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Congressional action is needed for telehealth not to return to a rural benefit, Seema Verma says

Final rule expands Medicare telehealth services and increases pay for office visits, but cuts emergency physician payment.

Susan Morse, Managing Editor

A final rule released by the Centers for Medicare and Medicaid Services late today adds more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the public health emergency.

But legislation is needed to make telehealth permanent beyond the pandemic in areas other than rural regions where virtual care is already allowed, and to continue telehealth in the home, said CMS Administrator Seema Verma.

Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, to allow beneficiaries to receive telehealth in their homes. 

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Congressional action is needed for telehealth not to return to a rural benefit, Verma said, adding that CMS sees the benefit of telehealth beyond rural use. CMS has heard from stakeholders that many flexibilities should be made permanent and is reviewing all to see which should become permanent, she said.

During the public health emergency, CMS allowed for 144 telehealth services to be covered by Medicare. These include emergency department visits, initial inpatient and nursing facility visits, and discharge-day management services.

CMS is making nine of these permanent within the confines of rural regions. These services include group psychotherapy, certain home visits and cognitive assessment. Another 59 services will be extended temporarily. CMS is commissioning a study on the remaining 76 telehealth flexibilities that will also explore new opportunities for virtual care supervision and remote monitoring.

CMS has been amazed at the speed the healthcare system has adapted to telehealth, Verma said. Preliminary data show that between mid-March and mid-October, over 24.5 million out of 63 million beneficiaries received a Medicare telemedicine service.
 
PHYSICIAN FEE SCHEDULE PAYMENT CHANGES

Verma said the annual physician fee schedule final rule is arriving later than usual due to the COVID-19 pandemic.

The rule increases payments to physicians of primary care and chronic disease management and decreases payment to other providers, such as emergency physicians, due to the program being budget neutral.

Common office visit increases and other final rule payments go into effect on January 1, 2021. 

The American College of Emergency Physicians said it was disappointed and dismayed by the rule that will cut reimbursement for emergency treatment to Medicare patients by 6% starting in 2021. 

"Emergency physicians and other healthcare providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19," said Mark Rosenberg, president of ACEP.  ACEP provided recommendations to mitigate the reduction when the proposed rule was released, but none were incorporated, he said. 

The cut will reverberate beyond Medicare to other payers, including private insurance, which often structures its payments to emergency physicians and other providers based on the Medicare rates, ACEP said. 

"Now that the final rule has been released, the only way to prevent these devastating cuts from taking place is for Congress to act by passing legislation that holds physicians harmless," ACEP said. 

"Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020" is a bill introduced by Representatives Dr. Ami Bera, D-Calif., and Dr. Larry Bucshon, R-Ind., that would temporarily maintain physicians' reimbursement in Medicare at 2020 levels for the next two years.

"Emergency physicians have courageously faced a global pandemic that has shaken our healthcare system to its core, unwavering in their commitment to their patients despite potentially deadly exposure to the disease for themselves and their families," Rosenberg said. "Congress must act now in order for them to continue playing this vital role in our communities." 

Going into effect in 2021 is an increase in payment rates for office/outpatient face-to-face evaluation and management (E/M) visits. 

These providers are seeing a growth in enrollment in beneficiaries having complex conditions, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions, CMS said. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, CMS said.

CMS is increasing the value of many services that are similar to E/M office visits such as maternity care bundles, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. 

"This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients' care," Verma said. "In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses."
 
In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. 

The rule also allows non-physician practitioners to practice at the top of their license. Specifically, certain non-physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests. Physical and occupational therapists will be able to delegate "maintenance therapy" to a therapy assistant. Also, physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient's medical record. 
 
THE LARGER TREND

This final rule delivers on President Trump's Executive Order on Improving Rural Health and Telehealth Access.

ON THE RECORD

"During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we're now moving to make many of these changes permanent," said HHS Secretary Alex Azar. "Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we'll keep exploring ways to deliver Americans access to healthcare in the setting that they and their doctor decide makes sense for them."

"Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck," said Verma. "But the pandemic accentuated just how transformative it could be, and several months in it's clear that the healthcare system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in healthcare delivery."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com