Welcome to Can You See Me Now? Optimizing Telehealth in Sports Medicine. This is a three-part webinar series from AOSSM. You can enter questions throughout the webinar by using the questions tab. Questions will be viewed by faculty and answered during the panel sections of the webinar. With that, I'll turn it over to our moderator. Thank you again for joining us. Well, welcome back, everybody. I want to thank you for joining us tonight. After a great session last week on the virtual physical exam and an introduction to telehealth, today we'll be transitioning to the medical legal aspects to consider when using telehealth and trying to come up with new ways on how to optimize it. So our first speaker today will be Dr. Michael Graue from OrthoSensei. He is also one of the founders and leading experts for OrthoLive, which is the first orthopedic telehealth platform, and he will be speaking today on the billing problem and tips and tricks on how to get paid. Hi, everybody. My name is Mike Graue. I'm going to be talking today about liability and billing inside of telemedicine. So I'd like to go ahead and share my PowerPoint now, and I'm looking forward to getting started with you guys. So this is the topic, billing problem, tips to get paid, a practice approach to billing and liability mitigation for telemedicine. My name is Mike Graue. I'm an AOSSM member and the founder of OrthoLive, an orthopedic-specific telemedicine company. Our agenda today is to talk about rules and tips for billing with telemedicine and also how to maximize telehealth in our practices. And then we'll do a little case study overview and a recap. So telehealth has been on the rise. Since 2017, we've really seen a doubling of telemedicine up to 2019, and obviously with the surge in what happened with COVID, we're going to probably hit over 100 million telemedicine visits this upcoming year. So we're seeing this obviously in all the market research, and there's been a surge in patients which really overwhelmed the telemedicine demand and required many of us to utilize services like ours to be able to help to see our patients and to keep everyone safe. So as an important part today, we're going to talk about a definition of the terms. We'll talk about specific things that I think are important to recognize as you're thinking about telemedicine. So first of all, telehealth and telemedicine are synonymous. They're basically similar terms. A synchronous visit, what is that? Well, that's basically a telemedicine visit that's held using real-time video. An asynchronous visit is a telemedicine visit that is a text-based visit. And we have other visits called check-in visits. That's a visit that's hosted via the telephone or using kind of live chat. And an e-visit, which can be done through a patient portal or even email interaction. There's coding for each of these visits. So I wanted to make sure I defined all the terms there as we look at billing. So effective March 6, 2020, President Trump signed into law a telemedicine parity law that was introduced, which made the visits being telemedicine being equal to an office visit, which was really important. Check-ins then could also be seen across state lines, which hadn't been the case before. And virtual and telephone check-ins were also allowed. Now, really, at this point in time, we've gotten through much of the crisis. We'll see what happens, obviously, in the wintertime here. But we want to know what does CMS believe is going to happen, and are these laws going to continue to stay in effect? And what we see from Seema Verma is she really says that she has a hard time seeing a lot of these things go back, and that we do need to rethink our laws around licensing, because it has the potential to provide better services and reduce some of the shortages of especially specialists in the United States, which I think is really important for each of us to keep in mind. So we do anticipate a lot of these laws to be able to continue. Now what codes can be used here? And we're going to kind of break them down. So obviously, we have our new 99201 to 99205 visits. Many of our practices are being required at this point for new visits to obtain a telemedicine rider for their insurance protection for medical malpractice. But established visits, 99211 to 99215 visits, most of the time, these practices have not needed the riders. That's kind of just what we're seeing across the country right now. We can build these codes, and then obviously, we have the check-in codes. The check-in codes are G2010, which are text-based check-ins that we might do with our patients, and G2012, which is a telephone check-in. Each of these are visits that can be billed as well. Additionally, the codes for e-visits go from 99421 to 99423, and G2061 to G2063. Each of these are inclusive of a seven-day period of time. They can't be billed more than that. And they basically include 10, 20, and greater than 20-minute check-ins for e-visits. Excuse me, I shouldn't have said a check-in, but that would be for an e-visit. And it can include any recent visits within the week. Obviously, if you've seen that patient within that week, you can't bill the e-visit time. Now, remote patient monitoring is another interesting thing. It may be worth it for some orthopedic surgeons, maybe not for others. And really, we have yet to determine whether or not remote patient monitoring is going to be used extensively within the orthopedic space, but there certainly can be decent revenue from Medicare enrollees up to $2,000 per patient per year. And you can see all these codes here. But it really is not the focus of the talk, remote patient monitoring. We just wanted to make sure that you guys were aware of that as a potential telemedicine and check-in type of visit as well. The place of service should be 02, and that can be used with their traditional 9201 to 9215 codes. Now, what type of orthopedic telemedicine visits are there out there? To me, there's really three main visits. There's the post-operative visit. There's established visits, and obviously, the new patient visits. And of course, we have the other two, which are check-ins, remote care monitoring visits, and even e-visits. But most of my partners and the people around the country that I've seen, they utilize the established patient and new patient visits and post-operative visits as their primary visit types. What are the main documentation rules so you guys can stay out of trouble It's important, obviously, to mention the patient's location and the physician's location and that you did use telemedicine inside the HPI. You want to document your examination as you normally would, and then code the level of the visit based on the bullet points that you hit, just like you normally would in the standard documentation that you would do in office. What's important here about coding for telemedicine is that in Medicare, we do not need a modifier. However, if you're billing private insurance, you want to use either a 95 or a GT modifier to make sure that they are aware that this is a telemedicine visit. The place of service, again, is 02, and for CMS, there are no modifiers. So remember that for Medicare and Medicaid. Now, efficient visits for sports physicians. Well, I think the most efficient visit out there really is an asynchronous visit. That's a text-based visit. Sometimes you can use that for post-operative patients, and we'll also use synchronous visits here as well. Sometimes at first visit, you just want to check the incisions, make sure that things are looking good, and that's a really great visit that can be very efficient. And also, you know, if anything looks obviously not ideal, then you have them come in, and it's a great way to really create some efficiency around that. MRI follow-up and post-injection follow-ups are great as well. And to me, these are really the easiest because from a documentation standpoint, they're easy to document, and it allows me to maximize my revenue through efficient use of time. So these are really, I think, the keys for sports physicians. Obviously, in 2021, there will be some new coding rules that will go into effect, but we're not going to discuss that during this talk. That's kind of out of the scope of the talk. But I want to give some example visits of what the documentation and coding looks like. So for this one, this is a post-operative recheck appointment. And one of the keys here is that I reviewed the surgical images and went through everything virtually with her in her home. And I also mentioned kind of that I'm at a particular office and that I did this virtually. Now, in terms of, you know, documenting as well for an MRI follow-up, same sort of thing, but we make sure that we defer the physical exam. I went over the MRI results, and I focused those coding efforts on my medical decision-making because we don't need the physical exam bullets in this case. And again, of course, we mentioned where the patient was. Another one, obviously, is the frozen shoulder, the post-injection follow-up. This is a 99213 visit. I'm able to do that by the way that I will document. And you can see I'm observing all these things inside the physical exam. And we check tenderness, have the patient push on their shoulder, and sort of show her range of motion as well. And so that's a good way of looking