With the spread of the Coronavirus and it’s impact on the field of counseling, I know many people are scrambling to figure out how to adapt. In order to help my fellow colleagues who may be confused, overwhelmed by technology or just don’t have time to sort through all the new information, I am compiling this straightforward guide to begin doing TeleHealth free, easily and HIPAA compliant. While I don’t claim to be an expert in this field, I do have a little technical knowledge and connections with a lot of smart, informed therapists. This guide is specifically geared towards Oklahoma providers, but will hopefully apply to others as well. I will try to keep this updated as more information comes in. This information is compiled from my own research or gathered from comments from other providers, so use at your own discretion.
Unless otherwise stated, when I refer to TeleHealth I am referring to using HIPAA compliant software to have video and sound communication with a client at a secure site.
While it is in your best interest to follow HIPAA and ethical practices, the Department of Health and Human Services is exercising their discreation not to enforce many of the HIPAA requirements on telehealth and telephonic services during this crisis as explained here.(Thanks to Lee Dodd for that one)
**Updated 3/20/2020 9:35pm**
Before getting to the How-To, here is what we know so far about insurance policies on TeleHealth during the Coronavirus Situation. These policies may or may not change when the circumstances change.
Private Pay is ideal in this situation because there are no restrictions other than making sure it is HIPAA compliant. You may want to figure out how to accept credit cards though if you do not already, but that’s another discussion.
HealthChoice has already been confirmed to reimburse TeleHealth in full, prior to the Coronavirus. Their policies can be found here. Just use Place of Service Code 02 and modifier GT* or GO. (*See Tricare/Humana for an explanation)
Optum/United Healthcare have released revised policies allowing TeleHealth during the Coronavirus. Those policies can be found here. It appears they have their own platform and policies, and their reimbursement is uncertain, but they said “You do not need join our virtual visit network in order to be reimbursed for the TeleHealth services you provide our members. Please continue to use standard CPT codes and a Place of Service of 02 for both video-enabled virtual visits and telephonic sessions to indicate the visit was conducted remotely.”
BlueCross/BlueShield OK has given mixed answers about telehealth, but most recent word is that they will be allowing TeleHealth. My good friend Cindy Freeman from the Oklahoma Christian Counseling Center said she spoke to Carol (Lore is out of town) at Blue Cross OK as of late afternoon on 3/17/20 and was told that it is to be billed with an 02 POS code and the usual CPT codes. Their website should be updated in the next day or two.
Tricare/Humana is covering TeleHealth. Reimbursement rates uncertain, but I assume it is the same. Use POS code 02 and a GT modifier*. (Thanks to AJ Brandon for providing the Link to these details) *According to the website, the GT modifier applies to “Synchronus” communication such as video chat, as opposed to something that goes back and forth like texting or messaging.
Medicare has waived a lot of the restrictions for TeleHealth during this crisis. There are some unique issues and restrictions on this one, so just take a look at this detailed FAQ. (From the CSWA via Elizabeth Fletcher)
Medicaid is allowing temporary use of telehealth and telephonic visits until April 30th. Use GT* modifier (no apparent indication that the POS code needs to be changed). The details can be found here.
Cigna sent me an email saying they are lifting restrictions on telehealth until May 31st. Use POS 02 and modifier 95. I will update with a link if I get one.
Aetna according to Lacey Leeanne she received an email and confirmed via phone call that Aetna is waiving all copays, coinsurance and deductibles for teletherapy.
Understanding the Issues
From what I have gathered, one of the main keys to using TeleHealth appropriately is choosing the right software. I won’t go into the details, but Skype and Facetime do not apparently pass muster for being HIPAA compliant. The following options have been the main ones I have found for free, unlimited, HIPAA compliant videoconferencing. Many of my colleagues have mentioned zoom, and I found out about the other options from this website.
Zoom (Here is the Link)
VSee (Here is the Link)
Doxy.me (This is the one I am using, found here.)
I found Doxy.me to be everything I needed in a super simple, professional looking package. It allows unlimited one on one videoconferencing for free and your clients can connect with you by following a link you send them, typing in their name and hitting a button. Since I am using this one, I will walk you through the process.
