Home Forums Coronavirus and the private practice

So far, we've reduced our hours by 2 each day. The schedule is staying busy with virtual visits, but I need to streamline the process so they take up less of our provider's time. I started pre-screening today to ensure patients are set up for video. Updox appears to be working diligently to make their system work better, and I'm finding other options if it doesn't work as expected. Did an appointment today through Facebook Messenger. As the weather gets warmer here, we're thinking about scheduling more "car-side" appointments. I have a tent I can set up outside the back door, a stand-up laptop desk, and we just checked the wi-fi and found it works outside. Since doctor's visits are considered essential, I suspect some of our patients are going to prefer this approach, especially if it gives them the opportunity to get out of the house for a little while.

The real question mark in my mind, especially for telemedicine, is how long it will take to get paid, or if we'll have to fight with insurance. I'll really be surprised if things process correctly the first time.

I love the secure visits too, it reminds me a bit when i use to do home visits 20+ years ago when i first started my practice. You get to see the patients in their home and pick up a lot of nonverbal info with their surroundings you just can't get at an office visit face to face.

We have done a blast Updox portal message, facebook post and google business post to tell patients about telemedicine but yeah, many many patients still do not know. Patient volume is down by 75%. Well checks with vaccines still being done in the office. WCC w/o vaccines are not scheduled anymore and the ones already scheduled are mostly being canceled by the patients anyway. Trying to think of other ways to get the word out that telemedicine is available, but since children are staying home they are probably getting sick less too.

My biller just came up with a good idea. Our audex starts off with, "You have reached....." if you want....select...

But, it could start off with "You have reached....Did you know we are now doing telehealh also known as virtual visits. Our doctors can call you, and it is just like a real visit. Etc. etc. I mean the receptionist or CMA could convert that call right into a visit then and there.

Or, "Due to the coronavirus outbreak, we are scheduling fewer office visits and offering virtual visits with Skype and Facetime or evern by phone."

Anyone like this idea and, if so, can you give examples of greetings.

I sent out a blast message (regarding the secure video chat appointments now available) to 1100+ portal account users last week, and I sent out a text blast message to 700+ patients just now, there will be a bit of a crossover but I do have some patients that text only or portal only so hope to reach more patients this way, and also my nurse is offering everyone a secure video chat anytime they call.

No matter how successful telemedicine becomes, I still feel I need to be here for at least wcc visits up to two years of age and for sick visits if the parent chooses if there is no cough or fever.

The patients either get right through to the receptionist or go in the queue. The queue has a courtesy prompt (that is what they call it) which allows to them to leave a message or start over (we still get people saying they were hold for 20 minutes, which means they ignored 40 prompts. But, that could be changed to, "Did you know that instead of waiting on hold, you could be seen virtually with essentially no wait?" Something like that.

Right now everything is working against PCP as far as visits go. First, they told everyone to stay home and not to go to their doctor unless it was urgent. So, everyone is rescheduling their wcc visits and not coming in for other things. Then all the kids are home and while I don't want them to get sick, the school is a virtual breeding ground.

So.....

The problem is that telemedicine visits and phone calls pay poorly. When you consider both the ramp up time to get yourself set up and the patient connected and the chart time, it equates to a full 99213 visit. But it will pay about 1/2 as much. And that's for a simple "you probably have a cold not COVID" visit.

This is a good idea. We actually pick up the phone right away during business hours but after hours I will change the recording to educate about telemedicine.

I hate to sound like a broken record, but I guess every state is different.

1. We do most (well all) virtual visits by telephone.
2. It is now state law that EVERY insurance must pay for virtual visits (telehealth or whatever) and pay at the same rate.

Given that they don't have to be video, it is simple to just put them in the schedule and tell them I will call them. I can call them right then or three hours later.

It is sooooo much like concierge medicine. As I stated earlier, it is fun to be a doctor again. Like you said, you are on the phone for five minutes, diagnose a cold and it is a 99213. I document it like crazy.

I don't feel bad, because when you think about it when you do them by telephone, it is like what you do on a page. And, my guess is Wendell has done arouind 100,000 free pages in his career. And, how many phone messages with your MA.

You are right the video. That has to be more coordinated and scheduled and you have to sometimes teach them. That is why we only use Facetime, Most people have Facebook and most have used Facetime.

But it also means that I bill every time I get on the phone, something I didn't do before.
Phone calls pay even less but are quicker to do overall.

You laid off your biller?

They do not need to pay a phone call the same as a televisit. It doesn't take much longer to set up and do a video visit than it does a phone call. We do as much video as we can; this is not just an economic decision. Patients adapt to it quickly and find it much more beneficial. I find it far easier to reduce anxiety when they can see my face, for example.

