480: Dr. Mark Milligan: Implementing Telehealth in Your Practice

Live from my personal Facebook page, I welcome Dr. Mark Milligan, PT, DPT from Anytime.Healthcare as he discussing how we can implement telehealth services into our physical therapy practice. 

In this episode we discuss: 

* How to set up a telehealth platform * How to perform an initial eval and follow sessions * How to bill (at least what we know right now) * The paperwork you need to start seeing patients today * And so much more! 

Resources: 

Anytime.healthcare

Doxy.me

Connected Health Policy/Telehealth Coverage Policies

State Survey of telehealth Commercial Payers

Telehealth Paperwork

 

For more information on Mark: 

Dr. Mark Milligan, PT, DPT, is a board certified, fellowship-trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions.

He is a full-time clinician with multiple patient populations and is the Founder of Revolution Human Health, a non-profit physical therapy network. Helping others create the best patient experience and outcomes through his continuing education company specializing in micro-education is also a passion.

His latest venture is creating the easiest pathway to access healthcare for providers and patients with Anywhere Healthcare, a tele-health platform. He is an active member of the TPTA, APTA, and AAOMPT and has a great interest in the pain epidemic, public health, population health, and governmental affairs.

Read the full transcript below: 

Karen: (00:07):

Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information you need to live your best life, healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, dr Karen. Let's see. Hey everybody. Welcome back to the podcast. I am your host, Karen Litzy and in

Karen  (00:40):

Day's episode. I am sort of re airing a Facebook and Instagram live that I did last Wednesday with dr Mark Milligan all about telehealth. So a little bit more about Mark. He is a board certified fellowship trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions. He's fulltime clinician with multiple patient populations and is the founder of revolution human health, a nonprofit physical therapy network, helping others create the best patient experience and outcomes through his continuing education company specializes specializing in micro education is also a passion. His latest venture is creating an easy pathway to access healthcare for providers and patients with anywhere. Dot. Healthcare. This is a telehealth platform. He is an active member of the Texas PTA, P T a and a amped and has great interest in pain epidemic, public health, population health and government, governmental affairs.

Karen  (01:41):

I should also mention that he is also on the PPS coven task force. So if you want to get the most up to date information on how the coven pandemic is affecting physical therapists in private practice, you can find that at the private practice sections website. It's all free even for non-members. All right, now onto today's podcast. Like I said, this is a recording from the Facebook live that we did last week. And in it we talk about what is telehealth. We talk about how to set up telehealth, how to implement telehealth, how to conduct a telehealth session for an initial eval or for a followup. We talk about how to get paid for telehealth and this is the information that we knew at the time. That was last Wednesday. Like I said, things are moving really, really quickly here. So the best thing to do in Mark says this is to check with your individual insurance providers, check with your state things are moving really, really fast.

Karen  (02:45):

And of course finally we talk about answer a lot of viewer questions. So a big thanks to Mark and I think this is really timely and I hope that all physical therapists that if you're listening to this, that you can set up an implement your telehealth practice ASAP. Thanks for listening. So today we're talking about how to implement telehealth into your physical therapy practice. As we all know, the COBIT 19 virus is causing a lot of disruption in healthcare and we're hoping that telehealth can help at least mitigate some of that interruption for the sake of our patients, for the sake of our own practices and for our businesses and for our profession. So Mark, what I would love for you to do is can you just talk a little bit more about yourself, where you're coming from and why we're doing this interview.

Mark  (03:34):

So Mark Milligan, Austin, Texas physical therapists board certified fellowship trained, but also for the last few years have stepped into a telehealth space and have anywhere healthcare, which is a digital platform for delivering healthcare. It's agnostic to provide her, so PTs, mental health providers, anybody that needs a HIPAA compliant platform to connect with patients. So the current situation is it's pretty mind blowing, right? We're seeing a, a world changing epidemic that will change the landscape of healthcare as we know it today. For several reasons. One is that people will be now exposed to a delivery of care method that they weren't otherwise are supposed to before. So telehealth and tele PT and tele medicine had been out there for a long time. Teladoc started in, in 1987, somewhere in there. So it's been around for a long time, but a rapid adoption of telehealth has really occurring right now for physical therapists.

Mark  (04:30):

What we need to know and what are the most important things right now are how it applies to us in this landscape. How can we be the best providers to meet our patients? Demand to help quell fear, doubt and an anxiety for our patients as well as, as providers and our businesses. And so stepping into this space is, it's been a little bit overwhelming. It's been a nonstop 70, 96 hours really. And so everything that I say today may or may not be true and four hours or smart [inaudible] because of how fast things are changing. So yeah, I think that tees it up. You want to kick it off? Yeah,

Karen  (05:10):

No, I think that's, that's great. That's perfect. So let's start out with, we got a number of questions from people from different therapists from around the country. And I think let's start with the number one question is how do you actually set it up? Totally basic one Oh one. So let's start with that,

Mark  (05:33):

Right? So the first thing you have to make sure is that you have patients that want this. And right now everybody wants that, right? So patient adoption of technology can be challenging, especially especially generational. So the issue with in, yeah. Pre COBIT has been adoption by, by therapists and by patients just because of ease of use. Now it's a, it's a forced adoption. So now we're in a set up where we, where are going to want this regardless of whether or not they want it. So first thing is patient population. Second thing is you need to look at your business, right? You need to look at your patient workflow and your business flow. So you need to have the appropriate from a business standpoint, you need to have a liability to make sure that you're covered in the telehealth space. So in my experience over the past few years, almost every liability insurance cover, it doesn't see telehealth as a, is a different delivery mode for physical therapy.

