their formalized telemedicine training during the pandemic's third year.

METHODS

A 33-item SurveyMonkey questionnaire was developed. Many quantitative (Likert scale) items were identical to items on the 2019 survey for direct comparison. An open-ended question was added for qualitative analyses. All 91 sleep medicine fellowship PDs were invited to participate. The SurveyMonkey platform provided quantitative item descriptive statistics. Qualitative data underwent thematic analyses using codebook methodology.

RESULTS

Forty (97.5%) PDs indicated their program offers a telemedicine experience. Thirty-two (80%) PDs observed at least a 10% increase in sleep fellows' telemedicine encounters compared with prepandemic times. Although 27 (67.5%) PDs agreed that a national telemedicine curriculum could be useful, 8 (20%) of them offer a sleep telemedicine curriculum. Qualitative feedback revealed diverging attitudes toward telemedicine's place in sleep medicine practice, fellowship training, and the utility of a national curriculum.

CONCLUSIONS

Sleep telemedicine utilization during fellowship training was markedly higher on this 2022 survey (97.5%) compared with a similar 2019 survey (33.3%), and most PDs agreed a standardized curriculum could be useful. However, relatively few programs offer formalized telemedicine training. These findings imply that, while most sleep medicine fellows participate in telemedicine, they lack the formalized training that may optimize their utilization of the medium in their postfellowship careers.

CITATION

Fields BG, Kaur K, Dholakia S, Ioachimescu O. The COVID-19 pandemic's impact on sleep medicine fellowship telemedicine training: a follow-up survey of program directors. J Clin Sleep Med. 2024;20(2):201-210.

Describing Perspectives of Telehealth and the Impact on Equity in Access to Health Care from Community and Provider Perspectives: A Multimethod Analysis

Introduction: The rapid adoption of telehealth as a result of the COVID-19 pandemic provided the opportunity to examine perceptions of health care access and use of telehealth for delivery of effective and equitable care in low-income and historically marginalized communities. Methods: Focusing on communities with high social vulnerability, a multimethod analysis of combined perspectives, collected February through August 2022 from 112 health care providers, obtained from surveys and interviews, and 23 community members via 3 focus groups on access to care and telehealth. Qualitative data were analyzed using the Health Equity and Implementation Framework to identify barriers, facilitators, and recommendations for the implementation of telehealth using a health equity lens. Results: Participants perceived that telehealth helped maintain access to health care during the pandemic by addressing barriers including provider shortages, transportation concerns, and scheduling conflicts. Additional benefits suggested were improved care quality and coordination attributed to convenient avenues for care delivery and communication among providers and patients. However, many barriers to telehealth were reported and considered to limit equitable access to care. These included restrictive or changing policies regarding allowable services provided via telehealth, and availability of technology and broadband services to enable telehealth visits. Recommendations provided insight into care delivery innovation opportunities and potential policy changes to address equitable access to care. Conclusion: Integration of telehealth into models of care delivery could improve access to health care services and promote communication among providers and patients to improve care quality. Our findings have implications that are critical for future policy reforms and telehealth research.

Asynchronous Telemedicine: A Systematic Literature Review

Background

Asynchronous telemedicine (ATM), which describes telemedical interaction between a patient and provider where neither party communicates simultaneously, is an important telemedicine modality that is seeing increased use. In this article, we summarize the published peer-reviewed literature specifically related to ATM to (1) identify terms or phrases that are used to describe ATM, (2) ascertain how this research has thus far addressed the various aspects of the quadruple aim of medicine, and (3) assess the methodological rigor of research on ATM. We also divided the literature into pre- and post-COVID-19 onset periods to identify potential variations in the literature between these two periods.

Methods

This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search, utilizing multiple databases and applying inclusion and exclusion criteria, initially produced 2624 abstracts for review. De-duplication and screening ultimately yielded 104 articles for data extraction.

Results

"Store-and-forward" and variations of "e-visit" were the most frequently used alternative terms for ATM. Care quality was the most frequently addressed aspect of the Quadruple Aim of Medicine-more than double any other category-followed by patient satisfaction. We separated cost of care into two categories: patients' cost of care and providers' cost to provide care. Patient cost of care was the third most addressed aspect of the Quadruple Aim of Medicine followed by provider well-being and provider's cost to provide care. Methodological rigor of the studies was also addressed, with only 2 quantitative studies ranked "Strong," 5 ranked "Moderate," and 97 ranked "Weak." Qualitative studies were generally acceptable but struggled methodologically with accounting for all participants and articulation of results.