They do.

Insurance Emergency Response Order
Coronavirus Public Health Emergency
Supplemental Order Regarding Remote Delivery of Health Services
By proclamation issued March 12, 2020, Governor Janet T. Mills declared that the anticipated impact of COVID-19 in this State has created a state of insurance emergency as defined in 24-A M.R.S. § 471. She has authorized and directed the Superintendent of Insurance, for the duration of that state of emergency, to exercise the emergency powers conferred by Sections 471 through 479 of the Insurance Code as necessary to protect the interests of health insurers, insureds, beneficiaries, or the public. Therefore, shortly after the governor's proclamation and pursuant to
24-A M.R.S. § 478 and Bureau of Insurance Rule 765, Section 5, I ordered, effective immediately, certain emergency measures for all carriers offering health plans subject to the Maine Health Plan Improvement Act, as defined at 24-A M.R.S. § 4301-A(7). Today, I hereby order the following additional emergency measure until further notice, for all such carriers:
Remote Delivery of Health Services: In my March 12 order, I noted the importance of telehealth during this crisis, reminded carriers that 24-A M.R.S. § 4316 requires parity between coverage of telehealth and in-person services, and directed them to review their telehealth programs with participating providers to ensure that the programs are robust and will be able to meet any increased demand , 24-A M.R.S. § 4316(1)(C), expressly excludes, among other methods, the use of audio-only telephone Audio-only telephone communication is often a necessary tool to provide effective remote access for patients. The Centers for Medicare and Medicaid Services has already taken measures to modify applicable federal privacy standards to accommodate this need. I am therefore ordering that in addition to telehealth as defined in the Insurance Code, carriers must also provide parity in coverage for other clinically appropriate remote delivery of medically necessary health care services, including office visits conducted by non-public-facing telephone communication methods that have audio-only or audio-video capability, to the extent that the provider is permitted by law to provide such services. All carriers are further ordered to ensure that rates of payment to in-network providers for services delivered via telehealth and other remote modalities are not lower than the rates of payment established by the carrier for services delivered in person, and to notify providers for any instructions necessary to facilitate billing for such remote services.

Yep same rate for phone only for the time being and bill as office code with place of service 02

So...the experiment starts.
Had several patients cancel their visits earlier in the week because of the virus concerns. Gave them the option of Telemedicine and they all agreed. Told them they would be called today between 10 and 2. Put them on a regular schedule in the office but did not notify them of a specific time. Called them - some were phone calls, some were video visits. All except 1 were medicare. She offered to pay her copay over the phone. Used regular visit codes with Telemedicine location (2). Will submit and see how we are paid.
Saw that Medicare will pay for Annual Wellness Visits with telehealth, These do no technically involve a physical exam anyway. Had my office contact 10 of them - told them they would be calling between 10 and 2 ("advange" of the virus is that they are home). Will do them on Monday, submit billing and see what happens.
If we are paid will arrange more AMW telehealth visits during this period.
Will keep you posted.
Holding my breath...

It won't be an experiment. You will get paid. With telehealth/telemedicine visits you will be reimbursed at 99211--99215 codes with 02 for location.

You will get paid for Check-in visits. And, you will get paid for e-Visits. This isn't a maybe it will work thing. It is the law since 3/6/2020 until the Corona Health Emergency is over.

I stand corrected.

Since starting the secure text feature with Updox a year ago, my nurse will put in the demographic page under the yellow tab left lower corner the patients preferred method of contact--portal, text, or snail mail, so if we have a text preference, we try the secure video chat, and usually goes smoothly but if it takes more than a few minutes because of old phone or whatever reason, I just do a phone call, or if snail mail is the preferred choice, just reach out by telephone. If portal is the preferred method of contact my nurse will determine if they have a smart phone and if so try the secure video chat. I prefer the secure video chat, I like the visual aspect of this communication a lot. But I don't want to get bogged down trying to get it to work and within a minute or two it will either work or not, usually less than that.

Yeah, it's funny. If I were sitting in front of a computer, and my MA told me so and so was on the line, and I could either do a phone call or a video chat, both immediately, I would choose the latter. The problem is I am seeing patients (the fewer face to face the better), and my staff will simply put the patient in the schedule. We have added another column for telemedicine patients. The staff will start the chart as always and send it to me. So, when I see a chart on a patient that is not in a room or I see a patient in the telemedine column, I know I have to have a telehealth visit.

It is SOOOOO easy to call one when I have five or ten minutes here or there. No particular order. And, when it is convenient for me. The video chat can take a little longer.

