Wild West of Waivers

Thank you for joining us for today’s legal/regulatory webinar related to the Covid-19 pandemic. This post contains links to the various resources that we discussed. Additional resources will be added after the event based on your questions

Disclosures
The webinar represents a partnership between Allina Health (David Frenz’s employer) and the Center for Practice Transformation. Please review Dr. Frenz’s disclosures, especially that bit about seeking counsel from experienced health lawyers like our panelists, Teresa Knoedler and Kit Friedemann


in partnership with

Questions to Ask Yourself

  1. Is the health care service permitted by law? (if yes, then go to #2)
  2. Is the health care service permitted by the patient’s health plan? (if yes, then go to #3)
  3. What is the claims submission process? For example, what CPT code and place of service code (Item Number 24B in the 1500 Health Insurance Claim Form) should be submitted for payment?


Introduction
High-level Explainer by Kit Friedemann, J.D.

Emergency Declarations
Federal
Minnesota
#StayHomeMN

HIPAA Enforcement
Office of Civil Rights resource page
Telehealth and Telemedicine Tool Kit

Medicare
Expansion of telehealth with 1135 waiver
CMS Interim Final Rule
MLN Booklet — Telehealth Services [requirements prior to Covid-19]
Medicare Coverage of Substance Abuse Services [prior to Covid-19]

Minnesota Department of Human Services
Waivers and modifications
MHCP Provider Manual

42 CFR Part 2
Substance Abuse and Mental Health Services Administration (SAMHSA)
Relationship to HIPAA enforcement discretion

Ryan Haight Act
Use of Telemedicine While Providing Medication Assisted Treatment (MAT)
Drug Enforcement Administration (DEA) Covid-19 Information Page

Predicting Suicide & Violence

I delivered this live webinar for the University of Minnesota’s Center for Practice Transformation way back on September 14th, 2018. I’m egregiously slow in posting, however, better late than never? ✸

Covid-19 Telehealth Training

Thank you for joining us for today’s telehealth training. This post contains links to the various resources that I discussed via screen share

Disclosures
The webinar represents a partnership between Allina Health (my employer) and the Center for Practice Transformation. Please review my disclosures, especially that bit about seeking counsel from an experienced health lawyer. I’m a medical doctor, not a juris doctor


in partnership with

Platform/Vendor Selection
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!)

Solo practitioners and small groups are able to purchase Zoom for Healthcare licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down

Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency; please see below)

Scheduling
Use security features. These include meeting passwords and waiting room features [Update: Please see new post for an illustrated explainer]

Conducting Sessions
Socialize individuals and groups to expectations including

  • Physical safety, e.g., no sessions while driving
  • Privacy, especially in shared spaces. Think: Headsets or earbuds on both ends
  • Minimizing environmental distractions (sound, light, motion)
  • Deferring personal activities to personal time: smoking, vaping, eating, toileting, et cetera
  • Video on (especially for groups); audio toggled on/off

Looking & Sounding Professional
Try at all times to exceed the standards of creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)
  • Keep your camera clean (and keyboard, too — wink, wink!). Optical wipes are available through Target and other retailers

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo [or: Zoom for Healthcare, et cetera]
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care [the final sentence can be edited or deleted]

Collecting Clinical Data
I love scales, measures and patient self-rating forms. The same instruments that I administer in my office can also be administered via telehealth through

I’m also okay with home drug testing provided the panel includes sample validity assays and GC/MS confirmations

Notable Waivers & Exceptions
All sorts of regulatory waivers and exceptions have been granted because of the Covid-19 pandemic. Those most relevant to mental health and addiction include

Good luck!


Update: Here’s a link to a recording of the webinar.

Free Telehealth Training

Allina Health is pleased to be partnering with the University of Minnesota’s Center for Practice Transformation on a free telehealth training this Friday, April 3rd, at 12 p.m. The webinar is an adaptation of trainings that John Sutherland, Ph.D., and I have been conducting at Allina in response to the Covid-19 pandemic.