Conclusions

Although "store-and-forward" is somewhat more frequently used in the studies included in this review, variants of "e-visit," are growing in recent usage. Given the relative newness of modality, it is not surprising that quality of care is the most researched aspect of the Quadruple Aim of Medicine in ATM research. We anticipate more balance between these areas as research in this field matures. Primary areas of research need currently relate to practitioners-specifically their costs of providing care and well-being. Finally, future ATM research needs to address research challenges of selection bias and blinding in quantitative studies and improved participant tracking and articulation of both study design and results in qualitative studies.

Changes in Telehealth Experienced by Advanced Practice RNs During COVID-19: US Survey Results

The sudden, expanded need for telehealth during the COVID-19 pandemic added to the challenges advanced practice RNs face in the United States. The purposes of this article are to summarize advanced practice RNs' responses about the use of telehealth before and during the pandemic and to analyze free-text comments about how the use of telehealth changed during the pandemic. A 20-item survey was distributed using convenience sampling to advanced practice RNs from June 1 to September 23, 2020. Analyses of descriptive and open text responses related to telehealth were conducted. Most of the respondents did not use telehealth prior to the pandemic (n = 5441 [73%]), but during the pandemic, half used telehealth at least daily (n = 3682 [49%]). The most common barriers related to telehealth were about the difficulty some populations had in accessing the necessary technology. The most common favorable comments cited by respondents were related to some patients' improved access to care. Telehealth use is unlikely to return to prepandemic levels. As a result, considerations of telehealth-related recommendations provided for advanced practice RN education, policy, and practice are encouraged for the purpose of increasing healthcare access.

Remote Therapeutic Monitoring in Rheumatic and Musculoskeletal Diseases: Opportunities and Implementation

Therapeutic Monitoring (RTM) is a new program in the United States that began in 2022 allowing electronic patient-reported outcomes (ePRO) and other patient-generated data to be reviewed by clinical staff between visits so that patients can receive clinical attention as needed. Remote Therapeutic Monitoring simultaneously enhances the capacity to generate prospective longitudinal data that may be useful for secondary research purposes. As many governmental and private insurance programs in the United States now provide reimbursement for Remote Therapeutic Monitoring, increasing numbers of rheumatologists may be incentivized to provide this service for their patient populations. Launched in 2015, the ArthritisPower® Research Registry and associated mobile and desktop application, registered with the Food & Drug Administration (FDA) as a Class I medical device, enables patients to track their disease across dozens of domains and to securely participate in voluntary research studies. ArthritisPower, in partnership with Illumination Health, has developed infrastructure and a clinical workflow for Remote Therapeutic Monitoring that will help rheumatologists more closely track their patients' disease activity and flares, identify primary non-adherence, record changes in key health domains (e.g. fatigue, pain, physical function, mental health) and meet the needs for other data elements important for clinical care identified by individual providers. Ultimately, the approach to use digital health tools between visits seeks to improve clinical outcomes for patients with rheumatic and musculoskeletal diseases. This editorial review discusses the evolution of remote monitoring in rheumatologic care, describes the opportunities for physician reimbursement as of 2023, and provides a suggested workflow in order to establish Remote Therapeutic Monitoring within rheumatology practices.

Telemedicine in Otolaryngology in the COVID-19 Era: A Year Out

One year ago, shortly after the onset of the coronavirus disease 2019 (COVID-19) pandemic, we published our initial experience with telemedicine. We showed that during the early pandemic, there was a dramatic shift to telemedicine and that 70% of our patients would decline telemedicine in favor of an in-person visit. As clinical limitations and stay-at-home orders relaxed, we sought to define how we have used telemedicine since. After the initial month of the pandemic, our utilization of telemedicine fell to an average of only 5% of visits over the past year. Nearly 80% of all telemedicine visits were routine follow-up visits, with its usage being unaffected by local policy and pandemic surges. The usefulness and applications of telemedicine have been well described; however, after our initial reliance on telemedicine, its use has been minimal. Moving forward, attention will need to focus on innovation and expanding comprehensive virtual examinations for otolaryngology to fully embrace this technology.

Do Medical Insurance Companies Reimburse Telemedicine Office Visits the Same as In-Person Office Visits in an Academic Oral and Maxillofacial Surgeon Setting?

PURPOSE

The use of telemedicine has grown exponentially over the last decade, but its widespread adoption has been hindered, at least in part, by uncertainty over reimbursement rate for services. The aim of this study is to compare reimbursement rates of telemedicine and in-person visits in an academic oral and maxillofacial surgery practice.

