Overview: There are numerous moving pieces involved in virtual care / telemedicine programs (for this discussion, collectively referred to as “virtual care”). When developing or expanding a virtual care program, it is important to (1) identify the details that are involved and (2) ensure that the details are addressed. The use of a diagram (schematic or model) can be extremely helpful in accomplishing this. 1,2 The following provides examples of the details that might be included in a virtual care program’s diagram.
1- Provider: There are several items to review regarding the provider that you may have provide virtual care services. For example, is the provider an existing employee or contractor who is already providing in-person care? If there is an existing employment / professional services agreement (PSA), is virtual care included? If not, the provider’s compensation may need to be revised (e.g. increased).3 In this situation, it can be helpful to draw-out or diagram the relationship between (1) your company, (2) the provider, (3) the contract between your company and the provider, as well as (4) the current and potential future compensation rates.
2-Payer: Your organization may have contracts with payers for in-person or “boots-on-the-ground” care. Do the contract(s) include virtual care? If not, a contract amendment may be needed. Is the virtual care service reimbursable by the payer based on the state, the provider, and the service line? 4,5 A diagram illustrating (1) the contracts, (2) the payers, (3) the states that are involved, and (4) the services to be provided can assist in determining if there are any gaps.
3-Policy/Legal: Healthcare is replete with oversight. Virtual care is no exception. It may be helpful to create a diagram that includes all of the details of the service offering as well as a high-level summary diagram. The ability to clearly illustrate and explain the virtual care structure can be helpful when reviewing the model with staff from legal and compliance. Also, when possible, include legal and compliance early in the process to “run the traps”.6
4-Place: Where will the virtual care sessions occur? There are multiple scenarios that are possible, such as traditional hub-spoke, direct-to-consumer, tele-clinic, and remote patient monitoring. A diagram can be helpful in identifying the various locations as well as related details. For example, in a hub-spoke model the diagram can show (1) where the consulting provider (e.g. remote provider) will be located, (2) where the originating facility (e.g. referring facility) is located, and (3) where the receiving facility (e.g. hub facility) is located. The diagram can also include the contracts that are in place as well as the fees that are involved. This level of detail can assist in clarifying the virtual care model as well as reviewing patient referral patterns.
5-Platform: When discussing or exploring “virtual care”, the platform (or technology) often receives significant attention. With regards to the platform, diagrams are helpful to identify (1) who is paying for what portions(s) of the platform, (2) what platform is being used, and (3) the individuals who have (or will have) access to the platform. There may be scenarios where a hub facility (e.g. receiving facility) would like to provide technology to a non-affiliated originating facility (e.g. spoke facility) at a reduced or no fee. A diagram with (1) contractual, (2) service line, (3) facility, and (4) provider details may be helpful when requesting to provide technology at less than fair market value. 7
6-Patient location and fee: In virtual care, the location of the patient should be determined as early as possible. In some models, such as direct-to-consumer, the patient may need to make a payment prior to accessing care. In other models, such as hub-spoke, the expenses associated with the patient receiving care from a specialist via virtual care may be included in the patient’s global hospital bill. Using a diagram to illustrate details such as (1) the patient’s location, (2) the consulting provider’s location and contractual status with the healthcare facility, and (3) payer reimbursement status may be helpful when reviewing the model with legal, compliance, and accounting to ensure the correct billing process.8
Closing: When creating or expanding a virtual care program, the use of diagrams should be considered. They can assist key stakeholders, such a legal, compliance, and accounting staff, to potentially identify items that may need additional analysis or review. This in turn can support the program’s success.
1.Laserfiche (2020). How to Diagram Your Business Process. https://www.laserfiche.com/solutionexchange/how-to-diagram-your-business-process
2.Lucidchart (2020). All About Business Process Mapping, Flow Charts and Diagrams. https://www.lucidchart.com/pages/business-process-mapping
3.Lacktman (2017). Foley.com Telemedicine Service Arrangements and Fair Market Value Assessment https://www.foley.com/en/insights/publications/2017/10/telemedicine-service-arrangements-and-fair-market
4.Lacktman (2019) Foley.com New 50-State Telemedicine Survey Finds Significant Progress in Commercial Payer Laws Nationwide. https://www.foley.com/en/insights/publications/2019/12/50-state-telemedicine-survey-commercial-payer-laws
5.Famakinwa (2019) Homehealthcarenews.com. When it Comes to Telehealth Reimbursement, ‘Just Start Billing’ https://homehealthcarenews.com/2019/08/when-it-comes-to-telehealth-reimbursement-just-start-billing/
6.Pratt (2019). Medical Economics: How to avoid the legal risks of telemedicine. https://www.medicaleconomics.com/news/how-avoid-legal-risks-telemedicine
7.Public Health Institute (2109) The Center for Connected Health Policy. Telehealth and Medicare. https://www.cchpca.org/telehealth-policy/telehealth-and-medicare
8. Lafolla (2020) evisit.com How to create your telemedicine billing policy. https://blog.evisit.com/create-telemedicine-billing-policy