But, at the same time, I want to do SOME video chats and to be honest, less because they are better, but I just feel better and feel less likely to be audited (not that they are supposed to do that), if I have a 4 to 1 ratio of video chats. While audio only is accepted it does say in the law that it is OK when there are reasons why video can't be done. Now, I can make a case that there are so many that video is a time constraint. And, that patients can't do it.

I also think that the current law is set for 90 days, and they will then re-evaluate. My feeling is that we HAVE to make those 90 days count, especially since we don't know when we could be out 14 days. I must say I would rather get it and be out the 7+ days, and know that I won't be quarantined again. It would be hard to be a "close contact" of a known positive person, be out, then come back and be a contact again.

With the lax unemployment laws, if it gets really slow, one could lay off an employee who would likely be happy. But, given the fact that I have to rake in the bucks during these three months (March 6th to June 6th), AND I am on the "front lines" I don't feel too guilty talking to a patient about conjunctivitis and charging a 99213 for an over the phone visit. It is still doing what the CDC and the government want, which is keeping the parent and the child at home so they don't infect someone or get infected, so a 99213 isn't a huge price to pay.

I wanted to post an update on payer reimbursement. We have gotten paid by 2 private payers for telemed. Both paid about 60% of a regular 99213.

Is that a different reimbursement or the same. We generally charge a 99213 $105 and get $70 from MC and around $75.00 from the privates.

Different - about 40% less than an in-office 99213, which is usually pays about $70. This is for 2 private payers: Cigna & UHC.

Medicaid is paying the same rate but in TX we get only about $40 for 99213!

The doctor is seeing enough patients to fill up his morning in-office or telehealth. He leaves after his last patient,but us, his staff, stay and triage calls and get any additional work we have. A couple of times a patient has called and wanted a telehealth visit after he leaves. So if he does a telehealth visit from his home (he has access to AC from home) is that still billable? I know things are lax right now, but is that also?

I can't see why it wouldn't be. It shouldn't matter where he is sitting at the time. I am damned sure billing for it. I think everything they are doing is to flatten the curve on the Coronavirus thing. I don't think they care about the doctors as much as they don't want everyone sitting in a waiting room.

So, if they didn't pay for a doctor to do telehealth from home, it would mean the doctor would be more likely to send the patient to the ED.

In fact, I am thinking of doing everything from home. Or as much as possible. I just don't see how doctors can work in office four or five days a week and not be exposed to it.

How many staff stay? How many staff does it take to do the triaging? Why not do it from home?

I figured it didn't matter if he did the telehealth from home or in the office, especially since he can remote in, but a biller asking advice from another office was very skeptical about it and made me question myself.

There are two of us who stay in office, myself and the MA. The MA stays here for things like blood draws, shots and checking blood pressures and also amazing how many calls we get after the doctor leaves. We do not have an answering service and we do not want to give out our personal numbers. Some patients do have the doctors cell number but they are pretty much respectful and call the office first.

We occasionally work from home if there is no need to come in or after hours.

No, I may be wrong. But, logistically I don't see the difference.

I was asking because I thought I could offer some ideas. Sure, a VoIP phone system may be difficult to put in, but if you have VoIP you can plug the phone in at home and it would be like being in the office. Yes blood pressures and blood draws and shots are hard from home but then you could be at home. Or they could be scheduled three days a week.

Of course, you wouldn't them to know your cell pone or home phone. Just an idea to limit your exposures.

It is not really a matter of logistics... as always, it is a matter of insurance company policy. Currently, as part of the emergency - so this is temporary, Medicare, (Maryland) Medicaid, UHC - and I am sure some others - say "Place of Service (POS) equal to what it would have been had the service been furnished in-person". So if you would have seen them in the office, the POS is 11, regardless of where the provider sits when they perform the service.

Coming back to Serene's point above about being paid less for a telemed visit... Bert posted the notice above from the Governor of Maine, mandating:
a. parity between telemed and in person reimbursement
and
b. parity between pure audio visits and those with video.

I understand that is the case in Maine, but I do not think it is a national policy. Perhaps in Texas, the privates can pay less for telemed than in person, and less for phone than video.
I know that in Maryland, phone is reimbursed less in many cases. While many private insurers are stating that they will pay the same for telemed, I do not believe they are required to do so.

That may explain Serene's experience in Texas.

