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Welcome to the Results and Recognition Quality Programs of 2021. This WebEx will present some material related to telehealth. The use of telehealth expanded rapidly last year in response to the COVID-19 pandemic. This shift to virtual care was necessary to protect patients and staff while maintaining the delivery of high-quality of care. Although we are slowly getting back to returning to in-person visits that does not mean that virtual care is going away.

The objectives of this webinar are: To explain the difference between telehealth and telemedicine - Analyze the effectiveness and challenges of telehealth - Understand reimbursement of telehealth services, and also - Identify available resources for you to use.

Telehealth vs telemedicine, although the terms are often interchangeable, there is a distinction between the two. Telehealth refers broadly to electronic and telecommunications technologies, services used to provide care and services at-a-distance. Telehealth, in addition to the clinical services, can also refer to remote non-clinical services, such as provider training, administrative meetings or patient health-related education. Telemedicine is a subset of telehealth and refers to remote clinical services. Telemedicine refers solely to the provision of health care services and education over a distance through the use of telecommunications technology. Both are part of a larger effort to expand access to care, making health management easier for the patients and improving the efficiency of healthcare delivery network. According to the World Health Organization, telehealth includes, “Surveillance, health promotion and public health functions.”

Telehealth is a little different from telemedicine because it refers to a broader scope of remote healthcare services. It allows long-distance provider and patient contact, education, interventions, monitoring and even remote admissions. Telehealth is healthcare’s natural evolution into the digital age. There are 3 primary modalities of telehealth: synchronous, asynchronous and remote patient monitoring.

Synchronous is a real-time telephone or live audio/video interaction with a patient. This is typically done with a smartphone, a tablet or a computer. This is the most common form of telehealth. Asynchronous includes “store and forward” technology where messages, images or data are collected at one point in time and interpreted or responded to later and is most commonly known as digital messaging. Remote Patient Monitoring allows direct transmission of a patient’s clinical measurements from a distance to their healthcare providers. This may or may not be in real time, some examples of this would be monitoring vital signs or an electrocardiogram.

Telehealth is proving to be very effective for a number of different reasons. Convenience: it reduces no-shows & cancellations; it allow the member the ability to virtually check-in and talk to their providers using a device without actually going to the doctor’s office. The member can receive the care in the privacy and comfort of their homes. There is no time in a waiting room, which decreases the risk of members and staff being exposed to germs, bacteria, & the virus. Telehealth is cost-efficient because it reduces travel expenses or loss of work hours. It helps to expedite the transmission of diagnostic reports when needed for a second opinion. It helps to improve communication between providers and their patients. And it is also in compliance with the HIPPA or the Health Insurance Portability and Accountability Act laws aiming to prevent secure medical records and other documents from being breached.

Let’s talk a little bit about some of the challenges of telehealth. Privacy and security concerns, we need to consider all potential threats to the integrity of that electronic protected health information. When you’re dealing with technology, electronic glitches may occur. It’s only as reliable as the electrical current that keeps it running. Which takes us to our next point of having technical support, which is a service that should be efficient and cost-effective. Inadequate assessments, although having the ability to interface is a great thing, not being able to perform the usual hands-on assessment and picking up on some of those non-verbal cues may be a bit challenging. Lastly is organizational culture and gaining the buy-in of stakeholders. This is so that everyone is on the same page about embracing a culture of change specifically when it comes to this type of technology and services.

According to a telehealth study conducted by J.D. Powers in 2019: Overall customer satisfaction for telehealth services based on a 1000-point scale was 851; these scores were among the highest of all healthcare, insurance and financial services industry conducted by J.D. Powers. Positive word of mouth seems to be the key to using telehealth. Nearly 2/3 of telehealth users used the service because of positive recommendations, by family, friends, their health care plan and some additional resources. Telehealth is working for those using the technology. More than 84% of telehealth users were able to completely resolve their medical concerns during the visit, 73% experienced no issues, 49% stated they experienced no barriers that made using telehealth difficult, and 87% described the enrollment process as fairly easy.