Mark  (06:26):

But with everything changing rapidly, it would be real. It would be highly advised that you contact your liability insurance provider and make sure that tele-health is approved as, as in your cupboard. All right? So that's logistics. Secondly, you need paperwork, you need onboarding paperwork for digital visits. You'll need a telehealth consent form and you'll need the digital release form. And if you're recording visits, you need to have a very specific form that that allows you to record patient visits. Some States don't allow recording some. And so you have to be very mindful of that. So onboarding paperwork, it's, it's good to have in fillable PDFs so that a patient can fill it out and then send it back to you digitally. Making sure that that transmission is is secure. You can also have E faxes, right? So they can electronically fax to you over a secure portal as well. So just basic things that we haven't really thought about as providers we need to adopt as mobile providers. Right. So, Oh, go ahead.

Karen  (07:24):

I know, I was going to say, so when we're talking about who is the best, what is the easiest way for us as a clinician to get that paperwork

Mark  (07:32):

Right? So they can email me. I've gotten a tele-health consent. I've got I've got that. So they can just email me at market anywhere. Dot. Healthcare. And I can send 'em I'm been sending that out over Facebook. I'm happy to share that with people. And of course you need to make sure and adapt it for your state in your practice. It's a word doc so you can switch out the logos and everything, but I'm happy to provide that for people. They can pass that that step.

Karen  (07:57):

And then one more question on paperwork and things like that. So when we are calling our insurance, our liability insurance carriers, aren't there specific questions we need to ask them or like what is the best way to have that conversation with our liability insurance providers?

Mark (08:16):

Right. Just say in this facing time that we're starting to provide care digitally. Am I covered for providing telehealth as a physical therapist? Simple. Straightforward.

Karen (08:25):

Okay. And so you may already be covered in your current policy, it might be part of your current policy, you just don't know it and then you're not, is that then added as a rider to your yes.

Mark (08:38):

Typically it's a very inexpensive writer. Okay.

 Karen (08:41):

All right. So before we set everything up, we get our liability coverage covered and we get consent forms, which can email to you or you can share them on under this post. It's whatever you feel more, most comfortable with or what might be easiest. And then we do what we got the paperwork covered. Now what?

Mark (09:06):

So you're sending that out to the patient. So they need to agree to be treated digitally. Right now it's really an interesting space. The CMS has waived temporarily a HIPAA privacy with when it comes to digital communication. I'm can't stress this enough that this is a temporary wave in, in the absence of mass abilities to communicate or HIPAA compliant platforms that patient that people are able to communicate via other means of non HIPPA compliant video software. So right now Skype and FaceTime are considered and what's the other one? Zoom and zoom and those well-known platforms are, are open, enable all those zooms just increased their prices yesterday. Yeah, so I would argue that you could use the, what's free and what's available right now in preparation as you prepare after this is over, you'll need to go back to HIPAA compliance. So in the immediacy video platforms are readily available across all. You cannot use public facing video platforms like tick talk or other things that mass put out your video. Okay.

Karen (10:22):

Instagram live or Facebook live. You can have your patient video, you can have your patient treatment sessions over live video,

Mark (10:30):

Right. That it means sounds, it sounds obvious, but you never know where people will do right by a group session. You can just do a giant group session. I'm going to train everybody on the East coast of America on a Facebook live.

Karen (10:42):

Yeah. Okay. All right, so good to know. So no one social media lives like we're doing right now, but for the time being during this outbreak, we can use face time, we can use zoom, we can use Facebook, zoom, Skype,

Mark (10:59):

Right. Totally. And you need to make sure that in your notes and documentation for your intake software or your intake paperwork, that you are waiting, that the patient is waiving their HIPAA rights during this time due to the COBIT outbreak and you are using this unsecured software and you will return to it as soon as possible. Right. Okay. This is a window. This isn't something that will last. And you need to note for your own CYA that you are, you acknowledged the existing coven scenario and that you will prepare for post that with, with my platform. Yeah. Yep. So technology on the technology side, it's really easy because you can plug and play as long as you get someone's if they have an iPhone or if they have Skype, easy set up, you can connect technology there. So once you get the form signed, you have the informed consent, the HIPAA, the HIPAA included waiver as well to sure that they understand that they are on an, they have to understand and agree to an unsecured network.

Mark (11:58):

Even though you can provide it, some people may not want it because FaceTime, that's all easily hackable. Right? So so they may not, or may, they may, they may not want to agree to that. So just have to be transparent with them in the, in your services. Right. So once you get that, I mean, it's really a matter of getting the patients, depending on your system, everybody's so different. So if you're, if you are a concierge PT and you're practicing out there for a fee for service cash base, you handle all your own scheduling when it comes for their time, you just flip them and you just call them on FaceTime, right? You collect their face, their number and you connect that way and you do your treatment, which we'll talk about in a bit, some other scheduling systems. You may have to, you know, type in a telehealth visit and your scheduling system or have some type of a demarkation for a telehealth visit versus an in person visit.

Mark (12:47):

And so work with your scheduling software, work with who you work with in order to make sure that that's appropriate so you can have the right amount of, or the right type of scheduling so you know where to go and what to do and how to bounce it. A billing, again, for the concierge practices out there, this is fee for service. Tele-Health doesn't take as long as normal to as normal PT. So I have my hourly rate broken down into 15 minute increments because it's roughly about 15 to 30 minutes. Is it an average tele-health followup evaluations in the last 40 to 50 minutes? But it just completely depends. So fee for service, it's really straight forward. You just charge per time, per minute, dollar, dollar, dollar, $52 a minute to 15 minute depending on your price point.

Karen (13:29):

Okay. All right. So now let's get into, so knowing how to actually set it up. So we've got a lot of these different things. What are some other platforms? I know anywhere. Dot. Health care. Doxy.Me.

