To accommodate the need for virtual care options during the COVID-19 pandemic, telehealth became widely available, starting in early 2020. In April 2020, overall telehealth usage for office visits and outpatient care was 78 times higher than in February 2020. Since then, as of July 2021, telehealth use has stabilized at levels 38 times higher than before the pandemic. Due to shifting consumer and provider attitudes towards virtual care as well as reimbursement flexibilities from the Centers for Medicare & Medicaid Services (CMS), telehealth seems to have staying power, especially to ensure access to care for rural or underserved communities. Throughout this guide we will: Provide tips for how to adapt to the changing licensing environment in response to the ongoing COVID-19 pandemic. Describe some of the unique challenges and opportunities related to the telehealth license verification process.
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Section One
During the early days of the pandemic, Congress passed The Telehealth Services During Certain Emergency Periods Act of 2020 to provide authority to the Department of Health and Human Services (HHS) to waive certain existing limitations on Medicare coverage and payment for telehealth services furnished to Medicare beneficiaries. The services include office visits, psychotherapy consultations, and certain other medical/health services that are provided by a doctor or other healthcare provider using interactive two-way, real-time audio and video technology. The following changes were made to Medicare coverage of telehealth services in 2020:
Additionally, in the 2022 Physician Fee Schedule, CMS proposed to extend the telehealth flexibilities through 2023 instead of through the end of the COVID-19 public health emergency, which is expected to run through the end of 2021. However, many provider groups are pushing for CMS to make these changes permanent.
"Removing telehealth services from the covered code list will prove disruptive to both practices and patients alike, as patients have become accustomed to receiving these services virtually."
– Medical Group Management Association
Section One: Expanded Medicare Coverage for Telehealth
Medicare also covers some services delivered via audio-only devices, including counseling and therapy for opioid treatment, as well as virtual check-ins and e-visits.
Beneficiaries can get Medicare telehealth services for certain emergency department visits at home, as well as physical and occupational therapy services at home.
Beneficiaries can get Medicare telehealth services at renal dialysis facilities and at home.
Section Two
State medical and licensing boards across the U.S. are adjusting qualifications and waiving requirements for certain healthcare providers under emergency response declarations. License portability has become a critical and coordinated effort to meet the needs of each state to respond to the pandemic. For a deep-dive into each state’s current telehealth licensure waivers, see this resource from the Federation of State Medical Boards (FSMB) as the waivers are changing on a daily basis.
Key considerations after emergency declarations end include:
OIG-LEIE
HHS OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an individual or entity on the OIG LEIE may be subject to civil monetary penalties (CMP). There are two main types of exclusions – mandatory and permissive as outlined by HHS OIG. Read more about mandatory and permissive exclusions. Download the OIG LEIE
SAM.gov refers to the System for Award Management, a database with the purpose of preventing companies from doing business with an individual or entity that has been debarred, sanctioned, or excluded by a federal agency. Read more about SAM.gov. Visit SAM.gov
SAM.gov
Most states maintain their own list of ineligible, excluded, or terminated providers, though a few report directly to the OIG without releasing their own datasets. Occasionally, states change their process for reporting exclusions, adding or discontinuing a list. See the up-to-date list of state exclusion sources. Even if your population is only working or practicing in one or a few states, it’s still important to check every available state exclusion list. We frequently find excluded providers relocating states in an attempt to evade detection and continue participating in government healthcare programs.
State Medicaid Exclusion Sources
Industry best practice is to monitor both licensed and non-licensed employees, vendors and subcontractors, owners of vendors and subcontractors, referring and ordering physicians, and both participating and non-partcipating provider networks.
Potential Match
Potential matches are typically delivered in a spreadsheet, requiring your team to then investigate each suspected exclusion by going to the primary source (LEIE or state list) and determine whether the excluded person or entity is the same as the one in your population. Solutions that match on name only or other unreliable fields can only return potential matches.
Exact Match
Exact matches have already been confirmed by the exclusion monitoring vendor. These high-quality, high-confidence matches protect your organization from risk and make your teams more effective. Exact matches should be delivered with documentation that empowers your team to follow procedures faster and with confidence.
Section Two: State Licensing Board Updates During COVID-19
Increased multi-state licensed providers.
Health systems will continue to expand services for growth and a decrease in overhead costs.
Higher demand for electronic primary care and remote access.