I will cover a broad range of topics including the logistics of conducting a telehealth encounter. I will also address regulatory issues such as documentation requirements, exceptions to the Ryan Haight Act, deferred enforcement of HIPAA and waivers and modifications granted by the Minnesota Department of Human Services.

Please consider Zoom for Healthcare if you haven’t already landed on a telehealth platform. It is device and operating system agnostic, and many patients are already using it for other reasons (e.g., distance learning for their children). Solo practitioners and small groups are able to purchase licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down.

Many thanks to Julie Rohovit, Ph.D., Joe Curtis and the whole gang at the Center for Practice Transformation for spinning up this webinar on very short notice. ✸

ECHO Wrap-Up

I appreciated the opportunity to discuss telehealth during today’s Project ECHO webinar. Here are some of the resources that I mentioned

Please contact me if you have any questions. ✸

Going Dry

I recently participated in a panel discussion that explored how we talk about alcohol. It was a Sober Curious sequel, of sorts, that Peder Schweigert and Erin Kincheloe of Marvel Bar (cum Bachelor Farmer) pulled together.

Jana Shortal, the KARE 11 personality, moderated the discussion. The panelists were Julia Bainbridge, the acclaimed writer, Peder and me.

The event was professionally recorded and the resulting audio file is available here. ✸

SBIRT — Updated

Just a quick post with my updated SBIRT slide deck. I mess with it a few times per year, generally when new research or policy developments appear.

Slide 39 now contains the current screening recommendations from the United States Preventative Services Task Force (USPSTF) concerning alcohol and illicit drugs. Both are B recommendations, although the latter is still is the draft stage (but is likely to become final).

Continuing thanks to Kari Caldwell and the Hazelden Betty Ford Foundation for including me in its Professionals in Residence (PIR) program. PIR remains a tremendous source of personal and professional satisfaction that has only increased with time.

Pain & Addiction: Common Threads

On November 1st, I’ll be presenting on the messy intersection between opioid addiction, chronic pain syndromes and other mental disorders. Please click here or on the image below for a full-sized PDF of the conference announcement.

You can register for the event here.

I’m still messing with my slides, however, my presentation will be a “new and (very much) improved” version of material that I’ve delivered to other audiences (for example, here and here)

Many thanks to Taylor Gilard, Susan Gordon, the University of Minnesota’s School of Nursing and Allina Health for involving me in the event.


Update: Here’s my PowerPoint.


Update: I’ve given this presentation a few times now. Here’s a link to a recorded webinar

Think Like a Health Plan

In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.

I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.

This post contains my key teaching points and didactic materials.

Suggested Thought Process

  1. Is the health care service a covered benefit? (cf. benefit plan)
  2. Does the carrier have a policy concerning the health care service?
  3. In the absence of a specific policy, is the health care service medically necessary?
  4. Does the member (patient) and/or evidence meet criteria?

Benefit Plan

At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).

Medical Policies

Medical Necessity

Group Exercise

# # #

Opioid Investigations & Enforcement

I’m honored to be serving as a panelist at Fredrikson & Byron’s upcoming “Opioid Investigations and Enforcements Breakfast Seminar” on May 22nd.

Opioids are a common and sometimes uncomfortable area where law and medicine intersect. For years, I’ve been extolling the virtues of the Federation of State Medical Boards’Model Policy” as a means for mitigating risk. It also serves as an excellent framework for approaching opioid-related incidents and investigations.

Fredrikson & Byron is hosting an opioid-related event

The Model Policy first appeared in 1998 and is now in its fourth edition (2017). Section 3 provides detailed guidance on patient selection, informed consent, medication agreements, drug testing, and so forth.

Adhering to the Model Policy ensures patient safety but also provides a safe harbor against enforcement actions. For example, the Minnesota Board of Medical Practice typically includes this condition in opioid-related discipline:

Respondent shall read the Federation of State Medical Boards’ “Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain”

Adhering to the Model Policy is a good way to avoid being investigated. And acknowledging the Model Policy and demonstrating compliance with it are an effective means to respond to questions about care.

Many thanks to Kevin Riach and Joe Dixon, shareholders at Fredrikson & Byron, for including me in this event. And I hope to see you there!