at things. And just to finish up, I mean, telemedicine can create some significant efficiencies inside your office and save quite a bit of time. Just as a case study, we can see that you can drive some significant new patient increase into your practice up to 7% of all your visits, net increase potentially year over year with virtual visits. So it can be fairly significant and help you drive some efficiency within your practice. Hopefully that was helpful. And a good overview of billing with telemedicine and liability mitigation as well. Have a great day, and we look forward to answering questions. Thank you. Thanks, Mike, for that talk. I'd now like to introduce Lisa Warren, who's the CEO at the Andrews Institute for Sports Medicine. And she's really been an expert and a frequent speaker on healthcare management, medical billing, and practice management. And I want to get her insight from the business aspect of things on billing and legal aspects. And so she will be speaking today on how to set up a telemedicine practice and do it well. Hi, I'm Lisa Warren with CEO at Andrews Sports Medicine and Orthopedic Center in Birmingham, Alabama. I'm going to be doing my talk today on how to set up telehealth in your practice. This will be a broad overview of telehealth and orthopedic practice. There'll be other webinars that will provide details on billing, coding, documentation, and other legal requirements. OK, we're going to start with some important considerations when you begin a telehealth program. The first is malpractice insurance. You need to confirm with your malpractice carrier what type of telehealth coverage your policy provides. There may be limitations on the types of patients you can see in telehealth. There may be types of visits that you're not allowed to have, or there may be limitations in what states you can practice. So be sure to check with your malpractice carrier on your telehealth insurance. The second issue is location and licensure issues. In some states, the patient must be physically located in the state that you are practicing in, that you're licensed in. I've included a slide at the end about reciprocal agreements that you guys can search and see which reciprocal agreements in states might work for you. Now, this may be a licensure problem, or it may also be an insurance company problem as far as reimbursement. So you need to be aware of both. Number three is vendor selection. It's important to have a HIPAA-compliant software. I know that during the beginning of the COVID crisis, a lot of the payers waived the requirement for a HIPAA product, but it doesn't make sense going forward. This would be a best practice to be sure to have a HIPAA-compliant telehealth software. The second piece is EMR integration. As telehealth has become more mainstream, a lot of the EMRs are working in telehealth software into your EMR, and this would be the most efficient way to use telehealth. Fourth is physician and staff education. This is one of the biggest piece that I found in our practice, and the challenge is that the physicians and the staff have to be trained on the technology. One of the most complicated pieces is the rules and reimbursement regarding telemedicine. As the COVID crisis continued, the payers started changing and adding the reimbursement for telehealth. That's the good news. The bad news is I think they were figuring it out as they went and the rules are constantly changing. Another thing to be aware of is while E&M codes are being paid for as telehealth visits now, most of the payers are continuing this through December 31st. I'm not sure what's going to happen after the new year, so please be aware and talk to your practice managers to make sure what changes are gonna happen in your state and your area with the new year and telehealth reimbursement. The fourth piece is requiring the staff phone scripts and email templates. We wanted to be sure to have consistent and complete messaging when our staff was talking to patients. So we created both scripts and email templates for our staff to use, and I'll share those with you guys in a little bit. The fifth piece is patient education, and this was also a big challenge. We had to educate them on what telehealth was, what was appropriate, how it could be used. And I think our doctor's biggest point of frustration on this was teaching patients how to use their own technology. They felt a new appreciation for IT support and a lot of frustration with dealing with this and the internet hookup and those types of things. So when this began back to patient education, we used an overlay on our website about COVID-19 and why we were starting to implement telehealth. We were limiting as many patient visits to acute as possible and trying to treat more of the chronic visits over the phone in order to provide for the social distancing. This is a piece of education material we put on our website. We also did an email blast to educate patients about telemedicine and virtual visits. We called telemedicine as the pure telephone call where the virtual visits is where we use the video technology. We are going to use this format going forward to help educate patients about telemedicine. We're going to remove that middle section that talks about due to COVID-19 concerns, but we're going to use this piece going forward to help educate patients about the process. Here is a PDF. We actually use Doxy.me as our HIPAA compliant telehealth platform. These are some detailed instructions for the patients that we emailed out when we scheduled their telehealth appointment. It gave them the opportunity to read up, understand what's going to happen. It gave our staff a full script to refer to on how to explain the technology, and we found it worked pretty well. So our telehealth workflow, the first is to identify the patient eligible for telehealth. And there's two categories, and I think one is going to be discussed in a later webinar, and is what type of patient clinically is appropriate for telehealth. The other piece is from an insurance standpoint, what type of patient is appropriate for telehealth. One of the biggest challenges, of course, is to understand every payer has a different set of guidelines. So you need to be able to triage those type of patients and determine whether it's appropriate for telehealth. We would then set the appointment on the schedule, and I'll show you in a little bit how we templated that out. Now, we did email a consent for telehealth as well as new patient paperwork. So if we were going to see this patient in the office, they would typically fill out their demographic information, their insurance information. And we still need that, whether we do a new patient visit telehealth or in person. So we had to get that information out to the patients. We had to pre-register the encounter and verify insurance. Again, these are things that happened on the front end if you're seeing them physically in the office, but they still need to occur for a telehealth visit if you would like to get reimbursed. So then the next step, obviously, is to provide the encounter. It was then document the encounter and then notify staff of follow-up issues. And this is another one of those workflows that when you're in the office and the physician comes out of the exam room and the patient needs an MRI or they need a PT order or whatever follow-up, that's frequently done yelling down the hallway or some sort of verbal communication. Well, if telehealth is being conducted after hours or at home, the physician needs to be sure and follow up with the appropriate messaging to the appropriate staff so people don't get lost in the shuffle. And then the last step, of course, is to bill and submit claims. Here's a virtual visit script. Obviously, we've now taken out the COVID-19, but this does a really good job talking about the requirements both on the insurance side, the device side, the internet side that your staff can use to help screen for the most appropriate patients. One of the big pieces here was making sure to verify the cell phone number and the email while you're on the phone with the patient making the telephone visit because you can't rely on what's being said whatever's in the EMR and may or may not be updated. An example of a schedule, you can see here 47 is the LOC, the location that indicated it was at telehealth and number two was just the location if it was a physical visit. We also use color coding to help the physicians say at a glance what they were doing with telehealth. The virtual visits email template. Here's an example of the email template that we used to email to the patients with their links. I've also included a consent for telemedicine on the virtual visits. It makes the patient understand that this is a telemedicine. They may be eligible for co-pays and other type of visits and that they were offered the ability to come in person. I've included the resources with a link to the telemedicine vendor we use, Doxy.me, as well as the link to find out about reciprocal agreements. And of course, feel free to email me And we'll now have our first discussion if our first two panelists want to go ahead and turn on their webcams and mics. Hello? Lisa, that was a great talk. I have a question for Tom DiBerdino, moderating this session. I'm in San Antonio and we're in a private