AcuteCare Telemedicine Blog


Looking Backwards to See Ahead – Part 4: Running the Business

This is another blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at 2011’s Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on several issues relevant to establishing and running a telemedicine service.

There are myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Often these are not immediately evident, although some may be the focus of business development meetings. This blog reviews the topics of business size, communication/documentation, ROI considerations, and coding/billing issues.

The size of a company will directly impact its ability to stay true to its mission. Our firm belief is that the future of telemedicine is in regional providers partnering with both local hospitals and government or not-for-profits. There are larger providers of teleneurology, and their scale may be a corporate advantage; a large staff of part-time physicians to fractionate call burden as well as development of proprietary hardware & software (the cost of which is hidden in a monthly service charge). However, their size is not beneficial to patients and hospitals. In reality, the size of these “McTelemedicine” services paints them as something hospitals fear; impersonal, computerized doctors. The need to focus on healthcare solutions tailored to the specific needs of the healthcare region has been addressed in a recent blog.

Communication must occur in a timely fashion. Otherwise, the telemedicine consult is for naught. Dictating is necessary for documentation of the initial encounter in the permanent medical record, but will be delayed even if transcribed as “priority.” Faxing or emailing is faster, but not always practical. In order to reduce error & liability, especially for critical care issues, direct communication with the local treating physician and nurse is paramount. In cases of acute stroke, providing the medical opinion of whether tissue plasminogen activator (tPA) should be given is sufficient. The actual order for administration of tPA should be given by a physician actually present to review that the dose was properly calculated and administration was expedited.

Return on investment (ROI) will depend on maximizing revenue and avoiding costs – this is relevant to any business. The perspective of both the telemedicine provider and the client hospital must be taken into account. For example, revenue may come to the client hospital through the increased use of value added ancillary services (e.g. radiology, PT, Rehab). One must also identify cost drivers, areas of poor market share (e.g. EMS bypass), obstacles to access, and obstacles to productivity (e.g. difficulty luring a local neurologist because of ER coverage responsibilities). The telemedicine provider may also benefit from the addition of value added services such as reading neurophysiology studies (EEG, sleep, EMG) or lateral expansion through the development of ancillary specialties such as tele-ICU, telepsychiatry or telecardiology.

Coding or billing expertise is not typically required for remote presence consultation, as it is a service provided to the hospital and reimbursed by the hospital accordingly.  Proven increases in revenue and improved patient outcomes absolutely justify this business model. However, in some situations, a physician may bill directly for their services, for example, if the hospital is rural or designated a disadvantaged Metropolitan Statistical Area (MSA). When coding these encounters, Medicare regards telemedicine as face to face time. Using a GT modifier prevents charge bumping if a patient is subsequently seen by a community physician on the same day. Records must also state “Services provided by telemedicine.” One cannot bill Medicare Advantage in an MSA unless there is a contract with the Medicare Advantage carrier.

Medicaid may reimburse encounters within an MSA, but Medicaid does NOT have to follow Medicare rules. Treat them like a third party payer. Keep in mind, the Medicaid staffer handling your reimbursement issues may require education. Finally, follow up telemedicine visits can be billed for 1 visit every 3 days.

Considering these issues, most of which were not immediately evident at the outset, has helped AcuteCare Telemedicine create impact in the market place. ACT not only hightlights the clinical value of its physicians but also addresses the comprehensive business needs of the organizations it serves.


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