Speaker 1: Hi everyone, my name is Dr. Eugene Gu and I am the CEO of a telemedicine company called Coolquit. Today, I'm going to be talking about three main topics, and they are 1, HIPAA, 2, telemedicine parity laws, and 3, the Ryan Hite Online Pharmacy Consumer Protection Act. So first, let's talk about HIPAA, otherwise known as the Health Insurance Portability Accountability Act, which was passed into law in 1996 and has been modified subsequently. So HIPAA, as it applies to telemedicine, first includes an important concept called covered entities. Now, covered entities are a set of medical providers, health insurance companies, and the medical billing clearinghouses that are explicitly mentioned within the text of the law as being held accountable to HIPAA. That means that other entities, such as employers, which are not explicitly mentioned within the law, are actually not covered under HIPAA and not responsible for adhering to the law. So when it comes to HIPAA, the most important thing to know is that Protected Health Information, or PHI, is an extremely important thing to safeguard for your patients. In fact, any kind of violation, willful or otherwise, in releasing Protected Health Information of your patients to people who are not authorized to see it can come with pretty hefty financial and even criminal liability. For instance, one violation of HIPAA can cost up to $50,000 for a healthcare provider or an insurance company or a medical clearinghouse. So it's something to take very, very seriously. Now when it comes to telemedicine, HIPAA is important to know about because you have to protect your patient's private health information on the internet, which is very prone to hacking, security vulnerabilities, and there are a lot of things with technology that is harder to keep secure than an in-person visit. So when it comes to telemedicine, first, many people, medical providers in particular, use a type of video conferencing technology like Zoom, like Google Hangouts, like Doxy.Me. And every time any medical provider uses this video platform, they have to be cognizant of the fact that HIPAA requires you to have a business associate agreement, otherwise known as a BAA, in order to use the video platform securely without violating HIPAA. And that's because when you form a business associate agreement or BAA with another entity such as Google or Zoom or Doxy.Me, you are in fact labeling the independent contractor as a covered entity, so that they too are responsible for adhering to HIPAA and protecting the private health information of your patients. So that's pretty much the gist of HIPAA in a very bird's eye view. There are a lot of intricacies within the healthcare law that I suggest you look into further, but the most important take-home message here is that if you're using telemedicine and you're using a video platform to see your patients, you can't just FaceTime them or Google Hangouts with them or just on the fly use whatever video technology you have available before actually having in place a business associate agreement with the platform that you are using. So now let's move on to the second topic, which are telemedicine parity laws. So first of all, what is a parity law and why do we even need it? Well, if you think about it, medicine for the longest time, it's a very old profession, has always been involving a doctor and a patient seeing each other in person. Whether it's in an exam room or the operating table, there's always this physicality to the doctor-patient relationship. Now with telemedicine, we're changing all of that to be an audio-visual two-way interaction or an asynchronous care, and this is pretty new to the field of medicine when you take a look at it in the grand scheme of things. And so the laws are now just starting to catch up to what that means in terms of reimbursement and billing. Thirty-seven states and the District of Columbia have laws on the books that require private health insurance companies like Blue Cross, Blue Shield, Aetna, and others to pay the same amount for a telemedicine visit that they pay for an in-person visit or exam. For the other states that don't have this law on the books, it's really up to the private health insurance carrier as to whether you're going to get paid the same amount as an in-person visit when you do telemedicine or even if you get paid at all, because some plans may actually have exclusions that don't allow the patient to use telemedicine and to have that be covered by the insurance company. If you live in a state that doesn't have a telemedicine parity law, meaning that the law requires the insurance company to pay the same amount whether it's in-person or by telemedicine, then the onus is up to you to call the insurance company and see what their specific policies are. Because even if you do live in a state or you practice medicine in a state that doesn't have a telemedicine parity law, many insurance companies will still reimburse you the same amount whether it's in-person or by telemedicine. Just call your insurance company, see what their policies are, and you may be pleasantly surprised about how they are actually reimbursing for telemedicine visits the same as an in-person exam. And one more caveat to this is it often can be confusing as to how you bill for a telemedicine visit, especially if you don't look through the arcane laws and policies that each different private health insurance company has regarding telemedicine reimbursement. So often the quickest and dirtiest way to bill for a telemedicine visit is to put a GT modifier in front of the CPT code that you would bill as if it was an in-person exam, except you put the GT modifier before that to kind of signal to the private health insurance company that you're billing for this service as a telemedicine service. And if you are in Alaska and Hawaii, actually instead of putting a GT modifier before your CPT code, it's a GQ modifier. So there are a lot of tiny little specifics and idiosyncrasies when it comes to billing for a telemedicine visit versus an in-person exam, but the key take-home message here is that if you just call the insurance company and see what their reimbursement policies are, you can often find out a lot that can help guide you within the state that you practice for telemedicine, whether your state has a telemedicine parity law or not. So now let's move on to our final topic, which is the Ryan Height Online Pharmacy Consumer Protection Act and how that relates to telemedicine. So for the longest time, the Ryan Height Act did not allow telemedicine providers to prescribe controlled substances such as opioids or stimulants like methylphenidate or Adderall to patients by telemedicine. And the only way to prescribe opioids and other substances in that category was to have an in-person exam with a patient, and then by follow-up visit by telemedicine, such controlled substances could then be prescribed legally. But otherwise, if you've never had an in-person visit with your patient, you couldn't prescribe any kind of controlled substance by telemedicine. On March 16th of 2020, the Secretary of Health and Human Services, Alex Azar, actually issued a directive that now allows telemedicine providers to prescribe Schedule II through IV substances, which includes opioids, narcotics, it includes barbiturates, and it includes stimulants like Adderall, methylphenidate. Essentially, all of the prescription medications that you could prescribe in person, you can now prescribe by telemedicine. As you know, this creates a great deal of new flexibility for telemedicine providers and can be particularly useful for chronic pain patients who need refills for their narcotic medications. You can prescribe buprenorphine now to patients who are addicted to opioids as a way to treat them for their opioid addiction. But I just want to caution everyone about the dangers of what this means. This new flexibility also means that you need to have a lot of new responsibilities as well. Because prescribing opioids has been a problem in the field of medicine for the longest time. We have an opioid epidemic that claims thousands and thousands of lives every year, and it's pretty dangerous, whether it's in person or by telemedicine, to prescribe opioids to your patients because there's a lot of patients who can shop around different providers to get the opioids they need to fuel their addiction. As medical providers, we have an ethical responsibility to take care of our patients and to make sure that we put their health and well-being as our number one priority over any kind of profit motives or anything else. Our patients come first. So even though there are these new rule changes that allow you to prescribe opioids, to prescribe stimulants like Adderall, and to prescribe barbiturates by telemedicine, I think that the responsibility that we have as telemedicine providers is even greater. And while we do have that ability to prescribe these things, we should be extra careful and not abuse this new flexibility and really take our patients' interests at heart. And when you take your patients' interests at heart, it doesn't mean just giving them whatever they want whenever they want it. It means using your best medical judgment to make sure that we safeguard their health and their lives. So that concludes all three topics today for telemedicine. I hope that you found all of this helpful for you in some way. And if you have any questions, feel free to post them in the comment section and I'll be sure to take a look at it and respond to as many as I can. Well, thank you so much and hope to see you guys next time.