practice group, large one, and we had a lot of difficulty going forward. We're trying to decide what platform to go with. What are some of the big top tier criteria you use as a CEO of your large group to decide in what kind of categories do you look for to decide what's going to work best for your group? Or maybe it's different for really small groups versus large groups. Number one, it needs to be easy for the patient to use. We were very careful to, we chose Doxy.me because it's a simple link. The patient didn't have to download an app on their phone. It wasn't complicated to manage. And so, you know, on the provider side, we can figure it out. But really, it was about the patient experience and how quickly could they get into our visit and have them understand what they were supposed to do. And you mentioned the HIPAA requirement, and right now that's obviously been waived, but everyone's heard the same. I think the last update we were told about at our big group meeting was December 31st is the witching hour. Have you heard anything else you'd said in your talk? I didn't know if that was recorded or not. Is there any new updates on that? December 31st, it's going back to completely the same or somewhat the same or just the HIPAA requirement? I have heard nothing, which is a little bit scary. Again, to me, it didn't make sense to start a project of telehealth and not do it right the first time. And so that's why we just started with HIPAA compliant and went from there. That makes sense. A lot of people, they had never done telehealth. They were either in a small group or they didn't see the need in a small town maybe. But when we have far-flung patients, I'm in Texas, half the states telehealth by definition, or they wish they were because they don't like to drive four hours and still only be halfway across the state. It's kind of ridiculous. So that's very interesting. Dr. Lau, do you have any questions? I had a question for Mike. I was wondering, you had mentioned some of the asynchronous and the text-based kind of billing. For me, we use Epic. Is that like MyChart messaging? Are you billing from MyChart messages and stuff? Yeah, so there are e-visits. And those e-visits can be done asynchronously. And I listed those codes out inside the visit, so inside the presentation there. But you can bill for those visits, and they are billable. So you can look into that and bill for those. Obviously, they're not highly reimbursable. But if you're doing email, patient portal-type interactions, they are billable. Gotcha. And another thing you had mentioned was the importance of listing the patient as well as the physician location in the HPI. What happens if you don't? Is there a location where they would say, well, you're sitting on the beach, so that doesn't count? Does that matter? No, it really doesn't matter. It's just the way that we're asked to document these visits via telemedicine. So when you actually document, in order to get paid, the rules around documentation involve making sure that you denote your location and the patient's location. And those have been the established rules for HPI with telemedicine. And unfortunately, you just got to follow those. There's no real rhyme or reason. You could be on the beach, potentially. As long as you bill place of service 02, they know that that is a telemedicine-type visit. And even in my practice orthosense, my billing coordinator was sort of worried about, well, what if we're not at our office? And obviously, if you use 02 as your place of service, you're in good shape. It doesn't really matter. Gotcha. Okay. And does it matter about the... We still have it. Sorry, I didn't catch that, Brian. If it happened on the patient, like if a patient was in their car, for example, I've had that happen a couple of times. Does that matter? No, it doesn't. It doesn't matter. Again, it's part of the documentation process. Jim? You tell them to pull over and get a safe spot because you share their phone with you. Yeah. We had that happen with our hand surgeon. The patient was driving and she was trying to put her hand in front of the phone. And she's like, please, please stop. It's okay. Just describe it for me. I had a patient that asked, if I had a way to get them to figure out how to use their big screen on their new car to use that for the video conference, I was like, please stop, pull over. Let's just make it a phone call. Lisa, I have a question for you. We all saw a huge uptick in end user or physician usage during the early months. What have you seen in your large group in several locations, I assume? I would say it's plummeted. Down here, there's no other word to say it. We went from all of our visits to now we probably have less than 15 a week across all our providers. We're using it some for post-op visits for people out of town. We're using it some for a new patient. So we're using it for a new patient. We're using it for post-op visits for people out of town. We're using it some for a new patient screening for people that are out of town. But down here in Alabama, COVID is not a thing, at least in their mind, and everybody wanted to come into the office. We've encountered quite a bit of patient resistance overall now that things are quote normal. Do you see that maybe as not so much a regional thing, but maybe a proximity issue where places that are remote? Obviously, I mentioned our place, but maybe smaller towns, smaller cities, or smaller dense environments. People want to get there because they can versus maybe I'm in Idaho. It's like this is a boon to my existence. I don't have to leave the ranch to go get my six-week checkup. I can just point my finger to my knee and say, looks good, doc. My total knee's functioning. My cows are marching down toward the barn. Everything's good. It's probably both. Again, most of our telemedicine, our post-ops are done for people who are far away. We do want to save them that trip. Sometimes the people in the rural areas come into town to eat and shop. They make it a big adventure when they come in. It just depends. Alyssa, I had a question. From the business side of things, I admit that I should know more about that, but having been through now a couple months of telehealth, have there been any claims that have been denied for whatever reason or any challenges you've seen on the back end that you've had to have doctors go back and re-document anything? We see more payer errors than I've seen documentation errors. Truthfully, I've not had any payer ask for a note as far as audit, but we did have a lot of problems with place of service. It wasn't necessarily our issue, but the payers were not consistent on modifiers. They weren't consistent on place of service. They weren't paying us at the rates they were supposed to pay us, which is no surprise. They don't do that anyway, but the fact that they are doing it for telemedicine was an additional problem. We did, on the claims processing side, it was not nearly as clean as a typical E&M in an office. I would go back and check those if I were your practice manager. Good idea. How about from the patient side? Has any patients been like, I don't want to pay a co-pay, it was just a tele-visit? Yes, that has been a huge barrier, which is probably another reason why we are going ahead and having them come into the office. Again, post-ops, it's easy because you don't collect co-pays anyway, but for those new patient visits or established follow-ups, we did have a lot of resistance with that, which again, it just was easier to bring them in and argue with them. During the peak, when everybody was super scared, we were able to collect it a little easier than when things died down. Mike, do you have any tips on convincing patients that it's a valid visit? Sometimes it can be hard. I think the main thing is providing your services as a physician. If you provide them with five seconds information and you leave, they're probably not going to want to pay a co-pay, but if you host the visit like you normally would a typical office visit, hi, how are you? Go through your typical physical exam and you go through your explanations and everything. I don't think people have problems. They understand why you're doing it and the purpose of it. I haven't honestly run into that in my practice, but you just got to make sure that people feel like they're getting their money's worth. One thing I've done is we've had our providers say, if you were here, this would be very much the same except we're far away for your convenience and ours for safety, but we would do the same thing and we can do picture capture for motion and things. They actually like that. I said, we tell them it actually builds a better note because there's documentation of maybe improving range of motion if they were a stiff shoulder or stiff knee and they seem to appreciate that ability to capture that data too, so it's interesting. All right. Well, I think that we're probably out of time with this first panel. We may have to move on to the next set of series of talks, but thanks so much for Lisa and Mike for your input. Absolutely. Thanks, guys. Appreciate it. Well, I'd like to move on to the next section and introduce Dr. Brian Forsyth, who is an orthopedic surgeon at Rush Sports Medicine, and he serves as a team physician for the Chicago Fire, the White Sox, and the