Increased credentialing and privileging efficiency.
Less friction for obtaining a license in multiple states.
Ready to learn more? Reach out to our team below.
Section Three
Nurses play a critical role in the success of any telehealth program, especially for primary care and managing medication and chronic illnesses. As virtual care becomes the front door to patient experiences, nurses are empowered to determine which patients should be seen by a physician.
Registered Nurses
See this resource from the American Association of Nurse Practitioners for the most up-to-date waivers of practice agreement requirements.
Section Three: Eligible Telehealth Providers
Telehealth services are poised to help address some critical challenges in U.S. healthcare: rural health and the primary care shortage. Advanced practice providers are a key class of caregivers for addressing both of these needs. Some oversight regulations for these providers were temporarily lifted in response to the COVID-19 pandemic. However, nurse practitioners and physician assistants delivering care via telehealth must still meet the oversight and licensure requirements for the state where the patient is located.
Advanced Practice Providers
Section FOUR
Section Four: Telehealth Fraud
>$6M
defendants were charged, including more than 100 licensed medical professionals.
in alleged losses.
medical professionals had their Federal healthcare billing privileges revoked.
345
256
Since 2016, the HHS Office of Inspector General (OIG) has seen a significant increase in telehealth fraud, especially during the pandemic and public health emergency. According to the OIG, the conspirators include telemedicine company executives, medical practitioners, marketers, and business owners. As part of a massive fraud takedown by the OIG in 2020 that included telefraud, or scams that leverage aggressive marketing and so-called telehealth services to commit fraud:
In light of the rise in telefraud, healthcare organizations need to be vigilant when it comes to monitoring their licensed professionals to help protect their patients.
Section Five
Section Five: Challenges of Telehealth License Verification
Like license verification for in-person healthcare services, telehealth license verification can be extremely complex and time-consuming. Only some of the challenges include:
Contracting requirements with Distant Site Hospitals (DSTE).
Credentialing and privileging costs for each state.
State medical boards vary widely.
Variability in primary source data and data verification.
Provider delays in renewal and bulky administrative processes.
Multiple frequencies for state board renewals.
Latency in reporting disciplinary actions
Constantly evolving licensure waivers.
Section Six
It’s essential to both verify a provider’s credentials from the primary source and also be aware of any outstanding disciplinary or administrative actions that may have been taken against them in each state. Because of unique circumstances such as COVID-19, some bad actors may be looking to take advantage of interstate licensure waivers to practice in a new state while leaving behind restrictions from others. Additionally, it’s more important than ever to ensure that all obstacles are removed when it comes to your providers’ ability to care for your patients. Completing all of the steps for credentialing and sanctions screening is no easy task. To ensure no excluded providers are on your staff and that all eligible providers are able to care for your patients, you should be referencing state and federal exclusion sources, or working with a third party like ProviderTrust to automatically screen for eligibility. Our monitoring intelligence includes:
Section Six: Comprehensive Credential and Provider Monitoring Intelligence
Our vital monitoring intelligence helps protect more than 500 healthcare organizations and millions of patients. Our industry-leading service and technology ensure that dangerous providers are prevented from treating the patients in your care and costing your organization through fines and fraud. We also ensure that all obstacles are removed when it comes to your providers’ ability to care for your patients.
Want to learn more about our monitoring intelligence?
Our Workflow Designs
We serve the entirety of the healthcare ecosystem through population-specific workflow design. Our innovative technology was handcrafted especially for humans, providing actionable intelligence when and where you need it most, connecting the systems that power your organization.
Exact-Match Results
We guarantee exact-match results via automation and real, human verifiers. We analyze and interpret thousands of primary sources across every state and healthcare discipline to verify and resolve every potential issue. Our intelligence catches and verifies issues no one else can.
Our Compliance Intelligence
We enrich primary source data for always-accurate compliance intelligence. From the beginning, we set out to do healthcare monitoring better than anyone else. Our proprietary technology is innovated for the most actionable healthcare monitoring and verification insights. We leverage a unique combination of machine-driven algorithms and human governance to ensure eligibility across every population we monitor.
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Monitor across all state licensing boards for administrative actions.
Sanctions
Verify multiple licenses and credentials for every job function within your health system.
Licenses
Monitor all providers across all Federal (2) and State Medicaid (42) exclusion lists.
Exclusions
