Audio-only Telehealth Coverage Essential During COVID-19 Outbreak

May 26, 2020 - The coronavirus pandemic sparked a rise in telehealth use. Video and audio visits allow patients to connect with their providers virtually, eliminating the risk of a clinic visit. Meanwhile, remote patient monitoring technologies mean providers can watch their patients’ vital signs for any emergent changes from the comfort of their homes. 

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These technologies have allowed providers to continue treating their patients with chronic conditions and even take on new patients during a time when many are uncomfortable coming into the provider’s office.

“We’re trying to limit all services where we don’t think we really need people in the office,” Steven Green, MD, chief medical officer Sharp Rees-Stealy Medical Group (SRSMG) told HealthPayerIntelligence. “It has really pushed us. And people rose to the task to work with our patients.”

Green’s group, like many others, has seen an incredible rise in telehealth visits amidst the pandemic. Before COVID-19, about two percent of their visits were telehealth. Now, about 74 percent of their visits use telehealth, he reported.

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When a patient calls to make an appointment with Sharp Rees-Stealy Medical Group, clinicians first screen the patient to see if a telemedicine approach is appropriate.

“The bottom line is that we realized we can provide a lot of our care with telemedicine,” Green explained. “We’ve helped patients with monitoring their blood pressures at home and giving us those numbers. We’ve really tried to minimize the need for patients to leave their houses and still get care.”

While video conferencing telehealth tools often take the spotlight, audio-only is also an option. In fact, some patients prefer it.

Research shows that about 80 percent of seniors have cell phones but only 42 percent have smartphones. Of these, there is uncertainty around how many feel confident in using all the phone’s capabilities.

For some of their patient population, audio-only visits are the only option. But this does not truly impact care, Green said.

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“The main value of having a video visit is more for the human connection and seeing their face. I agree that a video visit can help you get more of a connection to the patient while you’re talking with them,” he emphasized. “But I don’t think it contributes very much to what’s going on in their clinical care.”

For many chronic conditions such as congestive heart failure or diabetes, lab findings, vital signs, and the patient’s medical history play a large part in clinical decision making. The video component might not be unnecessary to deliver high-quality care.

And some patients just prefer an audio-only visit.

“If you do a video visit, some people feel they have to have the house clean,” Green pointed out. “From our standpoint, whatever the patient is willing to do as a way to get their care is where we want to help.”

But caring for patients using audio-only telehealth presents a big problem for reimbursement. Hierarchical condition category (HCC) coding cannot be completed from an audio-only visit.

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HCC coding and risk adjustment are linked to Medicare Advantage reimbursement rates. These condition codes designate the severity of disease patients have and adjust reimbursement to providers based on their patient population. Providers who treat sicker patients are reimbursed at a higher rate so they have appropriate resources to care for these patients.    

“The rule is that HCC codes must be coded at least once during a calendar year,” explained Green. “Some people may have had things coded in January or February but that’s a minority of the year. We don’t know when this will end so we want to be able to start addressing these during the year. It takes a while to get these codes in.”

About 40 percent of SRSMG’s revenue is tied to fee-for-service reimbursement, whether that is through Medicare or preferred provider organization (PPO). So proper documentation of these codes is critical.

“Prior to COVID-19, the rule was that an HCC code or diagnosis could only be entered on a patient encounter or face-to-face visit. During the crisis, it has been liberalized to include tele-video,” Green furthered. “But it’s been a problem for us that is not allowing us to get credit for HCC codes that we entered during an audio-only visit.”

Green warned that not adjusting the methodology could promote clinics to bring patients in unnecessarily.

“You might encourage bringing a patient into the office so you could get credit for an HCC code because it’s necessary to be able to get the funding to appropriately care for this patient,” he continued. “It seems a shame to make someone come in just because of a coding requirement even after this crisis is over.”

Patients could be taught how to use the video-conferencing technology or be given tablets if video-conferencing technology is not available to them. But these solutions come with their own challenges.

“You can have a family member help with the technology but then you’re losing some privacy that you may want,” Green emphasized. “We have to be careful. There are times where the workarounds like that will make sense but there are times they won’t.”

And providing every patient with smart devices requires countless resources and logistical planning, all under the assumption that the patient has internet capabilities to use the technologies provided to him.

“A lot of care is being provided this way, so it was fair to increase the reimbursement for the audio-only part of it,” articulated Green.

But change takes time. Overcoming these challenges to audio-only telehealth will require people like Green to advocate for its importance to patient care.

“If we remain divided, it would be a problem. We need to figure out how to work around that,” he concluded. “We’ve had a way of delivering care face to face over the last hundred years, and I guess it took a pandemic to get us to shake things up.”