Bulls. He's a member of the ASSM Education Committee, and he'll be talking about some of the lessons that he's learned in troubleshooting the legal aspects of telehealth. So take it away, Brian. Hi. I'm Brian Forsyth. I'm a sports doc at Rush. I'm going to talk about legal considerations of telemedicine. I'd like to thank Tom and Ryan for the invitation to present. I have no relevant disclosures aside from the fact that I'm not an attorney. We know that telemedicine is the new frontier, the Wild West, so to speak. The industry has been completely deregulated to provide access to patients who are socially distanced. We need to remember some common principles to stay out of trouble. Exercise common sense and practice defensive medicine. I think Jack Houston said it best, so let's focus on the latter. Telemedicine is defined as an audiovisual conferencing technology. It has its origins in delivery of care to rural areas. We've seen widespread adoption, and we're allowed to use FaceTime and Zoom to reach patients we otherwise wouldn't be able to see. Importantly, we can also see new patients, which is a first. So there's universal acceptance. We're supported by the federal government, the CARES Act, to the tune of $200 million. The AMA has a 128-page guidebook if you need to reference it for further detail. At Rush, we've got about 50 docs. Pre-COVID, we were seeing about 12 patients a week. At the height of it in April, May, we were up to 750 per week, and now we've sort of plateaued at about 140 interactions per week. We think it's here to stay. It's not necessarily the workhorse anymore of our clinical practice. Informed consent is an important issue, as it is with surgical procedures. Office visits with telemedicine may require written consent, and this is totally state and insurance-dependent. It's impossible to relate all of the details per state and per insurance company, so it's best to reference this website from the Center for Connected Health Policy. They will delineate which insurances and states and insurances require written consent. Again, I wouldn't conduct any visits without being sure that you're clear in that regard. You should remember why orthopedic surgeons get sued in the first place. Number one is an abnormal injury, typically surgery-related. I would draw your attention to number two and three, which is failure to diagnose and failure to treat. There's very limited case history in telemedicine. There's a landmark case from a physician or a psychiatrist practicing in Colorado. He prescribed SSRIs to a patient in California who committed suicide. As a consequence, he spent nine months in jail, so there's precedent for serious repercussions. What constitutes malpractice in telemedicine? Typically, it's number two and three, diagnostic error and failure to respond. The databases from CRICO and doctors tell us that two-thirds of suits are diagnosis-related. You're all familiar with entities like compartment syndrome and post-op infections, emboli, and hematomas. Many of those obviously are post-operative. I think more worrisome in some respects are the conditions that require imaging, which is not necessarily readily available via telemedicine. If you're suspicious of fracture, nonunion, malignancy, or dislocations, those types of conditions require urgent in-person evaluation and appropriate imaging. In my opinion, post-surgical complications present the biggest pitfall to all of us in trying to navigate patients via telemedicine. If there's a high-energy mechanism like an MVA or a sports injury, you got to get those patients in. I wouldn't do a new patient visit without careful follow-up in person. In terms of safety mechanisms that we can employ, have a low threshold for mandating an in-person visit, document that you told them to come in, send them to an urgent care or ER if need be. Under no circumstance would I personally prescribe narcotics. I think you run the risk of serious liability in doing so. Remember that malpractice insurance is administered at the state level. Where you do your patient encounter is actually quite important. In the state of Illinois, where I practice, I'm not allowed to provide telemedicine care to a patient in another state unless it's their second home. It's very idiosyncratic. I would recommend referencing this website from the Center for Connected Health Policy. Before the pandemic started, there were some states that were trying to make licensure transferability a little bit easier. Because of COVID, license requirements have been waived in certain states. Keep in mind that some states still require that you register. Just because you have a license doesn't mean you can practice without registering. I'll draw your attention to the middle of the screen here. You can practice in Florida, Connecticut, and so forth with a license if you're licensed elsewhere, but you still have to register. It's important that you keep this in mind. Health privacy is very important to patients. It builds trust, and it's also something that's protected by federal law, as you're well aware. HIPAA clients is a huge deal. Fortunately for us, the federal government has loosened restrictions on use of platforms like FaceTime and Skype and Zoom, so we can still interact with patients if you don't have something that's encrypted and embedded in your EMR The federal government has temporarily suspended enforcement of HIPAA penalties, but I would not rest on your laurels. I would not get too lax about this, because this could change at a moment's notice. It's really important that you're in a private environment when interacting with your patients. Don't do it in an open room with other patients and staff walking about. The majority of security breaches are secondary to hacking. We've all been subject to phishing emails. My practice got hit up for a $30,000 fine because of one of those. Any data breach is potentially subject to a HIPAA fine. They are temporarily suspended. It's important to remember that any breach actually has to be reported to the patient, typically by letter. There are serious fines which are currently suspended. They range from $100,000 to $50,000. If there's a breach, you need to address it in a timely fashion. If you don't, the fines increase. The maximum fine can be as high as $1.5 million. Your insurance carrier may not necessarily cover this. On the reimbursement side, new patients are now being paid for, which is a new phenomenon. There's a lot of variation from state to state. Remember that telemedicine requires a synchronous technology, meaning you can't just leave messages on a patient's phone and call that a visit. You actually have to have a dialogue and a conversation in real time. Fortunately, we are getting reimbursed for our clinical time. Reimbursement, again, as I said, it's state and insurance dependent. It's pretty equivalent in the state of Illinois. In summary, I want you to know that telemedicine is here to stay. Informed consent is a big deal. It needs to be investigated at the state and insurance level. You need to practice defensively. You should have a very low threshold for in-person eval and imaging. Don't prescribe narcotics. It's a good idea for your practice to invest in an integrated EHR platform. If there's a HIPAA violation, you can report it. You should report it. You're not going to be subject to a fine right now, but you should set yourself up for future success by having a well-integrated system. Thank you so much for your time. Look forward to the conversation to follow. Thanks, Brian. It's really informative. I'd like to now transition to an attorney perspective and introduce Mei Kuang, who's an attorney and executive director for the Center of Connected Health Policy, which is a nonprofit organization that works to maximize the use of telehealth to impact health outcomes, as well as cost-effectiveness. She's been really the leading expert in developing public policy as it relates to telehealth at the federal and state level. And so she'll be talking today and educating us a little bit on state regulations and the legal issues that we should be considering. Hello. My name is Mei Kuang. I'm the executive director at the Center for Connected Health Policy. I've been asked to talk about state regulations and legal issues that impact telehealth utilization. A few disclaimers first. Any information that I provide in today's talk is not to be regarded as legal advice. It is strictly for informational purposes. CCHP always recommends that you consult with legal experts and the Center for Connected Health Policy. If you have any questions, please feel free to reach out to me. Counsel would like legal opinion. And please know that neither I nor CCHP has any relevant financial interest arrangement or affiliation with any organization or commercial product if I happen to mention such an organization or show such a product. A little bit of background information about CCHP. We were established in 2009 as a California telehealth policy organization underneath the Public Health Institute, but an opportunity to become the federally designated National Telehealth Policy Resource Center became available in 2012 through a grant from HRSA. We applied for that and have been serving in that capacity ever since, but we also work with a variety of other funders and partners on