Still early with reimbursements coming in but so far so good for near equivalent charges for secure video chats as office visits, (medicare about 20$ less on 99213) and we will do telephone consults if patient unable to do secure video chats. Another nice feature with Updox and the secure video chat is when I am done "facetiming" with the patient I can print up a summary from updox secure video chat by clicking the tab "summary of secure video chat" and the amount of time is recorded, so that helps me determine level of service as well as the complexity during the visit.
Also, I am discovering all kinds of niches for secure video chats, the more I use the more I discover, depression with phq9, cellultis, chest pain screening, diarrhea eval, allergies, colds/covid 19 questions, bp f/u.
I don't know about any of you but I am having to retrain my brain on how to handle the office during the pandemic, very few face to face appts maybe 2-3 at most a day, and calls and portal messages and secure texts most of the time are turning into secure video chats or telephone consults with me, but by the end of the day I am really tired. I think a lot may be stress worry but some of it just learning how to do things a bit differently without the tactile sense involved.
Trying to get at least 10 visits (virtual or face to face) a day and most days exceeding that for now.

Thanks jimmie,

I really hope you can get that three face to face visits down to 0. We have closed our practice to any in office visits. Too many finger touches. Too many coughs. Just too many asymptomatic people. I think the biggest threat to your office is your getting Coronavirus if you are a solo doc. I don't like working from home, it just doesn't seem comfortable.

The only thing I worry about are the five-day-old newborns. It's kind of an important visit. We even put the one-month visit out until two months. I'm telling you. They don't want to come in either. I will do zoom with them even if it is a 99213.

We did a blast text to 1575 successfully recipients about the availability of TM with a link to a document I wrote. Many people don't know and don't want to come in. Every once in a while I feel guilty about the 99213 with what used to be a message, but you know what, I have done 100,000 pages in 24 years for free. Our office has pulled its hair out every day handling 15 triage messages which turn into 25. So, we try to turn them into TM. I think the idea and I know Janet Mills, our governor, is just trying to keep patients healthy but out of the ED and keep the doctors healthy and afloat. So, they would rather err on the side of a TM that should have been a message. My CMA sent me a message from a patient. She said I didn't think it was of an acuity for a TM. I ended up spending 35 minutes on the phone. Back when things were normal, I would have replied back to my MA, yeah change the zantac to pepcid and sure increase the Prozac.

We would love to do zoom, but I can do do 20 TMs in the time it would take me to do 8 video. The beauty of the telephone only is most aren't scheduled, and I can go down the list and do them in 10 minutes. But, if they need 30, I give them 30. But, with video, it means scheduling it, my MA setting it up (or I), teaching the patient, etc.

Don't get me wrong, I am envious of you. And, you are doing a more thorough job that I. But, I find I end the day feeling refreshed. Almost like Concierge.

The only thing I worry about is switching back to face to face full time. First, I worry about filling an empty schedule with the exception of those that are rescheduling and we reschedule. And, just changing. I will say my concentration is down, and it is easier to say you I will have to think about that.

Did you find the blast messaging helpful to increase the telephone consults?
Not sure if I am being any more thorough than you, more than one way to skin a cat. But my nurse and I are getting a lot smoother at transitioning from the face to face schedule to the virtual visits. She will call each one and ask about doing a secure video chat or pushing off visit for a month or two, surprisingly most, at least 2/3 want to try a secure video chat or telephone consult if they don't have a smart phone or computer/laptop with a camera/mic. Either secure video chat or telephone consults are quite a bit easier to fit into the schedule at a moments notice, can be quite a bit more malleable with the schedule than with face to face appts. Stay safe.

Thanks Serene. Coming from you that means a lot. Maybe I am milking the system, but we try to convert messages to TM. If you think about it, it's safer than my CMA handling it herself or sending me a message in a busy day. They are getting a reply back and it is an actual one on one with the doctor who handles it right there. MaineCare's whole idea here is to keep the patients at home, so they don't question the visits as long as it is well-documented. Private insurance is a little harder, because even though they are mandated by our governor to both cover and cover at full reimbursement, and copays and deductibles are waived, an occasional EOB and bill gets through. We have to let everyone know it is a paid visit that should be covered.

@jimmie We haven't noticed a huge uptick in calls. Of course, this all happened so quickly, it has been difficult to get the audex the same. Plus, one nurse quit, and the other nurse is working from home. My biller is working from home. I could, but I feel much more efficient in the office. I see newborns and one-months, but two-months can wait until 4 months. I believe Pertussis and pneumovax are the only vaccines that matter. Don't see much Hep B, diphtheria or tetanus in our area. But, if they got pneumococcal meningitis or Menigococcemia, that would be bad.

I was taking hydroxychloroquine as it had passed all the clinical trials that Trump did. And, Zithro. Then I got nervous about prolonged QT and it was making me rather tired. If it is efficacious,it seems that prophylacticly it would be helpful. Of course, treatment makes sense. Remdenisver seems promising.