No matter which software you use, make sure to get a BAA printed out. That is what makes it HIPAA compliant. If someone wants to explain what a BAA is an why, feel free to share and I will update this section.
Also, informed consent is an important factor and some providers are creating documentation to address the issues related to TeleHealth. Please scroll to the bottom to see a detailed explanation of this issue from Elizabeth Fletcher and a suggested informed consent form from the American Pyschological Association.
Step by Step Guide
You and your client will both need a device that has internet access and a video camera and microphone. I also strongly encourage wifi or a wired connection so that you and your clients don’t use too much data. You may also want to consider having the option to plug in your devices so you don’t run out of power. I have found that IPads and IPhones work like a charm.
I broke down every single step, so this may look long, but it should only take about 5 minutes.
First time setup
- Go to Doxy.me
- Hit the “Get Started – For Free button.”
- Click on “I’m a Provider”
- Fill out the super short sign up page, check the boxes and hit “Sign Up”
- You will be taken to your dashboard. You can explore it and personalize if you want.
- Click on the “Account settings” button.
- Click on the BAA tab
- Fill in all the fields
- Hit generate BAA
- I advise you to download and print a copy for your records
- Hit the Pre-Call Test button at the lower left to make sure all your hardware is set. If there are problems, please contact doxy.me for support because that is beyond the scope of this guide. It worked first time for me.
- Hit the Back button on your browser to get back to the dashboard.
To start a videoconference
- Sign into your Doxy.me account and you’ll see the main dashboard
- Copy the link to invite someone to your waiting room and send the link to your client via text or email.
- Wait for your client to follow the link. All they will have to do (aside from any technical difficulties) is to type in their name and hit a button.
- Make sure to hit the button to “Turn on webcam” in the top right.
- The client should show up in the Patient Queue at the top left. Click on them and hit the button to start chat.
- Start doing TeleHealth
I hope this allays your fears and gives you everything you need to provide services during this difficult time. I invite my colleagues to comment and share any additional info so I can keep this guide updated and thorough.
Addendum: Informed Consent explanation courtesy of Elizabeth Fletcher.
“Informed consent” is a term used to refer to the ethical obligation therapists have to make sure that every part of our practice that affects patients is explained to them in language they can understand, and that they agree to it in writing only once they understand exactly what they’re agreeing to.
This is to make sure that no one who engages in psychotherapy experiences something that feels like a violation of consent, something that they didn’t expect or agree to experience, or any form of exploitation at all.
Trust is an essential part of the therapeutic relationship. The therapist is in a position of power and authority, and we have a lot of rules and guidelines that are designed to protect patients from even accidental abuses of that power. For example, if a therapist suddenly told a patient that they weren’t going to accept credit cards anymore, only cash, effective immediately, the patient might not realize that they have a right to know about changes like that ahead of time, and that it might be unethical or even illegal for their therapist to make such a change. The patient, concerned about having an interruption in their therapy, might think they have no choice but to agree right then and there. This would be an abuse of power by the therapist, and a violation of our obligation to obtain informed consent for our practices.
Instead, a therapist could provide a letter about their decision to stop accepting card payments at least a month in the future, their reasons for not accepting card payments, and some options to help patients with that transition. The therapist could then give each patient an opportunity to discuss the change in policy with the therapist and either give written consent or begin termination of the therapy with referrals to other providers. This would be abiding by the ethical obligation of informed consent.
So right now, as many providers are being proactive about protecting their patients’ and their own health and safety by not meeting in person, it is necessary for us to provide each patient with an opportunity to engage in informed consent. We will discuss the benefits and risks of telemental health and videoconferencing with patients before patients decide whether this is something they feel okay doing, or if they’d rather have a referral to a provider who is providing in-person sessions.
INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES (From the American Psychological Association)
Prior to starting video-conferencing services, we discussed and agreed to the following:
· There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
· Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).
· We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.
· You need to use a webcam or smartphone during the session.
· It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
· It is important to use a secure internet connection rather than public/free Wi-Fi.
· It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.
· We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
· We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.
· If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.
· You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
· As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.
Psychologist Name / Signature:
Signature of Patient/Patient’s Legal Representative: