Stuart L. Lustig, MD, MPH

[[{"type":"media","view_mode":"media_crop","fid":"40457","attributes":{"alt":"Â© Rawpixel/shutterstock.com, telepsychiatry","class":"media-image media-image-right","id":"media_crop_498498346119","media_crop_h":"176","media_crop_image_style":"-1","media_crop_instance":"4149","media_crop_rotate":"0","media_crop_scale_h":"121","media_crop_scale_w":"150","media_crop_w":"218","media_crop_x":"70","media_crop_y":"10","style":"float: right;","title":"Â© Rawpixel/shutterstock.com","typeof":"foaf:Image"}}]]Telehealth is at a tipping point and is gaining momentum. As medical directors with a health services company, we wish to help psychiatrists and other mental health clinicians make informed choices about how to add telehealth to their clinical work in a way that is safe and effective for patients, legally sound for providers, and sufficiently remunerative to their practices.

It is important to understand why telehealth for psychiatry is on the rise. Because of increased access to technology (eg, smart-phones, computers, applications [apps]), doctors, more than ever before, are just a quick click or tap away from patients who live in remote areas and who have limited options for care. Furthermore, there is an increased demand for clinical service that is attributable in part to the Patient Protection and Affordable Care Act, which added 11 million people to the ranks of the insured.

Telehealth technology has improved tremendously. For example, the Veterans Administration, a pioneer in telehealth, invested significantly in technology and human resources for telemedicine. Although initially the service was not cost- effective, now multiple apps allow for immediate connectivity at low or no cost to the patient, with increased accessibility and viability. This means that telehealth is an idea whose time has come, and whose strongest proponents have come of age. Having grown up with it, young adults are comfortable with all types of digital technology and demand expanded access and convenience, sometimes to the apparent detriment of real-time, face-to-face encounters.

Telehealth is not a medical specialty in itself, but simply a newer modality to deliver health care. It is expected to increase access and decrease the cost of delivering care. Initially, practitioners felt that phone and video were impersonal means of communication that “altered” the quality of the physician-patient encounter. Eventually, many realized that psychiatry is one of the specialties best suited to video.

 Interactions with patients are mostly oral and visual: telehealth sessions provide information similar to that of an in-person examination and can thereby conform to the standards of care for psychiatry.

Physical examinations are frequently not necessary for routine outpatient care. In general, telehealth is feasible for patients who require routine outpatient visits (although it has been used in other settings, including prisons and emergency departments, with appropriate ancillary support).

Psychiatrists may be able to provide virtual visits to primary care clinics, hospitals, or other health care providers on a consultative basis. Patients for whom tactile or olfactory input is necessary to the examination (eg, detecting odors or testing for cogwheel rigidity) or patients who are at severe risk for harm are generally not good candidates for telehealth services.

For telehealth, psychiatrists must be licensed in the state where the patient is at the time of contact. However, this area is in rapid flux. Psychiatrists are encouraged to contact the AMA and Federation of State Medical Boards for updates. State laws that regulate the practice of telemedicine may include limitations on the use of specific technologies and prescribing practices. State medical boards may place additional regulations.

Psychiatrists who are interested in providing telehealth services from their current offices (or homes) have 2 options. The first is to work with one of several companies that provide telemedicine services. Many can be found online by searching for “telepsychiatry networks.” These companies offer several advantages: they provide the technology platform, technical support, scheduling support and, perhaps most importantly, the patients, enabling psychiatrists to supplement their incomes and diversify their patient populations from existing home or office practice locations. Psychiatrists may therefore choose to augment their face-to-face practices with telehealth. For example, a child psychiatrist who sees children and adolescents in the afternoon may choose to collaborate with a telehealth company in the morning to see adults.

For those psychiatrists who wish to cut out the proverbial middle man, it is now easier than ever to establish one’s own telehealth practice. A phone is a prerequisite, as is a computer, ideally one with a built-in web camera (webcam), which most have nowadays. The patient also needs a computer or phone with a webcam. Webcams allow computer owners to see themselves. You can therefore check to see how you look to your patients, mannerisms they might notice, etc.

Ideally, the video experience should be as similar as possible to a live session, so be mindful of visual or auditory distractions. Be careful, for example, not to lean too far into the camera so as to create a larger-than-life image of your head on your patient’s screen. Beware the sound of your typing if you are taking notes during your session or be aware if you are looking down at your keyboard or note pad and away from the patient. Reliable Internet access is essential as well. Currently, most Internet providers offer appropriate bandwidth for a good-quality connection.