more specific focused telehealth projects. We are also a member of the National Consortium of Telehealth Resource Centers. There are 14 telehealth resource centers underneath the same grant program that CCHP is under. There are 12 regional resource centers that cover specific states and two national centers. CCHP is the one on policy, and there is also one on technology. However, all 14 work very collaboratively together in order to stretch our resources and to ensure that there is a consistency of message and efficient use of the resources that we are given. Now, I've been asked to talk specifically about state policy changes related to telehealth, but there's actually a bit of interconnection between what happened on the federal level and also what happened on the state, and also a lot of commonalities as far as where the policy changes have happened in response to COVID. As you can see, this is very high-level overview of what the changes were, but the changes that occurred both on the federal and the state level focus in on specific areas or specific issues, and you'll see a lot of it has to deal with location of where the patient is during the time that interaction takes place, what provider is allowed to use telehealth and be reimbursed for it, what services are reimbursed, and also the modality or what technology is being used to deliver the service. There are other issues that impact the utilization of telehealth that does not involve reimbursement. Reimbursement is talked a lot because a lot of the established telehealth policies even before COVID really focused in on reimbursement, what gets paid either in the Medicare program or the Medicaid program or commercial payers, but there are other policy issues that impact the utilization of telehealth, such as, for example, licensing or privacy and security, malpractice issues, and consent issues, and some of those issues were addressed both on the federal and the state level as well. So, this is just sort of an overview of some of the different topics that were addressed in response to COVID-19 and other things that weren't addressed specifically by a policy change in response to COVID-19 but still also impact the utilization of telehealth. I talked a little bit a moment ago about reimbursement. Again, the largest area of where established telehealth policy is, you see that in Medicare, Medicaid, and in commercial payers. You also see that in federal statute as well as state statute, what's reimbursed depending on, like, what payer you're talking about, and also within, like, programs itself, such as Medicaid administrative guidelines and CMS guidelines for Medicare. So, that's where a lot of the policy changes in response to COVID occurred, but you also probably heard that there were other changes made to in other areas of policy, such as privacy and security. On the federal level, HIPAA requirements were relaxed, were waived temporarily in response to COVID, and this was really to allow programs and providers who did not utilize telehealth before COVID-19 rapidly stand up a program in response to COVID because in response to the pandemic. So, that's another area where there is not really specific policy to telehealth, but it impacts the utilization of telehealth. Now, consent is also another issue that we see more on the state level. Some of those consent requirements in regards to telehealth is embedded in state laws in some jurisdictions. So, consent on whether you need to get consent before a telehealth interaction takes place and how you get that consent. Does it need to be written consent or is an oral consent sufficient? When do you get it, the timing of obtaining that consent? Again, those were some of the policies that were also relaxed during COVID. Really, basically, sort of the things that they did were if it was a written consent, they would allow oral or the timing of when you got the consent was relaxed a bit to help, again, facilitate the use of telehealth. Establishing a patient-provider relationship and prescribing are usually connected together because you, as a provider, can't prescribe until you have a patient-provider relationship, and can you establish that patient-provider relationship over telehealth? There's two levels of looking at that. Again, there's a federal level because federal law controls how you prescribe controlled substances when you're using telehealth, and then the states basically cover everything else. So, there were certain rules as far as controlled substances and using telehealth. It's very narrow in how you can use telehealth to prescribe, but again, because of the pandemic, there was a way to relax that. Basically, the way to relax that was that in federal law, it said if there was a public health emergency declared, then you didn't have to fall into one of the other exceptions in order to use telehealth to prescribe. So, that involved controlled substances, but we also saw states relaxing some of those prescribing laws and what you can use telehealth for that were for other things beyond controlled substances. Then, usually, what went hand in glove with that was how you establish a patient-provider relationship if you can do it over telehealth. Then, licensing was a big thing, too. That is something the feds have less control over. That is left up to states to decide that. There may have been a thought that, well, there was something that the feds declared that they were doing around licensing, and what that turned out to be was in Medicare, there's a requirement that you have to be licensed in the state that the patient's located in. Medicare relaxed that administrative rule, but they could not change what state law was saying, which, for the most part, state law before COVID-19 was saying you need to be licensed by the state where the patient's located in. If you come into my state and you treat a patient here in person or via telehealth, you need to be licensed in my state. So, those rules, depending on what state you were in, and it varied widely from state to state, could have been relaxed where they were saying, you know, if you were in good standing in the state that you're located in, you can practice in our state without getting a license to going through a special process to allow you to do that. So, that was a little bit more varied in what we saw. Now, a lot of policy issues weren't addressed by the waivers and the relaxations in response to COVID, such as malpractice coverage. So, a lot of times people have questions of, like, how many malpractice cases are there around telehealth? And really, there aren't a lot, but then there also, before COVID-19 happened, telehealth wasn't utilized widespread, so it may be like a numbers game in that, you know, less utilization of telehealth, yes, less cases around malpractice, but there were some. However, a lot of them were settled out of court, so I really don't have the details regarding them, but one thing that people should be aware of was really more about malpractice insurance and not necessarily malpractice cases. And what I mean by that is that your liability coverage may not actually cover you if you're delivering services via telehealth, so you need to check with your carrier to see if your coverage extends to telehealth utilization or telehealth delivery of services. And also, if you are providing services into another state, your malpractice insurance may not actually operate in that other state. For example, I'm in California. I usually practice in California. My coverage covers me in California, but if I start practicing via telehealth in New York, my malpractice coverage may not cover those cases in New York, so need to double-check that. There's also, both on the federal level and the state level, protections against discriminatory practices, and telehealth may have some crossing with that. So, for example, utilizing telehealth to deliver services to people who may have a disability, are you meeting, like, ADA standards for that? So that's, like, something else to consider. And then there are also, like, state-specific rules and regulations that aren't specific to telehealth or really even to healthcare that might impact a provider providing services via telehealth, such as internet business operating issues. So, for example, in California, if you are a commercial vendor and you are trying to sell a product or services to citizens of California, you're required to have a phone number on your website where you can reach a live human being during business hours. Not related to telehealth, not even related to healthcare, but it is related to that commerce that telehealth, delivery of telehealth services would fall into, so you would need to be aware of that. So there's those other types of rules, too, to be aware of that can impact your practice if you're utilizing telehealth to provide services. And then also, states have licensing boards that have their own guidelines or regulations that they impose on licensees related to telehealth, and they do vary from state to state. Be aware of that, too, if you're operating in another state that you're not used to operating, you've gotten a license there, or you come underneath one of those special exceptions. There may be other rules you have to follow that you're not used to following because they don't have them in the state