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By Sarah Ovaska

The coronavirus pandemic quickly overhauled how medicine will be practiced for more routine needs, with doctor offices switching to virtual exams over the phone or video as the COVID-19 pandemic bears down on the country.

Instead of easing their way into the change, the switch to telemedicine has been more akin to plunge into the deep end of the pool.

Christoph Diasio, a pediatrician with Moore County’s Sandhills Pediatrics, began holding virtual sessions from his home with several groups of patients this week. Having appointments to talk about medications related to ADHD or spotting the tell-tale signs of pink eye was easy, diagnosing an ear infection without the ability to peer into a child’s ear canal was not.

But hard does not mean impossible.

“We’re really trying to keep people at home and we need to do everything by telephone that we can reasonably do,” Diasio said.

While the switch to telemedicine may seem sudden, the concept of providing care remotely is not new at all, said Joanne Fruth, a family medicine specialist and medical director of Raleigh’s Avance Primary Care.

“I’ve been doing it my whole career,” said Fruth, who has decades of experience as a primary care doctor talking to patients about follow-up treatments to procedures or ongoing care for chronic conditions.

What’s changed is that she can now bill for it.

Barriers falling

Insurance companies and federal payers such as Medicare and Medicaid had long been the barrier for practitioners. But most payers have loosened their rules in recent days on how and how much to bill for virtual appointments, part of the all-in attempt to reinforce social distancing to all aspects of life in America to slow the spread of COVID-19.

The goal is to keep people as isolated as possible and keep people with less significant conditions out of doctors’ offices to avoid exposure to coronavirus, which so far has killed thousands worldwide and 97 people in the U.S. In North Carolina, there have been no deaths, but 63 confirmed cases as of Wednesday afternoon, according to the N.C. Department of Health and Human Services. Public schools have been closed for at least the next two weeks and Gov. Roy Cooper announced Tuesday that bars and dine-in restaurants would be off-limits for the foreseeable future.

President Donald Trump announced Tuesday that Medicare, the health care program for Americans over the age of 65, would pay for telemedicine, a sea change for providers who have long sought that same flexibility. Federal health officials also announced they would waive relevant HIPAA restrictions so health providers can use platforms like FaceTime and more to connect with patients during the national emergency.

North Carolina has secured similar flexibility around telehealth billing for Medicaid, the safety net program that pays for health care for nearly 2.2 million low-income seniors, children and disabled persons.

On Wednesday, the state agency asked the Centers for Medicaid and Medicare Services for a temporary waiver around some Medicaid requirements to support telehealth.  The state agency has already released some billing codes and held a webinar late last week explaining the billing changes to medical providers and pledging to offer flexibility in order to keep as many people at home to prevent the spread of coronavirus.

Resources for providers:

The American Medical Association offers the Quick Guide to Telemedicine in Practice
CMS guidance for telehealth services for Medicare Advantage beneficiaries
A rate list and billing codes for physical and behavioral from Medicaid is available here.

Here in North Carolina, Blue Cross Blue Shield of North Carolina, the biggest insurance provider in the state, announced Tuesday it would cover virtual visits that occur over the phone, as well as video, at the same rates as face-to-face visits. That parity is an important detail for practitioners needing to know how to bill and also figuring out how to stay afloat financially during the unprecedented public health crisis.

Some providers have running start

Avance, the primary care practice in Raleigh, shifted to conducting behavioral wellness and nutrition appointments remotely several months ago. With the threat of coronavirus emerging early this year, the practice pushed for a goal of having at least half their patients able to be monitored and treated virtually.

“Social distancing is probably the most effective activity at this point,” Fruth said about avoiding the spread of COVID-19. “That’s why we’re ready for telehealth.”

But that doesn’t mean it’s all been smooth sailing.

Cisco employee Colleen Coogan talks with her doctor, Alison Guptill, about her new blood pressure medication via video link. All of the clinic exam rooms will be telehealth-enabled. Photo credit: Rose Hoban

North Carolina had been really at the beginning stages of moving to more telemedicine when the pandemic hit, said Shannon Dowler, the DHHS chief medical officer for Medicaid, in the webinar.

“This is one of those ‘turning the tanker in the canal’ challenges for us,” Dowler said. “We have fairly restrictive telehealth right now when we compare North Carolina to other states.”

With COVID-19 speeding up that timetable to right now, Dowler said she and her team would be granting exemptions to existing regulations. She and other DHHS officials are urging as many medical and behavioral health providers to move to remote care as possible.

Some telepsych services scaling up, too

In Rutherford County, Stephanie Lattimore, LCMHC, provides cognitive therapies to as especially vulnerable populations, children who have experienced abuse and often are in foster care or kinship care.

She’s moving to check-ins and visits over the phone this week but been able so far to get clarity about whether the LME-MCOs, North Carolina’s quasi-public managed care organizations that handle Medicaid claims for those with complex mental health needs in North Carolina, will allow her to bill for more than a half-hour appointment via the phone. Partners, the LME-MCO she primarily works with, has confirmed they will be able to pay her, but don’t yet know at what rate.

She’s planning on conducting therapy appointments remotely regardless, even if she only can bill for 30 minutes of the hour to 90 minutes she spends with a patient.

“I’m going to be taking a pay cut of at least half,” Lattimore said.

Lattimore began this week by connecting with all of her patients and their families, to let them know about the new telehealth approach and to check in on how patients are doing during this stressful time.

Fruth and Diasio both say the move to telemedicine is going to require creativity from medical providers. If a patient complains of a rash, and it’s not showing up on the portal, ask them to send a photo, Fruth said. Have medical staff reach out to patients before the scheduled appointment time to collect basic information about the need for the visit.

For Diasio, it means tapping families to help assess vital signs of his young patients and paying close attention to those visual cues that doctors use in their assessments every day. Patients that do need to be seen in person may be asked to stay in their families’ car, while doctors and nurses come out and assess the patient in the parking lot.

His pediatric practice plans on continuing well visits for those under 18 months, so that newborns and babies can protect themselves from the dangerous diseases that already have vaccines to combat. But other well visits and check-ups may need to wait.

“Everyone is trying to figure out how to do the right thing,” he said. “No one knows what the right thing is.”

With insurers and Medicare, Medicaid removing barriers to pay, more practitioners will treat remotely.

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Sarah Ovaska

Sarah Ovaska is a freelance writer based in Orange County, who has called North Carolina home for well over a decade. She’s reported on criminal justice, education, health and government issues at publications...