Next, we are going to talk about Reimbursement. Horizon Blue Cross and Blue Shield identifies telemedicine services when modifier 95 or GT are added to codes that usually describe in-person, face-to-face visits. Reimbursement for this service may be available for telemedicine that meet all of the requirements of a face-to-face visit between the provider and the patient. Reimbursement may also apply when telemedicine is limited to service using interactive, real-time, audio-video technologies to diagnose, consult or treat according to the member’s contract.

A couple other areas related to reimbursement: The provider who is performing the telemedicine services must be licensed in the state where the patient is physically located at the time of the telemedicine encounter. The provider is subject to New Jersey’s jurisdiction if either the patient or the provider is located in New Jersey. The provider is subject to regulations by the appropriate New Jersey State licensing board and must act in compliance with existing requirements of maintaining liability insurance. Also, any services rendered via an interactive communication technology as part of the health plan’s benefit, is only eligible for reimbursement to the provider rendering the service.

NCQA has made some adjustments to many of the measures to include telehealth service due to COVID-19. This was done in a way to obtain compliance for these measures because many providers and many members have had to rely on telehealth services. A few of those measures are noted here. These measures are also in the Results & Recognition Programs. These changes also align with the telehealth guidance from Centers for Medicare & Medicaid Services, or CMS, and other federal and state regulations.

Not all services are eligible for telehealth. Non-direct patient services such as coordination of care rendered before or after the patient interaction. Claims submitted with modifier GQ, which signifies services provided via asynchronous telecommunications system, as these services do not include direct patient contact. Any service that is not eligible for separate reimbursement when rendered to the patient in-person. HCPCS Code Q3014, this is the facility fee for conducting telehealth visits, such as reimbursement related to the use of a room and telecommunication equipment. CPT codes 99441-99444; however an exception was made during the public health emergency only, codes 99441-99443 may be considered for coverage.

To re-cap some important information relating to telemedicine: Services will be subject to the same practice standards as they apply to in-person settings. Providers using telemedicine must consider security, patient confidentiality, and privacy. A secure electronic channel is required to be used by the provider. All transactions and data communication must be in compliance with the Health Insurance Portability and Accountability Act. Documentation must be maintained in the medical record and must support the services or treatments rendered. By coding and billing modifier 95 or GT with a covered procedure, the provider is certifying that the member was present when furnished the telemedicine services. Providers are authorized to charge a deductible, copayment, or coinsurance as long as the amount charged does not exceed the charge for an in-person consultation. Reimbursement will be at the same rate as that of the existing Professional Agreement Allowance.

So let’s look at some best practices. Identify staff to conduct telehealth interactions with patients and develop a protocol so staff can triage the patients in a timely manner. Practice using the technology first, especially internally. You also should create a backup plan in case you encounter any technical glitches. Documentation and record keeping, you should be keeping a complete and accurate record in the member’s medical record of all interactions. Just because the service is not being performed in-person does not mean the documentation does not matter. The documentation should include any assessments and/or treatment plans completed at the time of the telehealth visit. In addition to your staff doing a test run to prepare for telehealth services, you should also request that your patients do the same.

The Horizon Blue Website is a very good resource for you. It provides a lot of useful information on many different topics.

For example, there is information in there specifically for COVID, such as billings and policies.

Also, there is information related specifically to telemedicine services.

This is a quick reference contact and it’s a key for you to sue for different departments in Horizon throughout the company. You can reach out to your Clinical Quality Improvement Liaison for a copy. Just a quick note, this is only 2 of 7 pages that you’re seeing. There is a lot of information in regard to contact information in this document.

Another resource, which you can access, is the CDC website. They have information related to telehealth & telemedicine. is always a great place to obtain current information on the happenings of any health care.

At this point, I’d like to thank you for listening to this webinar. If you have any questions please feel free to reach out to us, by emailing us at Thank-you.

Discuss telehealth versus telemedicine, effectiveness and challenges, reimbursement, suggested best practices.