Mark  (13:46):

Yup. Doxy.Me co view. So anywhere. Dot. Healthcare is the platform that I created. It's straight forward. Right now I'm offering you a $10 a month, unlimited use for anybody for three months while onboarding everybody. So to, to help people get to see patients doxy dot. Me actually has a free version where that's a, a room where people meet. So you can actually sign up. The patient is sent a link, they click on a link and it drops them right in a meeting room. Super convenient, super easy. There's no bells and whistles and it's free right now. So you can do that. I think a couple of other platforms I've seen throughout the Facebook live of Facebook groups that I'm in a few platforms are pushing out a free entry level software right now. So it's everywhere. So I think

Karen  (14:31):

We'll use G suite

Mark  (14:32):

D suite, right? So G suite, if you have a BA with, with Google, you can use Google meet. Right now actually with the, with the HIPAA waiver that's happening right now, you can actually use Google hangout. That would be another appropriate thing to use as long as the other person has the G suite or Google doc, a Google suite downloaded on their computer. So there are lots of, there's literally lots of options now there, there are other companies that offer other features, right? As you get into anywhere that healthcare, not only as a platform, but also as a billing feature and a scheduling feature. Doxy dot. Me if you upgrade to the higher levels, has a scheduling feature, a messaging feature, all types of stuff. So it really looking for different platforms. You need to be, do your due diligence and test them out to see what fits your practice best. I mean, some, some have exercises that are completely a part of the package that you can just have an HTP that sends right out from the program. Some have an actual, a range of motion measuring system so people can move their arm or their body in front of them. The then they can actually measure range of motion live on camera, which is pretty cool. So it just really depends on the need for your, your practice and also the practice size.

Karen  (15:44):

Got it. Yeah. Okay. So that's a lot of options for people going from free to low priced too.

Mark  (15:52):

$200 a month for co for HIPAA compliance zoom.

Karen  (15:55):

Right, right. Yeah. Yeah. Okay. So lots of options there for people. So we know we need some onboarding paperwork and we need to call our liability insurance carriers to see if they cover telehealth. Presently. And if they don't, then we need to ask them to put an addendum on and you can, they can do that immediately. It doesn't take like 30 days for that to happen. Right. Should be immediate. Okay. And so once we have all of the right paperwork and everything we decide what platform we're going to use and you just gave a whole bunch of different platforms that people can use. So all of those platforms are pretty easy to set up. And like you said, you send a link to the patient, they'd drop in and boom, there you go. And at this time we can use Facebook and Skype and, and not Facebook, sorry, Facebook. We can use Skype, regular zoom face time, all that. Okay. All right. Now

Mark  (16:58):

You may need other equipment though. You may, depending on the situation you may need. So some people, a desktop versus a computer are versus a tablet versus a phone all matter, right? So a desktop computer tends to be really well for you to have good communication and see the patient really well. But it's also very challenging for me to move my desktop to show somebody how to get on the floor and exercise, right? So the part of being a a digital physical therapist is that you have to be able to move and your equipment has to move with you. So some people use, I, you know, some people use a selfie stick to demonstrate exercises, right? Some people have one of those little iPhone holders that can be multiple or wrap around something so they can have different angles or show people at different places.

Mark  (17:41):

So understand that desktop can be good for this face to face interaction and the, and the immediate subjective interview. But maybe moving towards the objective exam or, or showing the exercise parts you may want to find or have a different device that's more mobile. So just thoughts for that. And you also need to think about your area or your headphones, your microphone and your lighting that can all add or take away from the experience of the digital experience. So making sure that you have those things. I use, I'm old school. I just use the old wired ear buds. They, when you're on the computer a long time, the wireless can die, right? And then all of a sudden you don't have new headphones. So I'm always a fan of just good old fashioned things that won't die on you after a long day of work.

Mark  (18:26):

So something to think about. You also may want to get a tripod to hold up your computer or you can get a standing desk. So there's lots of options in that space. But also you have to be considered for your backdrop. I love your backdrop that you have there in New York here and with the, with the cherry tree, that's all. It's very Boston's. That's awesome. I just have a plain white wall. Just be mindful of the environment that you're delivering this care in, right? You don't want you to be distracted. You don't want the patient to be distracted. You need to connect with the patient. Some of the key things that you need to think about are the connection that you're going to have with a patient. Something you can do easier face to face. It's challenging to get the connection and to have the emotional connection with the patient by a digital care. So setting up the environment for not only you to feel safe and, and that you feel comfortable that you're, no one's going to bust in, but also your patient needs to feel safe in that space too, so they can communicate to you in a free way that their patient information isn't being broadcasted to other people as well. So backdrops, microphones, computers, tablets, all have to be taken into consideration while you're doing this, while you're doing this intervention.

Karen  (19:32):

Okay, thank you. Those are great tips. How about cats that could, that could help or hurt you. Right? People love a cat. Great. If not, it can be a problem

Mark  (19:44):

Or at least they're not allergic to it. They're alerted to it. It doesn't matter. Right? So

Karen  (19:47):

Right. So pets can help or hinder, just kind of depends. Okay. So we've got, let's say now everyone has a better idea of how to set it up. And then the next question I got was how, Oh, they said this is great. Sound isn't great. I don't know why this sounds not great on, on Instagram, but, well, I mean it's going to be out on it as a podcast as well. So we'll, you'll be able to hear full sound tomorrow. At any rate, I dunno what to do. I could get my earbuds, but as we just said, what if they time out on me? Yeah. Okay. So let's talk about let's talk about how do you, what was it? How did, Oh, how do you actually execute a session?

Mark  (20:40):

Yeah. So once you've got somebody on the line, once you've got a patient in front of you, right? We know from our PT and our PT exam that about 80 to 90% of your differential diagnosis occurs in the subjective. So you go back to your old way of being, you shut up and you listen to the patient. Right? So, you know, so this is also assuming that you're doing an evaluation via telehealth, right? So most people at this space have patients that they'll flip from brick and mortar or in person into telehealth. So that's a different beast, right? So that's followup. That's exercise progression. Those are obvious things, right? That you're going to show them. You're going to talk them through their progression and talk to them about what they need to do next. Maybe show them a few new exercises when you're, we're, we're going to get, what we're talking about right now is the new patient that you'd never met before and what, how do you gain information to get them treated?