that you're used to practicing in. Now, the thing I want to say, though, is, like, all those relaxations, those waivers, those expansions that happened, the majority of them in response to COVID are temporary, so a lot of them are tied to the federal public health emergency. So if that went away, like, tomorrow, all of these exceptions and expansions will go away, too, unless they are made permanent. So, you know, it is kind of worrisome, I think, probably for providers who stood up programs very quickly in response to COVID, wondering, did I invest all this time that, yes, held my practice during those first few couple of months of COVID, but I've invested all these resources, am I going to be able to, like, you know, keep this around unless, like, things are made permanent? So there's still that question of what of, like, the temporary changes will be sticking around in, like, later months and years going out beyond the COVID-19 crisis. So these are just a couple of resources that CCHP has that you can access, and that is it. A very quick overview of state telehealth policies in response to COVID-19. Perspective, and I'd like to now introduce Stephen Fadden, who's another attorney, and is a partner at Barnes and Thornburg in Chicago, where he advises on healthcare-related issues for physicians, physician organizations, as well as nonprofit entities. And he's going to be talking today about and really teaching us how to stay out of trouble. My name is Stephen Fadden, and I'm delighted to talk to you today on how to stay out of trouble in the world of telemedicine. I'm a partner at Barnes and Thornburg, and I've been advising physician and physician organizations for the past few decades. I have a challenge for myself. I have several minutes to go over several ideas for you to consider. The first one is be mindful that when you're engaged in the practice of telemedicine, the standard of care that you will be evaluated by is the same standard of care you're evaluating the patient in the office and if you're evaluating the patient by telemedicine. What that means is that it's the physician's responsibility, it's the physician's judgment call about the setting of telemedicine is appropriate for that particular patient. And if it's not appropriate, the physician's responsible for that judgment that it was appropriate. So same standard of care, there are no exceptions for telemedicine. If you don't feel as though you can offer the same standard of care in the telemedicine setting, then it's your responsibility to bring the patient into the office. Most doctors never think about or are concerned about engaging in the unlicensed practice of medicine. And that's because most physicians understand they need to have a license in the state where they're seeing their patients. My concern is that in the area of telemedicine, physicians may not realize that they may accidentally engage in the unlicensed practice of medicine because they may be residing in one state and their patient may be residing in another state. The good news is there are a number of practical exceptions which I've enumerated on the slide that allow physicians to continue to use common sense to follow up a care for patients. Now what happens if a doctor were to see a patient and the patient lived out of state and the doctor wasn't licensed and someone were to find or conclude that the doctor engaged in the unlicensed practice of medicine? The number one concern I think is that there might be a presumption of negligent care by the mere fact that the physician's not licensed. Next is a question whether the malpractice insurance would be applicable if the care is determined to be not licensed medicine. State agencies controlling the license of medicine can issue various correspondence, there can be fines and penalties, and worst of all I guess is there can be felony charges if a physician were engaged certainly intentionally with the unlicensed practice of medicine. The practical issue I think is that some patients may want to be seen remotely and you may want to follow them because you've had a long-term relationship with the patient. So for example if you're seeing a patient in Illinois and the patient is in Florida half of a year and you're continuing to see the patient on a regular basis, the question becomes should you be licensed in Florida and the patient as a practical matter is saying please see me, it doesn't really matter where I'm located all you're seeing is me by telemedicine. My concern of that is that the patient if there is a problem going to a plaintiff's lawyer would be able to establish perhaps that that was the unlicensed practice of medicine, so you have to be vigilant to make sure that you're licensed where your patients are located, unless you can establish that you belong to an exception. With respect to this telemedicine world, so much remains the same, and yet there's some really critical differences. One of the differences is what goes in the medical record. In the Federation of State Medical Boards and the American Medical Association have come up with some guidelines to help us figure out how to do that. Now, I was a little bit surprised to see that there, but when I read the guidelines, I realized how applicable they were to common sense, we'll say. One is that a patient has a right to refuse telemedicine. My presumption is that most telemedicine visits are really at the request of the patient, but when you read this, you realize that some physicians might be doing it at their behest, and that is not going to fly. Patient has a right to see a patient in person. Now, in this pandemic setting, I'm not talking specifically in the context of the pandemic, because I'm kind of post-pandemic, I think there's a lot of common sense that has to be applied to the pandemic situation that may give some wiggle room for both the doctor and the patient. But look at what the AMA and the State Federation of Medical Boards is wanting the provider to address in the informed consent. They want to see documentation of where the patient's located, and that would be presumed ordinarily, but not now. And the X is they're anticipating and addressing issues like how does the patient get follow-up care? How do we make sure there's good communication back to the primary care physician? I'm going to argue that most of these requirements are common sense. Now, what I also pick up on for any provider to really seriously consider is in a robust informed consent, you as a provider can shift responsibility to the patient by informing them of some of the problems that can happen with technology, and that they're not guarantees that everything's going to work perfectly. So, this is an opportunity to be proactive in engaging with your patient in a very respectful way. Confidentiality is critical to physician care. I think everyone knows that. The challenge is what does it mean in a world of telemedicine? I personally would be following the standards as best I can tell of what my peers are doing, what my national associations are recommending, what my consultants are recommending. But I would also use a lot of common sense, and the common sense part is realizing where is the physician located, and where is the patient located, and is that a safe, secure, confidential location? I worry that people working from home or patients working from home are going to be in environments where perhaps things can be seen or overheard that would ordinarily not happen in the patient office. And that responsibility falls on the physician to make sure that that environment is safe and appropriate for their patient. Professional liability coverage. We know that coverage extends to the care for individuals within their state. But if someone is licensed to practice medicine out of state, the question is making sure that their professional liability coverage extends for acts outside of the state. Many insurers will say they insure for the state in which the policy was issued. So, this is just a confirming aspect and not one to be taken lightly. We have federal and state laws that govern prescriptions. Many people tend to focus in on the federal law exclusively. As we know, we have an exception right now under the Ryan-Hape Act for controlled substances. Ordinarily, there's a requirement for an in-person medical evaluation before a controlled substance can be prescribed during the pandemic. That requirement is waived. It may or may not be waived at the state level during the pandemic. So, doing the telemedicine, you need to be aware of both federal and state requirements, especially around the in-person evaluation. Now, I don't ordinarily focus concern about kickbacks in billing fraud. And I wouldn't ordinarily think there's any additional risk associated with telemedicine for those areas. But for the fact that the government thinks that there is heightened risk in telemedicine, they're very concerned that some folks are abusing the telemedicine platform, and they have substantially increased their resources investigating, reviewing, identifying potential problems in the telemedicine space. The smart strategy to do there is to have a compliance plan. If you don't have a compliance plan, institute a compliance plan. And be mindful in a systematic way that you're verifying that what your providers are doing is