The other consideration is software, a choice influenced by privacy requirements delineated by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA requires that secure, encrypted technology be considered. Practitioners need to do a risk assessment of the technology that they plan to use. They must also have a policy and procedure in place for using telecommunications for treating patients. In the absence of taking the recommended steps to secure protected health information (PHI), the provider needs to make the patient aware of the decision not to use secure technology, and explain the risk of exposing PHI. HIPAA’s rules apply to the provider and any vendors with whom he or she associates in delivering care. When in doubt, consult with your HIPAA compliance expert or legal counsel.

While most social media apps, such as Skype and FaceTime, are popular, they are not HIPAA-compliant. (Note that Skype now has a new service, “Skype for Business,” which provides a Business Associate Agreement and for which Skype claims HIPAA compliance.) These apps do not offer end-to-end 256- bit advanced encryption standard (AES encryption) and were not designed for doctor-patient interactions. The lack of strong encryption means that there are insufficient safeguards against communications hosted on its platform from being monitored by others. Accordingly, many third-party payers will not reimburse clinicians for Skype or FaceTime sessions.

Fortunately, clinicians have other options. In contrast to these commonly used applications, there are others available to psychiatrists and patients that offer the level of security recommended to meet HIPAA standards (eg, VSee, Vidyo, Polycom). For example, VSee, may offer a free download option for both the patient and the psychiatrist. Other options, such as Polycom (

), require an ongoing relationship with the company.

To find video conferencing companies that claim HIPAA compliance, search for “HIPAA-compliant video conferencing.” Be aware, however, that these companies provide a telecommunications platform for large organizations and require an additional investment in equipment and IT support.

These software options can help psychiatrists round out what may typically be a face-to-face practice. For example, they give physicians the flexibility to see patients face-to-face some of the time, while at other times, they enable physicians to see patients virtually-for instance, when they are ill or traveling.

Third-party payers have become increasingly sympathetic to the added value of telehealth, particularly as technology has improved. More than half of US states now have laws that require some type of payer to reimburse for telehealth services. To see a regularly updated list, visit the American Telemedicine Association 

 Some states mandate a face-to-face session before a physician can follow up virtually, and some states require third-party payers to reimburse the same as they do for face-to-face sessions. Check with your state medical boards about mandates, since coverage varies considerably from state to state.

Telephone sessions are not a covered benefit with many insurance companies, but many benefit plans no longer require that patients be in remote locations in order for telehealth services to be covered. Therefore, patients and physicians who prefer the convenience or comfort of telehealth may opt for this type of care.

The good news is that it is easy to get paid for telehealth psychiatric services. Using the CPT codes you would use for outpatient visits, either for evaluation and management (E&M) services for psychotherapy or some combination, simply add the GT modifier.

 Psychiatrists will be reimbursed at the prevailing rates for the corresponding code. For example, a psychiatrist whose E&M code is 99213, and whose psychotherapy code is 90833, bills for 99213 GT and 90833 GT. (For more details on how to use the current CPT codes, please review “

Seeing the Forest Through the Fees: Earn-ing your Green Using the New, Confusing CPT Codes

There are multiple resources available for psychiatrists interested in telehealth. The American Telemedicine Association is a good place to start. Its Web site includes state-specific information about regulations and coverage, and it offers online resources that range from practice guidelines to consent forms.

 The annual meeting offers the opportunity to mingle with psychiatrists and other specialists.

Psychiatrists thinking of providing telehealth services should do their own legal due diligence. The Center for Telehealth and e-Health Law

 is a good resource for policy and legal aspects of establishing a telehealth practice. For a modest fee to members, this organization provides research and consultation on legal and regulatory matters pertaining to telehealth.

Malpractice providers can also supply useful information about risk management. For example, the Professional Risk Management Services offers members an introductory overview of some of the liability issues in establishing a telehealth practice.

Finally, third-party payers are more than happy to help physicians understand any licensing or billing requirements. Simply call their Provider Relations department.

Telehealth is an exciting way to expand the scope of one’s practice, even while limiting one’s commute if practicing out of a home office. Although there are some technological and logistical hurdles, most practitioners would likely find these to be minor and outweighed by the benefits of expanding access to mental health care to those in need.

The authors gratefully acknowledge the editorial comments of Dr Douglas Nemecek, Mr Jeffrey Linstone, and Ms Princess Little.

Drs Lopez and Lustig are Medical Directors at Cigna. (The Cigna name is a registered service mark of Cigna Intellectual Property, Inc, and is used to refer to operating subsidiaries of Cigna Corporation, including Cigna Behavioral Health, Inc, and Cigna Health and Life Insurance Company.) The authors report no conflicts of interest concerning the subject matter of this article.

 Miller EA. Telepsychiatry and doctor-patient communication: an analysis of the empirical literature. In: Wootton R, Yellowlees P, McLaren P, eds. 

 London: Royal Society of Medicine Press Ltd; 2003:39-71.