Mark  (21:33):

So subjective is key, right? You need to have your differential diagnosis hat on. You need to ask the next best questions, their intake form. You should have looked over, created your hypothesis list and make sure that you have a good idea of what you're trying to discover. It's your responsibility as a provider. I know it's written in the Texas legislation that if you, if the patient is not appropriate for digital care, you have to get them to an in-person provider, right? So doing your, you still have to do your red flag screens, you still have to do your due diligence and your differential diagnosis and make sure the patient's appropriate. Right? This is, you have to consider a digital visit to be no different than an in person visit. You have to take every precaution that you would take. I'm minus taking vitals unless the patient has their own, you know, portable, vital kit. You're gonna have them do that. But you have to take every precaution you would from an initial evaluation perspective as you would in a digital space. So going back to forms, you also have to have your intake form and consent to treat in there as well. That needs to be signed off as well.

Karen  (22:31):

So the, the same sort of forms that someone would have if they were coming to you or if you're like a mobile practice like me, you have them sign that initial paperwork regardless of whether you're seeing them in their home, in your clinic or, or via telehealth completely.

Mark  (22:48):

This is, you cannot be this any differently. Right? So take it, having all the consent to treat forms, signed all your intake paperwork done, differential diagnosis, red flags, you know, your three tiers. Are they appropriate for physical therapy or are they a treat and refer or they refer. You have to have that, you have to have that hat on. And so if they're presenting with sub with symptoms that aren't musculoskeletal and presentation, you need to be mindful of that and get them to the approved provider, right? So you have to be a triage at this point. So once you get through and determine their appropriate for intervention, you have to get your thinking hat on, right? This is where, this is where things change. And as a mobile PTM, I know that you have walked into somebody's house and been like, huh, how are we going to do PT in here today?

Mark  (23:32):

Or you have to completely be a problem solver. Think about being a problem solver on steroids when it comes to digital health. Right? Because you didn't have, at least in someone's physical environment, you can see what they have available. Right? If you treating me right now, all you would know is I'd have a white wall behind me. You don't know what chairs I have. You don't know what equipment I have. You don't know anything that I have. So asking them about what equipment's available is important. I take all my patients, depending on what they have, if they have, my most common thing I treat is, is back pain. So most commonly about 20 to 40% of patients, that's 20 to 30% of patients will fit into some type of directional preference when it comes to low back pain. So I take them through an active range of motion our digital active range of motion to see what exacerbates or relieves their symptoms. And if, and if repeated extensions and standing it relieves their symptoms, I go why? Clear out other things, but I go right into treatment. Right. So you can use progressive movements, repeated motions right in your treatment from the get go the same way you would do in the clinic.

Mark  (24:35):

Some of them prior,

Karen  (24:36):

It's New York. I don't even literally grown even here at anymore. It's just did with something there. Is there the engine going up, I don't even hear it. Anyway.

Mark  (24:46):

White noise. White noise. Yeah. So you have to go through your objective range of motion in your objective measurements just like you would in home or in the clinic at home. So knowing your physical exam and having a musculoskeletal screen is super important. So if I have somebody with radiating arm pain that I'm treating, where's my arm on my camera? If I have somebody with radiating right arm pain, I'm going to take them through cervical active range of motion. I've actually even had people do over pressure to themselves. Right. To see, I've had somebody to do their own spurlings to see if it's ridic. So you have to get really creative teaching someone how to do a UNL TT a on camera is because you have to back up. Right? That's another thing. You have to have visibility and you have to have the ability to see what the patient's doing and also correct them while they're doing their motion. So I take my patients, do as many physical exams that they can do on their own without, without me being present to do it.

Karen  (25:45):

Yeah. So I think it's important to note cause my good friend Amy Samala said, can you do this for brand new patients in your practice or is this just to be used for existing patients? So I think Amy, I think we're covering that right now, that yes, Mark is sort of taking us through how he might do an initial evaluation with someone via telehealth.

Mark  (26:05):

Totally. Totally. Now I think we should probably circle back to billing again and payment. I think we, we've,

Karen  (26:12):

Yeah, yeah, yeah, yeah. Let's definitely talk about that. And one other thing that I, I want to make people aware of, Mark, is how using you want to have space. So not only you want to make sure that not only your patient has space or depth, but that you do as well as a therapist because you may need to step back to show them something and then come closer.

Mark  (26:33):

Right. And I've I often, so I have a flat couch in the back, so I have this couch that's right behind me so I actually use that. I pushed my chair of the way and I show repeated extensions and prone. It's a six or seven foot long couch and I show double needs to test and I sh if I mirror exercises for patients. So you cannot do everything verbally, you can't. Could you imagine telling somebody, okay, I'm going to walk you through a double a single knee to chest with words only. It becomes extremely challenging. So you get up and you move. I just hop on the couch. I'm like, all right, so you're going to lay on your back. You'll grab both knees. You see my hands on the outside of my knees. Knees are slightly apart. We're going to pull that all the way up until you feel a big stretch in your back and I show them.

Mark  (27:13):

I walked through the exercises with them. Same thing with, same thing with nerve glides, right? If I'm doing a U L T T a I'm going to say, I'll bring your a shoulder all the way up. Like you're going to put those little, or you CC that you're going to put the little ion right and then you're gonna lift your elbow up and see if that changes it. Right. And so you have to walk them through. It's easier for them to mirror you than it is to say, okay, you need maximum shoulder flection with external rotation. NOLA deviate. Like you can't do that.