appropriate. And be looking for any kind of arrangement that might suggest that there is a kickback. And it could come from a telehealth company, come from a medical device company, and it might be sold or wrapped up in something that sounds really good. But if it seems to be remuneration in exchange for any kind of referral, we're right dead center into a kickback arrangement. Compliance plans are the way to go. Now, this was a short summary of an awful lot of information. Additional resource that would be excellent is the AHLA's Practical Guide to Virtual Care. And I put information in the slide with how to identify that information. Thank you. And with that, we'll start our second panel. If our panelists can turn on their webcam and mic, as well as our moderators. Steven, that was great talking to everybody. But, Steven, I'm going to start off with you. We've heard the word, at least two of our speakers appropriately use the word common sense. And I think that's great. It's like it gives back to do unto others as you'd want them to do unto you. I don't want to expose my shoulder or my knee if I know the camera is facing toward the waiting room or something ridiculous like that. But what I wanted to focus on my first question with you to bring up the discussion of the common sense piece of the consent process. It sounds like it kind of needs to be boilerplated in a good way. Meaning, for commonality and for continuity, it almost seems like we do need to have access to a resource that tells the new clinician or someone just starting practice or somebody who's been in practice for 25 years, what is it that makes up a good telehealth verbal and oral consent? And maybe it's probably available on some of these websites that we've mentioned tonight. But I think I just wanted your input on that. Well, I, you do want to have a standard form for informed consent. That would be the recommendation. You'd want to comply. I would recommend complying with the guidelines from the American Medical Association, which has a comprehensive checklist of what should be in the informed consent. And that was prepared in conjunction with the American Board of Medical Specialties. So, you're going to hit all the bases. It's not law, it's a requirement, and it's the ethical elements. And what I use the term robust is from your perspective, there's an opportunity, you know, ordinarily you think of informed consent is you're letting the patient know that they have choices, that there's risk associated with the procedure and all those types of things. But it's really a compact between you and the patient. And here's an opportunity to make sure they understand some of the problems that can happen in telemedicine that wouldn't be your fault or their fault. So, you don't have this absolute responsibility for things. So, there's the legal component. I would have the informed consent be very patient-friendly, easy to read, and I'd be following the guidelines. And then there's the second part, which is not the legal part, but it's the ones you do ordinarily, where you really want your patients to understand what's happening and what their alternatives are. It's that human connection. Very good. Brian, going back to you, I mean, you talked a lot about consent too and at Rush. Do you guys have, I mean, Illinois may be specific to you all's existence, obviously, there's different rules, but what have you guys imparted at Rush? Is it more standardized or is there a form that your clinic for all 50 providers uses to get a verbal and an oral and it's locked up into the EMR? How do you guys actually logistically handle that? Tom, it's a great question. Just as I covered in my presentation, there are three tenets that need to be covered. One is information storage. The second is team participation, meaning that there's other healthcare members, nurses, PAs, extenders, et cetera, who might use the technology. Patients need to be aware of this. And you have to describe the telemedicine visit in your consent form or package. So we have an integrated system. We use Athena. And the fact that it's integrated sort of facilitates the consent process because patients are immediately prompted and they have to click to confirm. So we have sort of electronic digital consent. And obviously, the fact that they're clicking on it and that they've checked that box, that they read the terms, qualifies for, I think, a robust informed consent process. So I think this is the advantage of an integrated system. If you can't use one and you're just using a FaceTime or a Zoom, which is still appropriate and functional, again, make sure you have privacy and make sure that you document in written form that you've identified location and the patient's understanding of the process. And that's where we are now. And I have to say that the virtual visits are easy. Patients sometimes want to talk a little bit longer because they didn't waste so much time traveling to and from. Well, they get banged for their buck. They paid a copay. They want your time. Oh, yeah. We're going to suck it all up. Brian, do you have a question for our panelists? Sure. For all of them, I really, you know, so one of the things we had talked about a little bit before was the ability to see patients from a distance and either serve as a screen or something else. And, you know, just obviously some of those challenges, you know, in terms of liability and crossing state lines. So that's one issue I want the panelists to address. The second is established patients. So patients you've already seen, they've come to you in person and then they go back to across state lines, but you've already established a relationship with them and you're following up on them. Maybe it's a post-op, maybe it's not. Maybe they've done some therapy and just want to check in with them. What's your advice for us on those? Should we be doing those? I mean, I think that's one of the advantages of telemedicine, but what's your thought in terms of Brian's experience, I know you guys have a lot of people traveling over to see the experts at Rush, and then, you know, from the attorney's perspective, whether we should be more careful with that? Well, I'm glad I've got two attorneys here to sort of vet my answer. I would say that the initial visit, they're supposed to be in state. So a new patient in Illinois should be seen in state, and Steve can back me up on this, I hope. They can do a follow-up from their lake house in Wisconsin or Indiana or Florida if you're the governor. But, you know, I won't get too political, even with the election coming up next week, but you really need to confirm that they're in state. And a follow-up, I think, might be acceptable during COVID, but I'm not so sure that that's the case in non-COVID times. And I would be really wary about patients post-operatively who you see telemedicine out-of-state for their second visit, because if they do have a complication, I think that a plaintiff's attorney might make the case, well, you saw them out-of-state, and you were less likely to bring them to the hospital or refer them to your urgent care clinic. So I think you're assuming some liability, but if it's a six-month or a one-year follow-up and it's a routine shoulder arthroplasty or ACL or what have you, I think you're probably a little bit better covered. But in the perioperative period, first three months, I think you're potentially assuming a lot of liability. Steve or May, any more of your thoughts? I like the way Brian said it. I think not only does it follow Illinois law, I think it follows what's in the patient's best interest. Because remember, what we're really ultimately trying to do is what's the quality of care? And you need to have that in-person exam at one point, perhaps, but not another. If I were a physician and I had patients, let's say, in Illinois where they were coming from Wisconsin and Indiana and going to spend a lot of time in Florida, I would be familiar with what the requirements are for what Illinois permits and what those other states permit. Because the thing that's so confusing for most Americans who are not lawyers is that every state operates as a separate country. And you cannot assume what works in one state works in another state. So I just look and see where the greatest pattern is of where your patients are and make sure you're not running into problems with patients who may be spending an awful lot of time in Indiana and hardly ever coming into Chicago. Yeah, that's a question the resource centers get frequently, the whole thing of like, well, they vacation for three months out of the year in a different state. So what do we do if they want to do a follow-up? And during COVID, you got people who were stuck in states and not in their home state needing to access their care. I would agree with what was said before. There are a few states that have very narrow exceptions. For example, you know, a state that may say, if you are doing it infrequently, we're not going to require you to have a license. So that may apply in that situation. But again, probably not for those, you know, post-operative situations that Brian was talking about. But maybe for like, you know, just more of a consultation or follow-up, simple follow-up, that's what you can use it for. But those are very few and far between those types of exceptions in