As part of its efforts to provide patient-centered care and reduce costs for Medicare beneficiaries, the Centers for Medicare and Medicaid (CMS) have developed an Innovation Center model for ambulance care teams: Emergency Triage, Treat, and Transport (ET3). As part of this model, the agency has proposed two potential telehealth offerings: 1) An individual who calls 911 may be connected to a dispatch system that has incorporated a medical triage line to be screened for eligibility for medical triage services prior to ambulance initiation, and 2) telehealth assistance via audiovisual communications technologies with a qualified provider once the ambulance arrives.

Key participants in the ET3 model will be Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers. In addition, to advance regional alignment, local governments, their designees or other entities that operate or have authority over one or more 911 dispatches in geographic areas where ambulance suppliers and providers have been selected to participate in the ET3 model will have an opportunity to access cooperative agreement funding. As such, both state regulations and CMS regulations will apply to the use of telehealth offerings under ET3. This post explores early-stage questions of ET3 implementation and reimbursement, the intersection of state laws governing telehealth, and what potential participants and telehealth companies should know about the program.

How will CMS support the ET3 model implementation?

The key telehealth development for the ET3 program is that CMS expects to waive the telehealth geographic and originating site rules as necessary to implement the model, including waivers that will allow participants to facilitate telehealth at the scene of a 911 response. Additional information on these waivers is expected to accompany the ET3 Request for Applications (RFA), slated for release this summer. Overall, Medicare coverage requirements provide that the patient must be in an approved originating site at the time of the telehealth visit (e.g., hospital) and must be located within a rural area. CMS has waived these two requirements for other programs, such as the SUPPORT for Patients and Communities Act (the SUPPORT Act) in October 2018, which eliminated the originating site restriction for substance use disorder treatment, because doing so is necessary for these programs to succeed.

How are these telehealth offerings covered by Medicare?

The first telehealth offering, a screening through a medical triage line before initiation of an ambulance, will not be a Medicare covered professional service because it’s done by phone, rather than a synchronous audiovisual (video chat) visit. It is important for ET3 participants to remember that there are potential state laws and regulations that govern the delivery of healthcare services via the phone when designing the phone triage offering. For example, the practitioners delivering assistance via telephone may need to hold a professional license in the state in which the patient is located at the time of the call.

Participants that facilitate treatment after the ambulance arrives using audiovisual communications technologies may be paid a modified telehealth “originating site” facility fee equivalent to the BLS-E or ALS1-E base rate, depending on the level of service provided. In addition, a qualified health care practitioner who partners with an ET3 model participant and furnishes a Medicare-covered service to a beneficiary through telehealth may bill Medicare for the professional service using the applicable HCPCS code for the service furnished pursuant to existing Medicare FFS rules. As a reminder, telehealth services are paid at 100 percent of the fee schedule amount. Note that, with a few exceptions, paramedics and Emergency Medical Technicians (EMTs) are not considered qualified health care practitioners under ET3.

What do providers need to know about participating in the ET3 program?

Timing

CMS is aiming to release a RFA for Medicare-enrolled ambulance suppliers and providers in Summer 2019. Once participants have been selected and announced, CMS aims to issue a Notice of Funding Opportunity (NOFO) in Fall 2019 for up to 40 two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate. The anticipated start date for the ET3 program is January 2020.

State Laws

Participants should design the telehealth offerings with an eye to compliance with both Medicare requirements, and state and federal laws and regulations. There is a complex legal, administrative and regulatory framework that underpins the use of telehealth and other advanced technologies to deliver healthcare services, and this framework is changing faster than most areas of digital health. States play a particularly active and important role, with policies and regulations that affect Medicaid coverage, payment and coverage “parity” mandates, professional licensure, professional standards, scope of practice, prescribing regulations, malpractice, and in some states, additional regulations addressing credentialing and privileging, health information exchange and broadband communications infrastructure.

What should ET3 participants look for in a telehealth company partner?

The right telehealth offerings will be instrumental in providing effective and efficient care for patients treated under the ET3 model, and participants will be responsible for building their own partnerships with qualified health care practitioners who agree to render services via telehealth. In order to identify qualified telehealth company partners, we have provided the following checklist of considerations:

  • Licensure: Does the company hold all necessary licenses and registrations to conduct its business – both in the states in which it has physical locations and where its customers and the patients are located? Is the company structured in a manner that addresses state corporate practice of medicine prohibitions, if applicable?
  • Professional Standards: Has the company confirmed that its care delivery model, policies and procedures and technology platform support the delivery of telemedicine services in a manner that meets all applicable state professional practice standards, including those that govern remote prescribing?
  • Electronic Prescribing: If patients may receive prescription medications as part of the telemedicine service, has the company established a process for transmitting the prescription to a pharmacy of the patient’s choosing?
  • Payer Requirements: Has the company confirmed that its care delivery model, policies and procedures and technology platform enable the telemedicine providers to deliver and document the performance of telemedicine services in a manner that meets all applicable payer requirements governing coverage and reimbursement?
  • Consent: Does the company secure the consent of patients in a manner that is consistent with any applicable state law and payer requirements? Note: There are rules that potentially govern the content of the consent form and/or the manner in which consent is obtained.
  • Telemedicine Platform and Other Technologies: Has the company secured all authorizations and consents that are necessary to provide the telemedicine providers with log-in credentials and access to the telemedicine platform, including any electronic prescribing solutions?
  • Insurance: Does the company have adequate insurance coverage for the delivery of its services?

The ET3 model presents exciting opportunities for improved patient care, the broader use of telemedicine in the US medical system and technology and telehealth companies themselves. However, compliance-driven policies are crucial for the success of any health care innovation. Visit McDermott’s Digital Health page for more information on telehealth, health care IT and regulatory compliance.