METHODS

The investigators implemented a retrospective cohort study. The sample was composed of patients who were treated by the oral-maxillofacial surgery service at the University of Pennsylvania Health System from March 17, 2020 to February 27, 2021. The primary predictor variable was the type of patient visit, either telemedicine or in-person. Patient status, either established or new, was a covariate. The outcome variable was the mean reimbursement-to-charge (RC) ratio. Descriptive and bivariate statistics were computed, and the P value was set at .05.

RESULTS

This study included 6,082 submitted claims for 4,045 patients for in-person and telemedicine oral-maxillofacial surgery office visits. The mean reimbursement per insurance payor was $98.07 for a telemedicine visit (mean RC ratio = 0.48 with a standard deviation of ± 0.20) and $109.5 for an in-person visit (mean RC ratio = 0.50 with a standard deviation of ± 0.19). While there was a significant difference between the RC ratio for total telemedicine versus in-person visits (P = .001), the magnitude of the difference was only 2%. When stratifying the comparison by new (P = .73) and established patients (P = .20) for both telemedicine and in-person office visits, there was no significant difference in RC ratios.

CONCLUSIONS

The results suggest that there are no major discrepancies in financial reimbursement rate between telemedicine and in-person office visits. Both methods of treatment may be financially effective for oral-maxillofacial surgery providers. Future studies can compare reimbursement rates among different insurance providers and among different institutions in the United States.

The Impact of a Culinary Coaching Telemedicine Program on Home Cooking and Emotional Well-Being during the COVID-19 Pandemic

The coronavirus pandemic enforced social restrictions with abrupt impacts on mental health and changes to health behaviors. From a randomized clinical trial, we assessed the impact of culinary education on home cooking practices, coping strategies and resiliency during the first wave of the COVID-19 pandemic (March/April 2020). Participants (n = 28) were aged 25–70 years with a BMI of 27.5–35 kg/m². The intervention consisted of 12 weekly 30-min one-on-one telemedicine culinary coaching sessions. Coping strategies were assessed through the Brief Coping with Problems Experienced Inventory, and resiliency using the Brief Resilient Coping Scale. Home cooking practices were assessed through qualitative analysis. The average use of self-care as a coping strategy by the intervention group was 6.14 (1.66), compared to the control with 4.64 (1.69); p = 0.03. While more intervention participants had high (n = 5) and medium (n = 8) resiliency compared to controls (n = 4, n = 6, respectively), this difference was not significant (p = 0.33). Intervention participants reported using home cooking skills such as meal planning and time saving techniques during the pandemic. The key findings were that culinary coaching via telemedicine may be an effective intervention for teaching home cooking skills and promoting the use of self-care as a coping strategy during times of stress, including the COVID-19 pandemic.

Sharing patient-generated data with healthcare providers: findings from a 2019 national survey

OBJECTIVE

Our study estimates the prevalence and predictors of wearable device adoption and data sharing with healthcare providers in a nationally representative sample.

MATERIALS AND METHODS

Data were obtained from the 2019 Health Information National Trend Survey. We conducted multivariable logistic regression to examine predictors of device adoption and data sharing.

RESULTS

The sample contained 4159 individuals, 29.9% of whom had adopted a wearable device in 2019. Among adopters, 46.3% had shared data with their provider. Individuals with diabetes (odds ratio [OR], 2.39; 95% CI, 1.66-3.45; P < .0001), hypertension (OR, 2.80; 95% CI, 2.12-3.70; P < .0001), and multiple chronic conditions (OR, 1.55; 95% CI, 1.03-2.32; P < .0001) had significantly higher odds of wearable device adoption. Individuals with a usual source of care (OR, 2.44; 95% CI, 1.95-3.04; P < .0001), diabetes (OR, 1.66; 95% CI, 1.32-2.08; P < .0001), and hypertension (OR, 1.78; 95% CI, 1.44-2.20; P < .0001) had significantly higher odds of sharing data with providers.

DISCUSSION

A third of individuals adopted a wearable medical device and nearly 50% of individuals who owned a device shared data with a provider in 2019. Patients with certain conditions, such as diabetes and hypertension, were more likely to adopt devices and share data with providers. Social determinants of health, such as income and usual source of care, negatively affected wearable device adoption and data sharing, similarly to other consumer health technologies.

CONCLUSIONS

Wearable device adoption and data sharing with providers may be more common than prior studies have reported; however, digital disparities were noted. Studies are needed that test implementation strategies to expand wearable device use and data sharing into care delivery.