states. So I have a question. Everyone's got cell phones now. And this is being kind of being the devil's advocate, but it's like the snake in the grass, maybe. I see a lot of patients that travel in all over Texas and all over the country that come in for different weird things. And I'm having my office call their cell phone, because that's the phone a record, just to check in on them. You know, I don't know that they're traveling salesmen and they're in Kansas. And literally, I tell my office, check in on Jim. He missed his appointment. See how he's doing. I mean, we do that as just administrative kind of taking care of business, dotting the I's and crossing the T's. And that's kind of characterized in our EMRs as messaging, communication. Could that get twisted on us outside of the pandemic? And, you know, I don't know. I'm trying to ask. I think there's a snake in the grass that we're missing. I would say the way you describe the services would be the staff people. That's not the practice of medicine. That's administrative. That's communicating. It's scheduling appointments. That doesn't jump out to me as a concern. But I want to get across this idea that, you know, if I were a patient and I were out of state, I didn't want to bother you. I might tell you, you know, the question is, you're supposed to ask where they are. Right. And I would be inclined to maybe not tell you accurately. Right. If I'm a patient and I'm in Florida, maybe I tell you. How would you know if I'm not right there in your city? So but then the burden's on them and you're documenting what they told you. Exactly. OK. Snake stepped on good. I have a question. I have a question for the physicians. Are you concerned about your ability to offer the same standard of care when you're using telemedicine? I. Yeah, Tommy, you can go. No, go ahead, Brian. I point you. OK, well, I'm concerned primarily in the perioperative period. I think post-op complications are probably the most likely pitfall for all of us practicing telemedicine. So I have a very low threshold for referring patients to the office or to an emergency room in those instances. I think earlier that the situation that Tom described, I felt that was more administrative. And I would think that if you're not billing for that phone call, that you're probably not subject to the same repercussions that would involve a malpractice suit. But I'm defensive by nature because, you know, nothing ruins a good operation like follow up. And if you're if you're operating, you're going to have complications. So it's just part and parcel of the business. And you've got a one percent. You've got five. Sorry, background. You've got five or ten serious complications a year. So you just can't miss those. I think that relates back to what Stephen was saying, though. It is that the provider physician just utilizes their common sense and like how to use telehealth. However, you know, from as a policy person on policy perspective is that but the policy should give you that flexibility to do that, where you are allowed to exercise your common sense, your judgment based upon your experience, your education on whether it's appropriate to use at that time. And they shouldn't put up artificial barriers to to that when you think like, but it could be appropriately used for X. Yeah, I mean, I mean, isn't it right? Good. It was that you mentioned when you were talking about that, one of the biggest things that you've noticed is the difficulty in the liability insurances, the malpractice insurance and recommending that we all check our malpractice insurance prior to covid. How many in your experience and how many malpractice insurances that most physicians get actually cover telehealth and all of us going back and checking, checking it? I mean, but how likely are we going to have to change? You know, it's gotten better. I've been doing this for 10 years and I've noticed the evolution from like when I first started to like just before covid that there were more and more carriers expanding their their their coverage and either like adopting it, allowing that to be underneath somebody's current plan or they were offering some sort of additional coverage. What had been sort of the big stumbling block was and it's related to those malpractice cases. The pricing of the premiums was where plans had sort of an issue where there weren't enough cases for them to like figure out what would be a good premium to price. So they tend to price on the higher end and that made coverage the additional coverage for some providers like not accessible for them. So they wouldn't utilize telehealth. It had gotten better over the years. But really, when I first started in that beginning, it was kind of tough in that a lot of carriers, they weren't familiar with telehealth, so they were covering it or they weren't familiar with it and covering up the charge of very high premiums. Now, with the the exposure during covid, I think probably that probably helped on the coverage part as far as like having more carriers cover telehealth within their plans and maybe stabilizing some of those higher premiums and bringing them down a little bit. Do you see a purpose for societies? AOSSM is an example in the overriding governing board of societies, specialty societies. Do they play a role or responsibility in trying to get that appropriate policy to change, maybe to make it more not transparent, but more inclusive of just blanket covering telehealth and in-person coverage? Just make it one flavor of coverage instead of dicing it up and maybe missing parity in pricing, obviously across state lines, it could be different. But just making it it's so common or hopefully, as Dr. Verma hopes, it becomes the the standard of availability for everybody because it provides a broad swath of care to people remote and people in the city and people in the small town like, you know, so they still have access to care. And just for for safety and for coverage, do you do you see that as a responsibility? Societies are going to push for that. I see it as a responsibility of societies to provide their input into it, only because the the approach that CCHT takes to policy is we try to be as inclusive as possible because we want the policy eventually to work for everyone. As as a policy person, I can craft what I think is a beautiful policy. But if it doesn't work for essentially the people who have to put it in place, it's not a good policy then. So the more more feedback, the more information that we we get in order to like structure the policy, the wider application I'll have, the more I'll work for more people. So I think the societies do have a responsibility to provide their input. And like, you know, we think it would work better this way because of these reasons. This is how we actually practice medicine, how it actually works for us on the ground level. This is like what's in practice here, not this theoretical what the attorneys say. And as an attorney, I'm like, you know, I can say this, what the attorneys say works. Like, but I'm not actually a practicing physician. I don't know how your practice really goes. I'm not in that room with that patient. You guys need to tell me how that really goes so we can help structure the policy so it works for you guys and the patient. Tom, I I don't spend a lot of time looking at malpractice insurance policies, but I will tell you, my first instinct is it should be covering the practice of medicine, drop, period, right there, stop practice of medicine with telemedicine. So now it sounds as though they've introduced perhaps excluded exclusions. And I don't know on what basis. So if it's out there, national associations always play a role in moving the dial or moving the knob on the dial. Excellent. Brian, are we coming near the end, I think? I think so. So on that issue, Tom, I just have a moment would be careful what you wish for. If you have interstate transferability of licensure, it's it's sort of it gives free reign to the patient to call you whenever, wherever they are. So I think that we may need to rein this technology in if we get too liberal with it and we shouldn't get too aggressive early on. With Brian, I'd like to respond to that, because this is where the AMA and the American Board of Medical Specialties is so important. Only you can decide what's safe and what's appropriate. And they're putting the burden on you. And that needs to be understood by all the doctors so that they could be anywhere. But you have to decide what your comfort zone is. It doesn't matter what the laws are. Anyone else's. It's your license. It's your patient. You decide if you got to see him in person. Yes. Well, thanks. Thanks to all of our panelists is really enlightening and humbling as well, as we get excited with the new technology and the things that we have to be careful about as well. So thank you very much. And thanks to all the participants who have joined us today and in the future. And next week, we will finish out this webinar series and talk about innovative ways to use telehealth. Well, thanks, everyone. Have a great night. Thank you. Bye bye. All right. Bye bye.

telehealth

sports medicine

AOSSM

billing

telemedicine practice

legal considerations

COVID-19 policy changes

patient location

malpractice insurance

informed consent

standard of care