 Kornbluh RA. Telepsychiatry: ready to consider a different kind of practice? 

 American Telemedicine Association. State Telemedicine Gaps Analysis. 

http://www.americantelemed.org/policy/state-policy-resource-center#.VYD_chNVhBc

. American Medical Association: Chicago; 2014.

 Shah V, Lustig S. Seeing the forest through the fees: earning your green using the new, confusing CPT codes. 

http://www.psychiatrictimes.com/psychiatry-compensation/seeing-forest-through-fees-earning-your-green-cpt-codes

State Telemedicine Gaps Analysis: Coverage & Reimbursement.

http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis--physician-practice-standards-licensure.pdf?sfvrsn=8

 Robert J Waters Center for Telehealth and e-Health Law. http://ctel.org. Accessed June 23, 2015.

 Professional Risk Management Services, Inc, Arlington, VA. An Introduction to Telepsychiatry. 2014. (Please contact Professional Risk Management Services for a copy of this paper.)

Articles

Telehealth is at a tipping point and is gaining momentum. Although there are some technological and logistical hurdles, most clinicians would likely find these to be minor and outweighed by the benefits of expanding access to mental health care to those in need.

Telepsychiatry: Watching Your Back While Staying in the Black

[[{"type":"media","view_mode":"media_crop","fid":"25019","attributes":{"alt":"Managed care, psychiatry","class":"media-image media-image-right","id":"media_crop_8541704501287","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2276","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 6px;","title":" ","typeof":"foaf:Image"}}]]Many psychiatrists believe that managed health care is a contemporary innovation. In fact, its rudiments date back to the 19th century, when various homegrown health plans connected to urban benevolent societies and progressive rural groups provided prepaid physician services. The early plans focused on medical, not psychiatric, care and were usually limited to worker groups and their families or the residents of a particular area.

 By the early 20th century, although many plans were still associated with employer groups, a widespread need for low-cost health services led to the creation of new plans. While the structure of plans varied, the shared aim was the provision of reasonably priced, quality care for members while maintaining a consistent income for providers.

Assorted employer and physician economic issues along with obstacles to consumer access of basic health services stimulated a range of private and government enterprises. The foundations of managed health care comprised prepaid group practices and medical service plans. In due course, modernization led to the development of alternatives such as HMOs, independent practice associations, and preferred provider organizations.

Mental health benefits were administered like other specialty care, as part of a complete medical insurance package, until the mid-1980s. However, as HMOs gained importance and began incorporating managed behavioral health care principles, this practice eventually extended into the domain of private health insurance companies and employer benefit plans. It was also around this time that unscrupulous psychiatric hospitals promoted a climate of excessive, unnecessary care, which triggered various scandals.

“This began a period of declining public confidence in behavioral health providers” and an upsurge of behavioral health plans providing what became to be known as the “carve out” of mental health benefits.

 Seemingly, these troubled times were familiar and reminiscent of 1973, when it appeared as if physicians were “providing more services rather than . . . providing appropriate services” and the HMO Act of 1973 was passed because of the government’s concern about unwarranted Medicare expenditures.

 As managed care groups proliferated and evolved, legislation was passed for regulation and oversight, and standards for clinical and business operations were created.

Over the years, newer collections of physician-hospital managed care arrangements were established, including, for example, integrated delivery systems and physician-hospital organizations. In addition, private insurance companies that had previously offered indemnity insurance and focused on claims payment realized they could impact mounting costs by developing their own managed care networks, and several insurance companies, such as Aetna, Prudential, United Healthcare, Cigna, and Anthem, did so.

As part of the extended managed care infrastructure, new external institutions for supervision of medical necessity, appropriateness, and quality of care were formed. With the support of the federal government, the Professional Standards Review Organization was established in the 1970s to review the Medicaid and Medicare programs. Subsequently, other bodies, such as the National Committee for Quality Assurance, began accrediting HMOs along with a growing assortment of managed care programs.

Psychiatrists experience the impact of managed care perhaps most acutely during the utilization review process, which has become a standard tool for the review of treatment modalities and levels of service in the managed care environment. Although these reviews have caused much anger and angst, the topic has received minimal attention in the literature. The reviews focus on medical necessity, of which there are multiple definitions: legal, federal, and those particular to specific professional organizations. For instance, the AMA definition of medical necessity is:

Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, treating, or rehabilitating an illness, injury, disease or its associated symptoms, impairments, or functional limitations in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider.