Karen  (27:39):

Yeah, we know jargon doesn't work. Yes. You can never say that in an NPR. If you are face to face them, you would never just sit there with your arms folded and be like, okay, flex your arm to hear externally. Like if you just want to do that, you wouldn't do it. I think it's important to know that we can still certainly in well versed in strong verbal communication in this space. Oh, that's nice. From work. Yes. Or there was a delay. Oh, okay. So I think we're good. So Amy said, yes, sorry, there's a delay. She's all the way in New Jersey, so forgive the Jersey part. Yeah, New Jersey. Okay. all right. So I think people get an idea that yes, this is how you can set this up. You just want to make sure that each of you have enough physical space to do everything that you want to do. That yes, you can do your initial evaluation. It's all about the subjective, in my opinion, in that initial evaluation anyway. Definitely. and then once you see them for the initial evaluation, as you start progressing them, like you said, it would be like any other exercise progression you're just not putting hands on, but it can be done.

Mark  (28:51):

Definitely. Definitely. If you think about the interventions that we do in the clinic that you can apply to home. So I work with people that you know, that don't, they may not have good balance. So safety is a, is a concern in that space. Right? So I talk people in a corner, I show them what it looks like to get into a corner with a chair in front of me or in front of my couch or the chair in front of me and teach them how to do single leg stance while having my fingertips on the chair. Right eye. You have to physically show people what to do so they understand that better. And so like you said, it's about being able to show and speak at the same time, right? Because a lot of the field like nerve tension testing, a lot of times it's, you can feel the tension before the symptoms ever get there.

Mark (29:34):

So you have to educate somebody that has a really angry nerve that's a, it's a hot nerve and say, look, we're just going to take this up until you barely feel it. Right. We're just going to touch it. And then if you feel it there, just bring it back down. Right. You, you can't rely on your hands to feel that tension anymore. Not that we can reliably feel it anyway, but we want to make sure that we prime the patient for success. Right? Communicate expectations. Like we're going to do some discovery today. We're going to walk through a lot of different movements to see what's happening with your body. See if we can figure out ways that we can help you feel better through movement. Cause that's what ideally what we're going to do, right? We need to make sure that we enable patients and make them feel safe and comfortable that we're going to help them. We're going to take them through this. We just need to, we need to communicate to that. This is going to be something that I should be completely comfortable with. Yeah.

Karen  (30:24):

Perfect. All right. Now let's get to the part that everybody really wants to know about billing. Someone. let's see. Oh, Mark Rubenstein also New Jersey. He had kinda some of the same questions. No, I have nothing against New Jersey, New Jersey. So he kind of had the same question I had before we went live. He said but Medicare will only pay now for existing patients as per info yesterday. So this is the info, I guess on that evisit versus tele-health. So can you kind of give us, cause I know just for background, Mark is a part of a PPS task force and he is really being updated a lot. And I'll let you kind of talk a little bit more about that and, and how you are helping to work the billing aspect of things and the difference between an evisit and tele-health.

Mark  (31:20):

Right. I'd like to first shout out to the PPS members, Allie shoes and the I and alpha are our lobbyist for the APA. We are meeting for hours daily and we are, so everyday we have scheduled calls on this task who have a task force. We're pushing out content on the APA plus the PPS site. So there are 18 to 20 people that are hard at work to get, to gather information, to interpret it and then to question it and then make sure that it's legal. Right. Because there's information that comes out that it's great information, but it may not be legal for us to do based on practice act. So there's, there's a federal level, then there's the, then there's the PTA level, then there's the state level, then there's your individual insurance levels. So there's a, there's so many different paradigms. It's not just a cut and dry situation.

Mark  (32:06):

So right now, some of the biggest things that we're working on behind the scenes with this PPS task force are really are defining out what it means from Medicare as it relates to the visit ruling. So E visits technically are not telehealth. Medicare is not calling these eVisits tele-health. They're calling them eVisits because they derive them from the medical, from the MD coding as, as a bra, a brief and abrupt follow up to a situation where the patient is in an engaged patient. So imagine somebody who may not be feeling well after seeing, having a doctor's appointment just to follow up to touch. So the visit codes right now can only be billed based on time, so their cumulative time and there are three levels. The max level is 21 minutes to be billed one time over a week. And so you add all the time for one week and over 21 minutes is the third code.

Mark  (32:59):

And that can only be a build a once every, well in seven one time in seven days. There is a question right now about whether or not that code can be repeated the next seven days. That information has not been gotten yet. We have not had a clear answer on that. So please be patient while we investigate whether or not that code can be repeated the next week. So right now, currently we are still working on whether or not now that these eVisits have come out, the question is now whether or not CMS sees us as telehealth providers, which upfront does it look like they do. But we still haven't gotten for Bay. We still haven't gotten the, the appropriate word from CMS whether or not we are. We are providing tele-health, which they said we're not. So we can assume we can assume anything.

Mark  (33:49):

But so they said we're not providing tele-health, but we think they will. They won't include us in the, as a telehealth provider, which is extremely important because if they don't consider us Medicare providers, then we can, well, I'll wait about Medicare billing Medicare patients, we'll, we'll wait to hear what happens. I'll have to have an update on that. And so right now we are not approved providers for telehealth, for Medicare. And we can build he visits with an established patient that has to make contact through a patient portal to the provider to request their evisit. Now it's been clarified that you can notify a patient that they have the option of that type of care. You can tell the patient, Hey, you know, we're not treating people in person, but you do have the option for an evisit. Here's how you do it. If you choose, if you were to choose to have an E visit, you would go to this part of our website to our port, your patient portal and request a visit so you can prime patients to go utilize that service. Whether or not you can only do that for one week or multiple weeks, that's in question.

Karen  (34:52):

Okay. And a patient portal is not Skype zoom face time or any of the telehealth platforms that is not a patient yet.

Mark  (35:04):

Well, some platforms have a portal, some, so it has to be a patient portal. So it has to be a place where a patient can log in and request a visit. And so we're still also waiting for a clear definition of a patient portal. But for our understanding the patient, it's a place where the patient goes to get their information or connect or message their provider. Right. So right now that's still being clarified through CMS on the other private payer front and medicate well, so Medicaid is being rapidly adopted by payers all across the country. Right. So we've seen, I know Louisiana is about to release a wording today at some point. I know that I think Minnesota, I think that a few others have already, Medicaid has already blasted that inflammation and that are, that are, that there are approving and paying for telehealth or physical therapists, payers on a national level are all over the place.

