Throughout the COVID-19 pandemic, we heard a lot about "surges" that happened all over the country regarding the virus. One of the other interesting "surges" we have followed is the "surge" in new healthcare business start-ups, particularly businesses owned by advanced practice providers, such as nurse practitioners, physician assistants, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists ("Advanced Practice Providers" or "APPs"). One of the hottest areas in the healthcare start-up surge has been the creation of practices that are telemedicine focused.
While telemedicine is not a new concept, the number of practices and providers actually utilizing telemedicine has increased dramatically since the start of the pandemic. With this soar, providers, particularly APPs, have increasingly asked for assistance with appropriately structuring these new businesses and tackling questions regarding their telemedicine scope of practice and their ability to prescribe medications to patients who have not received an in-person examination. This article will address common questions that we have been asked by APPs trying to implement telemedicine in their own practices.
Scope of Practice:
The first things to remember with regard to telemedicine is that a provider must generally follow the laws and regulations of the state where the patient is located at the time of the visit. With regards to scope of practice for APPs using telemedicine, it is important to note that this is rapidly changing, particularly because the drive for APP autonomy and full practice authority is in full force across the country, and each state's scope of practice rules and regulations are different.
Additionally, each state has wide variation in their telemedicine laws governing scope of practice while utilizing telemedicine, and those parameters have been changing quickly. For example, in Pennsylvania, there were no telemedicine statutes in place prior to the pandemic, which meant rules neither prohibited nor authorized the use of telemedicine. However, Senate Bill 705 was introduced in 2021, which addressed the regulation of telemedicine by professional licensing boards and insurance coverage for services provided via telemedicine.
Similarly, in Ohio, as a result of the pandemic, House Bill 122 was passed and will take effect March 23, 2022. As a result, Ohio Revised Code § 4743.09 lists advanced practice registered nurses and physician assistants among those health care professionals permitted to provide services via telemedicine, using either synchronous or asynchronous technology. Essentially, through this rule, the Ohio Board of Nursing (for APRNs) and Board of Medicine (for PAs) are granted permission to implement telemedicine rules in order to carry out the Bill.
Prescribing to patients who an APP has not seen in person is another issue that has presented itself during the pandemic, with many states' scope of practice laws not addressing the issue. However, states such as Virginia, for example, have implemented remote prescribing rules, focusing primarily on limitations associated with prescribing controlled substances.1 With telemedicine being widely used since the start of the pandemic, it is likely that states and licensing boards will begin implementing more concrete rules related to remote prescribing, if they have not done so already.
Another common category of telemedicine questions relates to what services providers can provide to patients utilizing telemedicine, and how these services are to be billed. For Medicare patients, the Centers for Medicare and Medicaid Services ("CMS") has provided a list of services that may be reimbursed if provided via telemedicine in their "List of Telehealth Services for Calendar Year 2022."
While state Medicaid programs usually try to mirror Medicare, not all requirements will be the same. As such, it is important for nurse practitioners to look at their state's Medicaid laws addressing telehealth in order to determine what services are covered and review any additional requirements there may be.
Commercial insurers are also likely to list the telemedicine services they cover for reimbursement. Additionally, many states have implemented rules protecting coverage of telemedicine services. For example, in Missouri, health carriers and health benefit plans cannot deny coverage for a service solely because it was rendered via telemedicine if the service would have been reimbursed if the patient was seen in person.2 Ohio's H.B. 122 includes similar protections that require insurers to reimburse for telemedicine services.