During the utilization/medical necessity review, the psychiatrist reviewer examines medical information already available to the managed care organization (MCO) and gathers additional information in dialogue with the health care provider. The aim is to evaluate the necessity of a specific level of care (eg, inpatient) or treatment (eg, ECT) and the potential for a clinical response. The reviewer does not direct medical care of the patient. Rather, the reviewer provides consultation on clinical questions or authorizes reimbursement for treatment that is considered to be effective and not overuse of resources. Given that the psychiatrist reviewer frequently has access to comprehensive data and historical information such as the patient’s prior treatment (eg, medications, hospitalizations, adherence) the dialogue between the health care provider and the reviewer can present an opportunity for discussion of potentially unidentified clinical and therapeutic alternatives.

However, as the organization of managed care has evolved, the relationship between attending psychiatrists and medical necessity reviewers has regrettably tended to be adversarial, but it need not be that way. In fact, the purpose of the review is to ensure effective treatment and to maximize the functioning of the patient through services within the benefit plan. Yet, the myth of the crafty, denial-oriented medical necessity reviewer who is refusing to grant something believed to be a right persists and often impedes the review, presenting a barrier to effective, mutual communication.

Psychiatrists have a unique position: they speak with various clinicians; they become familiar with different treatment methods and pharmacological interventions; and they are asked to review a myriad of cases locally and nationally and at many levels of care. Although not necessarily experts in specific treatments, many reviewers become knowledgeable about experimental and cutting-edge treatments, new research, organizational standards, and government mandates.

Furthermore, the psychiatrist reviewer can be a practical resource to the treating clinician by assisting with after-care planning (ie, identifying step-down facilities and available outpatient providers). This consultation can spark new ways of thinking about an illness and new approaches to the treatment of the condition.

Commonly, managed behavioral care organizations (MBCOs) seek to hire psychiatrists for a medical director position who have completed residency training in general psychiatry and have at least 5 years of post-residency experience. In addition, some medical directors may have sub-specialty training or advanced education in areas such as child/adolescent psychiatry, addiction psychiatry, geriatric psychiatry, psychopharmacology, and psychotherapy. MBCOs have different processes to address complaints; usually, a senior medical director or chief medical officer will respond to grievances regarding a medical necessity reviewer or the review process.

MCOs must be open and explicit about the standards used to evaluate medical necessity and about the benefits that are available to their members. Consumers desire a diverse array of convenient health care services, but to provide effective and better-quality treatment for patients, MCOs and clinical practices need transparency. For example, MCOs, unbeknownst to most members, credential their network of providers and facilities and review performance and utilization data of hospitals, pharmacies, and inpatient and outpatient services. And, comparative costs to patients charged at different facilities are now also being made available. Therefore, medical necessity review is just one of the many activities that MCOs provide to their members.

The MCO’s psychiatrist evaluates clinical information and verifies that the patient is receiving timely, customized, and cost-effective treatment for health problems within the parameters of his or her contractual benefits. Performance is reviewed and graded to identify areas that need improvement.

The delivery of appropriate, cost-effective treatment is fiscally and ethically healthy for the consumer, the mental health care provider, and our country’s health care system. The psychiatrist medical necessity reviewer has an important role in this process. By working in a collaborative and constructive manner, the mental health care provider and psychiatrist reviewer can serve these aims.

The authors wish to acknowledge the helpful comments of Drs Alvin Blank, Robert Cirelli, Michael Cohen, Frederick Green, William Lopez, and Victoria Shampaine on earlier drafts of this article.

Dr Pedowitz is Medical Director and Dr Lustig is Lead Medical Director at Cigna Behavioral Health in Eden Prairie, Minn. They report no conflicts of interest concerning the subject matter of this article.

 Fox PD, Kongstvedt PR. A history of managed health care and health insurance in the United States. In: Kongstvedt PR, ed. 

. 6th ed. Burlington, MA: Jones & Bartlett Learning, LLC; 2013:1-18.

 National Council on Disability. Appendix B: A Brief History of Managed Care. 2013. http://www.ncd.gov/publications/2013/20130315/20130513_AppendixB. Accessed May 14, 2014.

 Kessler KA. History of managed behavioral health care and speculations about its future. 

Managed Care: What It Is and How It Works

. 2nd ed. Burlington, MA: Jones & Bartlett Learning, LLC; 2004.

 Statement of the American Medical Association to the Institute of Medicine’s Committee on Determination of Essential Health Benefits. January 14, 2011. http://www.iom.edu/~/media/Files/Activity%20Files/HealthServicesEssentialHealthBenefits/2011-JAN-13%20and%2014/Gerald%20Harmon%20Statement.pdf. Accessed May 14, 2014.

Psychiatrists experience the impact of managed care perhaps most acutely during the utilization review process, which has become a standard tool for the review of treatment modalities and levels of service in the managed care environment.

Stuart L. Lustig, MD, MPH

Articles

Telepsychiatry: Watching Your Back While Staying in the Black

Medical Necessity Review: History, Innovation, and Missed Opportunity