Mark  (36:00):

So if you are a, in the work provider, you need to call your payers and ask very specific questions and we have people working on this across the country. You have to ask them if your patient has tele-health benefits, you need to ask them if those benefits are payable to a physical therapist. So if a therapist is a PT, a paid as a payable provider of telehealth services, if they need any modification codes, right? So like an Oh two location code modifier, right? That needs to be asked and then what CPT codes they reimburse for. Okay. Right. So manual therapy is not going to be one, but neuro, our neuro they're ex their acts home care, self care, all of those codes should be available. And it just depends on the, on the payer and the carrier. Okay. I have a Google doc that we can link that I'm trying to collect that data from across the country.

Mark  (36:58):

So people can have open access to it that I can send you that link here and it's on a couple of Facebook pages. But we're trying to collect that data so people can see because, and you don't put any reimbursable fees, don't breach your contracts, don't talk about a fee per schedule, but where you're scheduling fees or your fee schedule. But I'm just put whether or not they pay if it's parody, right? Some States out parody. So here's the kicker. Parody States doesn't miss it necessarily mean payment, right? And this is a, this is a very confusing, a very confusing thing. So somebody says, Oh, we have parody in the state so that, and then we are going to get paid equal in person as we do digitally. Just because you have parody doesn't mean to pay your pace for telehealth, right? They may pay for physical therapy, but they may not pay for tele rehab, right? Yes. Check.

Karen  (37:47):

Why can they just not make this easy?

Mark  (37:50):

Right? So you can have parody in a state and you could have a parody law and then the payer not even pay for telehealth. Right? So there's nuances upon nuance, on nuance. And in some States, some carriers have contracts with larger telemedicine providers and their members can only have telehealth through that tele provider and they may not have tele, they might not have tele PT. So then they had no tele-health, physical therapy option for that payer. Does that make sense?

Karen  (38:28):

Okay, so I'm going to just do this. So for example, I'm just going to take a for example, and tell me if I heard you correctly. Oh one more thing. So Rina said, we're talking about the visits, that's all specifically for Medicare patients only the egoist. Yes, yes.

Mark  (38:46):

As of now we have, we are unaware. I am unaware. I'll say that of any payer that's adopted the evisit policy and that's as of our Medicare Copa. Our coven call ended at noon today. So I don't know. That may change.

Karen  (39:02):

Okay. So let's talk about your individual. Let's talk. Oh, somebody said, Oh Mark, can you bring your microphone closer to your mouth? But you've got the ear buds in,

Mark  (39:13):

Right? So I have my phone a lot. Loose ear buds are going to the computer, but now you see if you can bring the microphone closer to your mouth, then they see my giant fivehead here and I'm like, I mean, how about if I go, that's fine. We'll do that.

Karen  (39:32):

We'll do that. It's fine. It's fine. Okay. Oh, so here, let me just ask some, get some of the questions. So Kim wants to know, she's in New Jersey also. He lives in New Jersey, but her practice is in Brooklyn. How do we find out if our state has parody?

Mark  (39:51):

So again, I, the, I will link you guys to the center for connected health policy and I also have a link to the parody in the different States. So I have links to both of those that I can give you, that we can add to this.

Karen  (40:07):

Yeah, we can put that in the comments under this Facebook under the live here.

Mark  (40:12):

So where, and so the, the commercial parody book is only 150 pages of nice, easy light reading. Where should I go for Facebook live?

Karen  (40:23):

Just go, if you go to my page, just go to me and then you can put it in. You'll see, you'll see us. You can put it in the comment section or we could put it in the comments section. When we're done with the live, we can add it in as well.

Mark  (40:35):

Oh, there we are. All right. So I'm dropping it in the, yeah,

Karen  (40:37):

You can drop it in right now too.

Mark  (40:38):

There's the parody laws. Here is the fact sheet on the UpToDate. This is a live document on what's happening in the world right now. As far as tele-health policies and procedures across the country. So those two documents should have a lot of information. But here's the kicker. Just because the state has a parody law doesn't mean that, that, that the payers have a policy that reimburses tele PT,

Karen  (41:08):

Right? So parody and, and just to be very clear parody means because you, you can do tele-health because you see them in person. So it's like

Mark  (41:20):

No. So parody only means parody only means payment. So parody means if they have a parody law and they both reimburse for inpatient physical therapy and for telehealth benefits, they paid equal.

Karen  (41:32):

Say again

Mark (41:33):

If the, if the, if a payer say let's let's say blue cross blue shield, if that, if that patient has a blue cross blue shield policy and they have a physical therapy benefits and they have tele-health benefits that a physical therapist can provide, they pay equal. Right. Okay. So it's the same face to face as the say. So because a lot of insurances will the 75% or 50% of impersonal versus digital. So it's literally a payment equality clause.

Karen (42:02):

I see. Okay. Okay. But you have to call blue cross blue shield because they may not actually, that patient's policy might not include tele-health.

Mark (42:13):

Right. And then even if they have a parity law, you're not getting paid for it.

Karen (42:17):

Got it. Right. I got it right. It's okay. Kim. I hope that my inability to understand help you. Dah, dah, dah, dah, dah. Can hear Mark fine. I'm physic. Oh, Deborah joy Sheldon. She said, is there a particular language that needs to be included in the documentation? So when we document the visit, how, so? Let's say we know how to set it up. We have the visit, how do we document it?

Mark (42:47):

Right? So you typically documented as a telehealth visit. So there's no you, your billing will coat it with an OTU location modifier, but you need to denote specifically that it was a digital visit. Okay. Yeah, that's the,

Karen  (43:02):

Because we just got a question on what's the location coding for telehealth and you just answered it. So Abby, I hope that that helps you. And [inaudible] can we skip insurance and just bill cash or has this new E health stuff messed that up?

