Lessons Learned from the First Wave of COVID: How to Navigate the Second Wave and Implement Lasting Changes to Benefit your Practice

Author: by Guillermo Beades, Esq. of Frier Levitt, LLC, Wiks Moffat, CHC, of HealthCare Compliance Network, LLC, and Jim Tudor, PCA, CPC, of HealthCare Compliance Network, LLC

When the COVID-19 pandemic reached our shores, it instantly changed the way we lived and worked.  Many businesses were shuttered, and most people have yet to return to their offices since the March 2020 lockdowns.

Virtual meetings, remote learning and limited socially distant interactions became the “new normal” for businesses.  Those industries who were already set-up for remote access and had work from home capabilities in place were able to transition more smoothly to the new COVID normal.

The medical community was hit hard as they were our front line against this deadly pandemic.  From the initial rush to ensure there was sufficient personal protective equipment for all providers and staff to setting-up a telemedicine platform, some practices were better equipped for the necessary changes to survive COVID.

We recently spoke with Wiks Moffat, Principal and Executive Vice President at HealthCare Compliance Network (“HCN”) and James Tudor, PCA, CPC, Director of Coding and Billing Compliance at HCN.  Mr. Moffat has worked in Healthcare Compliance for thirty (30) years, is a sought-after speaker and has helped thousands of healthcare organizations implement regulatory compliance plans.  Mr. Tudor is an expert with over twenty-five (25) years of experience in auditing and billing compliance and has designed and administered billing compliance programs for hospitals and physician practices.

We discussed with Mr. Moffat and Mr. Tudor what lessons practices should learn from the first wave of COVID that could help them both navigate the second wave and implement meaningful changes going forward.

Below are some highlights from our discussion, including answers to some of the most frequently asked questions by providers:

If I did not implement telemedicine during the first wave, did I miss my chance?  Is it too late to do so now?

It is definitely not too late! Telehealth is here to stay, and according to CMS administrator Seema Verma, “reversing course would be a mistake.” A number of other major payers have permanently incorporated telehealth services performed outside the rural domain into their policies, and it is reasonable to assume the vast majority will ultimately follow suit.  It is expected that elements of telehealth will evolve over time, but not in a way that would diminish its use.

For those practices who still use paper charts and are not “tech savvy”, what is the biggest challenge to implementing telemedicine?

There are three challenges, one is the “human element” and two are compliance components.

As to the human element, it is the lack of personal contact that some physicians struggle with at first.  Physicians who have not used interactive video technology, or have limited experience with it, may be apprehensive.  A lack of technical acumen is usually just a part of it. The physician may worry about confidentiality breaches, or the ability/willingness of the patient to use the technology. Virtual visits can be “uncomfortable” for a physician unaccustomed to seeing patients outside the traditional in-person episode of care.

From a compliance standpoint, you have the IT concerns, particularly HIPAA security, and the second is on the billing side. Practices must make sure their IT systems and staff are adequately prepared for the challenges brought about by telemedicine. This includes your EMR and all devices you will be using. The process should be incorporated into written policies and procedures, your Security Risk Audit (SRA), and a formalized training program. These should be updated in response to any organizational or regulatory changes, but in no event less than annually.

When it comes to billing and collecting for telemedicine services from CMS and commercial payers, we suggest practices self-audit to ensure compliance and to make sure they are billing and collecting what they deserve.  It is not uncommon for some practices to unintentionally under-code and leave money on the table. Providers are ultimately responsible for the claims being sent to a payor for reimbursement, whether it comes from an in-house billing department or outside biller.  In an audit, the billing service, and the provider both may be culpable, but ultimately it is the provider who is liable.  Self-audits, particularly of telemedicine services, is highly suggested.

Do I have to completely change the way I document when I do telemedicine visits?

According to CMS, the physician must document a) location of the patient, b) location of the provider, and c) names of all persons participating in the telehealth service and their role in the encounter. In all other respects, documentation may be made in the same fashion as any other face-to-face office visit encounter. However, on January 1, 2021, new guidelines for evaluation and management (E/M) services went into effect. The changes impact documentation of new patient (99202-99205) and established patient (99211-99215) office/other outpatient encounters. As these rules apply to telehealth services normally performed in the physician’s office, it is important to understand those changes.

Telehealth usage has increased drastically in light of COVID, and the likelihood of audits related to telehealth will be increased.  Since auditors will also be reviewing more telehealth services, they will be more adept to shortcomings.  Sloppy or incomplete documentation will be under an even finer microscope in light of its increased usage.

Do you expect telemedicine to be audited in the future?  What do you perceive as being potential areas of weakness?

Telemedicine will be audited in the same manner as other billable service, albeit not at the same frequency based on the volume disparity. We expect that payers will develop policies relative to frequency, standard of care, and medical necessity of telehealth visit. New codes and/or modifiers may be created to accommodate unique reporting requirements and facilitate compliance.

One potential hotspot could involve billing for a phone call versus telehealth visit. Much confusion arose during the early part of the public health emergency (“PHE”) about this very subject, largely due to CMS policy changes, payer coverage variations, and state law. This left many providers confused about whether an office visit can be billed using audio-only. As things currently stand (January 2021), CMS requires use of real-time video to bill office visit codes. Phone calls without a video component are captured using the CPT codes intended for that purpose. The documentation must show a clear establishment of a bona fide physician-patient relationship.

The main area of weakness, we expect, will be being unprepared with an implemented and compliant telemedicine program. It is important to note that you must clearly document your program and training with site-specific policies and procedures.