For the past four years I have taken Tamiflu daily for four months. So far, so good. Unfortunately, I think it has no efficacy.

MaineCare is unblievably help here. They are taking off a lot of restrictions on huge groups of meds like any asthma med, DME, etc. I can't list it all.

I am not doing testing as I consider every positive an exposure no matter how well I gown and glove and N95. I strongly feel that drive through testing is the way to go. Those who are doing it are trained and have volunteered to do so. They do have the right equipment. Their masks are fitted. Some of the Abbott tests are rapid turnaround. We have to beg to get testing kits. There are great reasons to test, but I just don't see the benefit being worth the risk. I don't mind saying that. I have done 10,000 strep tests and 5,000 RSV and Influenza tests and never been infected wearing nothing. Just not going to get Coronavirus after my third test. As stated earlier, I was coughed on six times and sneezed on three times by a 17 year old with symptoms who had returned from Florida recently by airline. I didn't sleep until her test came back, and there are false negatives.

Reply to Jon & Bert.

Yes, each state has different parity laws. I thought TX had parity, but on closer inspection, it's not really payment parity, just coverage parity. You can see all the different state laws here: https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies#

Thank you Bert! I did change the message already but we're still not seeing many people interested in telemed. Or maybe it's just because nobody is getting sick. I need to find another way to blast text message all the patients. I did it on Updox but unfortunately, we have been putting the patients' cell phone numbers in the "phone number" box instead of "cell phone" box since we started using AC and the Updox blast only reads the cell phone box.

Serene,

We ran into the Home (landline) vs Cell problem twice. But, of course, 14 years ago a lot less four-year-olds had a smart phone (actually I mean people in general). We got lucky lately because most people give us their cell phone, and is has to be in the home field of both medware and AC to show up. Unfortunately, our demographics sheet for patients always says Home ___ then Cell ___. And, people still have landlines.

We use 1800notify.com for sending our texts. Amazing web interface and support is always Melinda. I think she may be the only one who answers the phone. Anyway, you pick a date in the Medware scheduler and load an Excel that it documents and choose when to send out the reminders. Out of 20, maybe 2 will be landlines and will be yellowed out.

With out blast texts, we queried not seen after 48 months and not inactive. This can be exported to a cell sheet. Emailed it to Melinda and clicked on the result. We got 1709 patients of which about 75 had errors. We made an Excel sheet and entered about 100 cell prefixes from the good ones, then used a couple of scripts to put them in order and delete the duplicates. So, we had a list of 50 good cell phone prefixes.

We went through all 75 and using AC (moving a cell phone number if there to the home field) and into Medware looking and fixing any ones we could. We ran it again and we were down to about 45 still not working. So, we wrote the text messages and sent the new Excel sheet and the message to Melinda. Along with the text message, we had a link they could click which went to a document (you are welcome to look at it -- I edited it like 20 times) on a website. She sent the text at 11:00 am and almost all were successful. We sent the document as a letter to the 45 without addresses and the few that didn't work. (their carrier verifies it hit their phone). So, I would say around 1675 got the message. It was funny. We had six people come in that day for regular appointments, and all of them had it on their phones.We also corrected a lot of cell phone numbers in the process. We now ask specifically for their cell phone. As you know. Everyone checks their text messages. You can have it call or email them. The funny thing was. In all those texts only two opted out. You would have to think at least five would have transferred and hadn't been inactivated.

Just curious how many positives for COVID-19 have you all had.

I have had 1/9, nasopharyngeal swab +.

I have had 0/0 as I still don't have tests in office.

I did have an 87 year old be admitted to hospital (through ER) and die of covid. hospital has access to testing.

I'm 2/6, both healthcare workers, both testing (+) 2 weeks after initial (+), neither very sick.

It has been difficult to get the COVID swab kits from LabCorp or Quest in our area of Central Florida. Now I think I know why. LabCorp just announced a program to send home nasopharyngeal swab kits to any patient who requests them directly by signing up on their website. The patient has to pay $119 upfront, most insurances will reimburse $50 or less. It is the national labs' version of the $10 paper mask rip off, to victimize panicked people.

It is nice to see Americans pulling together to support each other during the pandemic. Not only big companies like the national labs, also those mega businesses and organizations like Harvard University, ShakeShack and Ruth Chris Steakhouse who used their relationships with the banks to jump ahead of the small businesses and soak up millions of dollars of Paycheck Protection Program funds, leaving the small businesses to go broke.

Wow, I am not a fan of his, but was Bernie ever right about American Big Business.