Mark  (43:26):

So that's unsure right now. So the visit has, it's not considered telehealth by early information. That's not considered to be telehealth. We are still not telehealth providers by Medicare. So that should not impact that. That's my, that's my personal uninformed or relatively informed opinion. Please don't take that to anybody else. We're still discovering that. And private payers still do not, are not adopting that yet. That we've heard of. And so you should,

Mark  (44:01):

If you are currently billing or having people pay cash in there and they do not have coverage, then you should be able to continue doing that. Does that make sense? Okay. Right. I mean, you need to check your contract language. Where we get sticky is, is this considered a non-covered service by a policy? Right. So this is where the sticky sticky comes in. Okay. Is tele-health considered physical therapy just delivered in a different manner, not a non-covered service, right? Yeah. Yeah. Well that V that opinion varies. And so if it's a non-covered service for Medicare, you can, they can, you can charge cash for that service. Right? And so, and that also applies to other payers. Correct. So if, if your payer has a policy that considers telehealth to be reimbursable by PTs, you wouldn't be able to pay, have them pay cash. But if

Karen  (45:03):

Your individual patient's insurance does not cover telehealth right, then can you charge the patient cash?

Mark (45:12):

I'm not a healthcare attorney. But we're doing that.

Karen  (45:16):

Where the heck, I know she's on here somewhere here in Jackson. I know she's watching, I saw her log on,

Karen  (45:23):

Come on or Jackson answer that question for me

Karen  (45:25):

Or an answer that question please in the comment section if you're still watching if not, maybe we can ask her or care Gaynor through the APA might be able to answer that question. So again, that question is if Aaron's still watching is if your patient's specific policy does not cover telehealth, again we'll use blue cross blue shield. So they have blue cross blue shield, they do not cover telehealth. Can you charge cash to that patient if they don't have it covered on their policy?

Mark (46:02):

That is a good question. Yeah, that's a great question. And I think, I mean I, I think I know what my answer would be but I cannot speak as

Karen (46:12):

Brought any information to anyone or misleading information. So maybe that's something we can ask Cara Gaynor on Twitter. Maybe she can answer that or if Aaron is still listening, maybe she can pop that into the comment section at some point. So

Mark (46:28):

And having amazing people that are listening that can help. Yeah, exactly. Taking, cause this is a, this is a mad house right now when it comes to legislation and information. So it's all over the place and apparently so yeah, it's just all over the place. We can't information that was [inaudible] I did hear that. Some of the bigger things for Rhode Island and for Pennsylvania this morning, that the governor, the governor assigned legislation that would massively require all payers to pay all providers for telehealth. All right. Yeah. Yeah, yeah. Okay. One other big question that comes up is location for these for, for billing. Right. And so the word from CMS is the, the, the POS code is the location of the billing practitioner. So in the case where remote services are rendered it does not matter where the corporate address of the billing provider is either, nor does it matter what the beneficiary's address, it matters where the services was rendered. That is where the biller is located. Okay. All right. So when that happened,

Karen (47:43):

Put that into like example.

Mark  (47:45):

So when that happens, let's say yes. So if you are, New York has parody, right? Or you got to know you guys have compact revolution, right? Correct. I thought you did. So let's say you're a large provider and you have multiple States that you are in charge over that or multiple States. You treat patients and you're billing Medicare that the, the, the service in the, in the billing, in the service location code is the place where the provider is located.

Karen  (48:18):

I see. So like for example, if we use something like Athletico like a big gigantic company or maybe someone like, I think Michelle Kali has some places in Rhode Island. I think she just went to Massachusetts, but the headquarters is in Rhode Island. So if you're a therapist in their Massachusetts office, you're using Massachusetts.

Mark  (48:40):

No, you're using wherever you are and delivering the code. Deliver.

Karen (48:43):

Where do you get where you are? Okay.

Mark  (48:45):

Okay. Yup.

Karen  (48:46):

Okay. and then Michelle Townshend said, how does this work with EHR? Ours?

Mark (48:55):

Yeah. So eeh

Karen  (48:57):

So she is looking at a separate telehealth provider from our EHR who also does our billing.

Mark  (49:04):

Right. So EHR is, there's only a handful of the HRS in the physical therapy space that offer tele-health as a part of the platform. I think PT everywhere is a platform that has that has it built in. And self doc is another ER EHR that'll be live and in the next couple of weeks they'll have a platform within six weeks. But most of them are stand alone freestanding. So you just have to find the best system that are set up that can work simultaneously with your other systems. There's really no way to unless the company has an integration with your EHR, which the HRS don't like to integrate with people because that's patient data and it's a, it's a whole hot mess. So most of these are just freestanding side by side. So you'll have your EHR on one side and you're in your camera on the other. So you just do, and that's what I did with anywhere healthcare, it's just basic connection so you can document everything ever somewhere else. Okay.

Karen  (50:03):

All right. And then Debra says, Mark, my state has parody related to my hospital being F, Q, H C I do not know what that means. Any insight on that? So what does FQHC mean? Any thoughts if not, maybe

Mark  (50:25):

It's a federally qualified health center federally. Okay. So they have parody. I don't think I understand the question.

Karen  (50:33):

Yeah. In my S my state has parody related to my hospital being FQHC. Any insight on that?

Mark  (50:40):

Oh good. So she Oh, she said they have parody.

Karen  (50:43):

Yeah, they have PR has parody. Yeah.

Mark  (50:46):

I'm unsure on that. That has to parody is I've, I linked that doc into the live on Facebook. I can look up parody by state and by organization. Okay. Yeah.

