April 2020

Medicare support for telehealth services is scaled up

> Government

By Natalie Butler, Special Counsel

The range of Medicare-subsidised services that can be delivered via telehealth channels was significantly expanded by the Australian Government last week (as of 30 March 2020). The move bolsters Government efforts to minimise the spread of COVID-19 by balancing the need to protect patients and health care professionals, while preserving community access to Medicare funded consultation services.

Telehealth services are alternatives to face-to-face consultations that can occur via video link or by telephone. Each channel of communication raises its own issues, which we highlight below.

While the telehealth item numbers recently added to the Medicare Benefits Scheme (MBS) have been flagged as ‘temporary’ measures[1], the usual requirements for professional attendances, record-keeping, the assignment of Medicare benefits and privacy, remain the same.

For those that are new to telehealth services, or practitioners exploring how best to offer telehealth consultations on a more regular basis, here are some tips to help navigate the new item numbers.

Eligible patients

Telehealth consultations are available for Medicare eligible Australians. However, patients must not be hospital-admitted patients.

Providers allowed to perform telehealth services and permitted locations

There are telehealth item numbers for services provided by:

GPs, other medical practitioners, specialists & consultant physicians;
Nurse practitioners & participating midwives; and
Allied mental health providers.

While the provider and patient each need to be in Australia, there are no specific geographic limitations imposed on the telehealth items. There are, however, some location-related matters to keep in mind.

Providers do not need to be at their regular practice location to deliver the services. According to the Department’s guidance material, providers may deliver telehealth services from home, if self-isolating or in quarantine, if it is safe to do so and the consultation would meet the usual professional standards. Practitioners should use the provider number for their primary practice location in those instances.

Medicare rebates are not payable for telehealth services in the event the practitioner is an admitted patient. Location does matter, in those situations.

Bulk-bill items and assignment of benefits

The new telehealth item numbers are bulk-bill only services. Patients must agree to assign the Medicare benefit payable for the service, to the practitioner. The practitioner must, in turn, accept the Medicare benefit as full payment for the service. No additional fee can be charged.

Practitioners need to decide how they will demonstrate, and document, the assignment of benefits. Ordinarily, providers delivering telehealth services might:

Post a Medicare assignment form to the patient, to be returned to the practitioner once completed; or
Rely on email communication with the patient to confirm the assignment of benefits.

The Department has flagged a more flexible approach to the assignment of Medicare benefits with respect to the new telehealth items. Practitioners can record a patient’s acknowledgement of a bulk-billed service, and agreement to assign their benefit, in the clinical notes. Providers intending to deal with the assignment of benefits verbally might consider adopting a template or checklist that prompts them to deal with this essential administrative issue, and to record the fact that the conversation took place.

Prescriptions

Medical practitioners may elect to post or email prescriptions:

Directly to patients; or
To the patient’s nominated pharmacist.

If emailing prescriptions, we suggest practitioners take reasonable steps to ensure the privacy and security of those communications. For instance, consider using encrypted or password protected files.

Some practitioners may prefer to complete hard-copy prescriptions for patients or carers to collect from consulting or treatment rooms. While this approach minimises interactions among patients, practitioners and staff – the consultation having been conducted via video or telephone, and the patient attending rooms only very briefly to collect the prescription – we do not recommend it as a ‘standard’ approach for the next few months. Our reasons for recommending caution are as follows:

Consider how you would help execute contact tracing in the event a patient attending treatment/ consulting rooms tested positive to COVID-19. Would it be possible to quickly and easily identify those people who came for the sole purpose of collecting a prescription?
Having patients or carers collect prescriptions may provide an opportunity to ‘bundle the paperwork’. For instance, patients might be asked to complete the assignment of Medicare benefits form, when collecting a prescription. However, since this would prolong the person’s presence in waiting rooms and reception areas, it’s perhaps best reserved for special circumstances. There are other ways to deal with the assignment of benefits, as noted above.
Practitioners should comply with the spirit of the MBS telehealth services, as well as the specific requirements of the item descriptors. Limit the number of people physically attending consulting rooms, wherever possible, to minimise the risk of negative inferences being drawn about practitioners’ uptake or implementation of telehealth services.

Safety and clinical relevance of the telehealth service

The Department’s guidance states that ‘[a] service may only be provided via telehealth if it is safe and clinically relevant to do so’. An assessment of the safety and clinical relevance of a service, by reference to professional standards for example, is not new. However, this requirement may have some practical privacy ramifications where practitioners are supported by staff who conduct preliminary triage or screening of a patient’s suitability for a telehealth service.

Where that triage or screening is likely to involve conversations with patients in a level of detail that they, or staff, are unused to, it may be advisable to refresh privacy compliance practices. Practitioners should ask themselves:

Do privacy policies need to be updated or expanded? Are there any changes to the nature or volume of sensitive health information collected from patients, outside the actual consultation?
Are work/ office layouts suitable for staff to have these sensitive conversations, without being overheard by other patients, for example?

Mode of delivery – selecting the telehealth channel

Guidance from the Department of Health indicates that videoconferencing (VC), that establishes an audio and visual link, is the preferred mode of delivery for attendances offered as alternatives to face-to-face consultations. However, in response to the COVID-19 pandemic, telephone-based services (audio only) will also be permitted, when VC options are not available. We explore that qualifier – the availability of VC – in a little more detail below.

There are separate item numbers for telehealth consultation services which correlate to the mode of delivery (i.e. VC or telephone). So, as with any MBS item number, it’s important to select the right one.

Other than a handful of obstetric telehealth item numbers, choosing telephone as the means of communication is not expressly precluded, even if VC options are available.[2] However, given the Department’s emphasis on VC in preference to telephone attendances, there are a couple of issues that practitioners should keep in mind when deciding which ‘comms channel’ to use.

Practitioner/ patient familiarity, and confidence, with VC options.
Ability to deliver an end-to-end service via video or telephone.
- Practitioners must be able to provide the full service, safely and in accordance with professional standards, by the chosen telehealth channel.
Connectivity and network coverage.
- For a Medicare benefit to be payable for the service, the practitioner must maintain:
  - A visual and audio link with the patient, in the case of a telehealth VC attendance; or
  - An audio link with the patient, in the case of a telephone attendance.
- Whether VC options satisfy privacy and security requirements. This may require a preliminary assessment of the features and user-customisation across various video chat platforms/ products. We suggest looking for options that allow:
  - Practitioners to initiate or ‘host’ the VC session;
  - VC sessions to be ‘locked-down’ or operate on an ‘invite-only’ basis;
  - File sharing and screen sharing to be disabled;
  - Encryption as a default setting, or the option of encrypted file-sharing; and
  - Practitioners to determine (or set) how long certain records generated in connection with the video session are retained by the service provider.
- Provider profiles and departures from ‘usual practice’.
  - Those intending to maximise the availability of telehealth services may wish to consider the extent to which provider profiles (or the inferences that may be drawn from them) should be managed in clinical notes. Apparent departures from a practitioner’s ‘usual practice’, with respect to the new item numbers, may warrant an entry in patient records. For instance, practitioners who provide mainly video-based services may wish to record, for individual telephone attendances, why VC could not be utilised on that particular occasion.