Karen  (50:59):

Okay. Let's see. Let me we already touched, so I'm just kind of, what paperwork do we need? We talked about that. Oh, what if you're not a Medicare provider? Gosh, all right. Dah, dah, dah. Oh, we are usingG suite and doxy.me. This is from,uKelly Dougan, I think. Yeah. But haven't started officially yet. We have an ABN and I wanted to have liability form as well. So those liability forms, that's something that we can, that you can maybe share also on this link here and people can make it their own. Is that by liability? Like the patient has to sign off on saying yes, I'm okay with having telehealth.

Mark  (51:51):

Is that of course for me. Yeah, I would assume that what she's saying. Yeah. So I'll, I'll create a, I'll create a Google drive folder and drop a link in to the chat

Karen  (52:05):

And then one other, we've got two other questions. So to clarify for service location code, so that you said that, is that like the OTU code? Right. Okay. If I or any of my PTs are in their own home while tele-health with patient, is she using her home address?

Mark  (52:28):

Oh, that I can't answer that I haven't gotten, yeah, that would be a billing question. That hasn't been brought up, but I, we have a meeting tomorrow morning and I'll ask that question.

Karen  (52:39):

All right, Kimmy, we will get to that.

Mark  (52:43):

We're saying the PTs can just stay home and bill from there. But Medicare has specific guidelines on origination sites. And I know if origination sites apply to eVisits versus telehealth. That very question. Do origination, do originations, I'm writing it down so we can ask this to origination sites. Apply to eVisits. Yeah, cause that's, that's a game changer too.

Karen  (53:11):

Yeah, yeah. Oh, sorry. She said, sorry, I meant to say service location. Did you clarify for service location address? If I or any of my PTs are in their home while doing telehealth, do they use their home address or does she use her address? So Kim, like lives in New Jersey, her practice in Brooklyn. So that's a really good question. So, Kim, maybe we can get back to you with that answer.

Mark  (53:33):

And is she a Medicare provider?

Karen  (53:35):

Kim, are you a Medicare provider? I think so. We'll see. We're on like a 22nd delay.

Mark  (53:43):

Yeah. So I'll ask, I'll ask service location for employees versus brick and mortar versus mobile provider.

Karen  (53:52):

Perfect. And then Sarah Catman says, if you are licensed in more than one state, but only practice, may single state, can you only do telehealth in the state you practice in or can you do, hello, hello, hello. Telehealth and States you are licensed in.

Mark  (54:12):

Yeah. So that's where it comes to state rules and regs and yeah. So everywhere that you have a practice reciprocity or you have a licensed in other States, as long as they, you are allowed legally to practice tele-health in that state. Yes, you can practice telehealth in that state. I mean it's, but you have to sit, you have to make sure to abide by the rules and regs when it comes to our the licensure compact of the rules and regs of the state that the patient abides in or they live in. Right. Cause that's just compact language. So like I can do tele-health and Missouri, but they don't have direct access. So I would still have to have direct access or I'd have to have a referral for that patient if I want to open Missouri. Right. So like example. Yeah. so I think, yeah, so we have to make sure that you abide by the laws of the state that the patient resides in. But yes, you can do tele-health across the country. That's the beautiful thing about the compact, right. Compact allows for us to practice across this country with with little, with, without a lot of that a lot of restraint or not restraint, but a lot of challenge.

Karen  (55:20):

Okay, perfect. All right, so we're at about an hour, which is as long as I think people's attention spans are, and I think we have an apparently as long as Instagram will go live. So if anyone has any other questions, please you can keep adding them into this feed here and we'll try and get to them as, as best we can. Thank you Mark for dropping that stuff into dropping those links in here. And again, we'll get some of the, the onboarding paperwork from you and maybe can drop it in here as well, or you can point us to maybe where it's been put in other Facebook Facebook links. But yeah, everybody, you're welcome. You're welcome. And Mark, thank you so much. This was above and beyond. I think what you had to do but I think we all appreciate you so much because we're in a time where there's a lot of uncertainty and tele-health is at least a way to one, keep our patients healthy and moving and to kind of keep our practices going as best we can in these times because we don't know.

Mark (56:38):

Yeah. We don't know.

Karen  (56:41):

Okay.

Mark  (56:43):

Yeah, I think, I think, I think as a profession we need to remain calm and PT on, right? Like there's a lot of things happening right now. There's to be the, the future is unknown for us as a healthcare profession. All I do know is that it's going to be changed on the other end. This will no longer be an exception to the rule. This will be an expected method of care. People will, will now grow to understand that digital health is a real opportunity in every aspect, not just in, in telemedicine. So I think if I can say one final thing is just be prepared to adopt this and, and, and set up your systems for the long game. Not for this short, immediate, even though the immediate needs to happen. We have things in place like the waiver for using different platforms just to make it happen while it is, but set your practice up, set your systems up for a long game to provide digital care to your patients. Because that's where we're going to go. Part of it is so yeah, but be patient with each other, love each other be kind and wash your hands,

Karen  (57:49):

Wash your hands and don't touch your face. Yeah. And be mindful of the people if you are still, if your offices are still open, be mindful of the people coming into your office. If you are a home health therapist, be mindful of the people that you're that you're going to be treating because they may be in that vulnerable population. And because we, there's so much that we don't know, just be very mindful of how you're doing that and utilizing telehealth is a great way to have that extension of care for our patients, so.

Mark  (58:27):

Right. And feel free to reach out to me market anywhere. Dot. Health care. I'm here as a resource. I'm trying to be as available as I can. I have to go to the bathroom occasionally or drink some water, eat some food, but I'm trying to be as available as I can in order to help help us transition and get through this, navigate this time.

Karen  (58:45):

All right, well Mark, thank you so much. Got it. You've got everything there. Check out. Also, check out Mark's platform anywhere. Dot healthcare. I'll be happy to give a plug for that of course. And thank you so much. I really appreciate it. This is everyone else on this, on this call, so thank you.

Mark  (59:01):

Beautiful. Thank you.

Karen  (59:04):

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