What the end of the COVID-19 public health emergency (PHE) means for dermatologists
Answers in Practice
By Faiza Wasif, Associate Director, Practice Management, May 1, 2023
Each month, DermWorld tackles issues “in practice” for dermatologists.
The Biden Administration announced that the end of the COVID-19 public health emergency (PHE) will be on May 11, 2023. This announcement is both welcome and overwhelming. The pandemic brought with it many fears, uncertainties, and challenges. The end of the pandemic may bring similar sentiments because although the worst may be behind us, the many flexibilities and exemptions that were put in place during the pandemic may also be coming to an end. But with awareness and preparation, dermatologists can begin to re-establish pre-pandemic health and safety standards and billing practices.
Telehealth flexibilities ending after the PHE and 2023
HIPAA provisions
During the PHE, the Office for Civil Rights (OCR) used discretion in collecting penalties for the “good faith use of telehealth.” This meant physicians could use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA rules. HIPAA-related concessions are set to expire at the end of the PHE on May 11, 2023.
Medicare physician supervision requirements
CMS temporarily modified the regulatory definition of direct supervision during the PHE. Pre-pandemic, direct supervision required the supervising physician or practitioner to be “immediately available” to help and give direction during the service. However, during the pandemic “virtual presence” of the supervising physician using real-time audio and video technology was permitted. This broader definition is set to expire at the end of the calendar year in 2023.
Remote evaluations and virtual check-ins
During the PHE, physicians can provide remote evaluation of patient video/images and virtual check-in services to both new and established patients via a number of communication technology modalities, including synchronous discussion over a telephone or exchange of information through video or image. Following the end of the PHE, these services can only be provided to established patients.
How does this impact dermatologists?
Dermatologists should prepare to revert to pre-pandemic:
HIPAA compliance requirements to provide telehealth services to patients beginning May 11, 2023. See additional Academy guidance.
On-site supervision for services.
Providing remote evaluation of patient video/images and virtual check-ins to established patients only.
Telehealth provisions that end on Dec. 31, 2024
Federal telehealth flexibilities
The Consolidated Appropriations Act of 2023 extends the following flexibilities through Dec. 31, 2024, which were originally set to expire 151 days after the end of the PHE:
Originating site and geographic restrictions
Medicare beneficiaries in any geographic area can receive telehealth services, rather than beneficiaries living in rural areas only and home can be one of the originating sites.Qualifying physicians eligible to furnish telehealth
Dermatologists can continue to offer telehealth services to patient until the end of the flexibility.Coverage of audio-only services
Some telehealth services can be delivered via telephone instead of equipment with both audio and video capability.Federally qualified health centers (FQHCs) and rural health clinics (RHCs) furnishing telehealth
FQHCs and RHCs can provide telehealth services to Medicare beneficiaries rather than limited to being an originating site physician for telehealth.
State telehealth flexibilities
During the pandemic, physicians and non-physician clinicians could provide telehealth care to new and established Medicare patients across state-lines without restriction. This flexibility will remain in place through Dec. 31, 2024. However, physicians should consult state law as there may be additional licensure requirements. These flexibilities may not apply to private payers. Therefore, it is best to check with individual payers before providing services to ensure appropriate reimbursement.
How does this impact dermatologists?
Dermatologists may continue to provide telehealth services:
to new and established patients via audio-only and other remote technologies until Dec. 31, 2024; and
across state lines, if state law permits, to new and existing Medicare patients through Dec. 31, 2024, but should be diligent in checking with private payers before providing services as their flexibilities may differ.
Other flexibilities
Testing and vaccines
The FDA has the power to authorize vaccines, tests, and drugs on an emergency basis. The FDA notes that the end of the PHE “will not impact FDA’s ability to authorize devices (including tests), treatments, or vaccines for emergency use. Existing emergency use authorizations (EUAs) for products will remain in effect and the agency may continue to issue new EUAs going forward when criteria for issuance are met.”
How does this impact dermatologists?
Most dermatology private practices are exempt from the CMS vaccine mandate. However, it may be judicious to consider encouraging your practice staff to get vaccinated voluntarily to minimize the risk of staff shortages and other related operational pitfalls. Ensure your practice has documented policies and procedures in place to address this issue.
iPLEDGE
iPLEDGE is a distribution program designed to prevent pregnancies in patients taking isotretinoin and to prevent pregnant people from taking isotretinoin. During the PHE, at-home pregnancy testing was permitted to satisfy the requirements of the iPLEDGE REMS program based on prescribers’ best judgment. Unfortunately, this flexibility will no longer be in effect and patients who can become pregnant will have to submit a pregnancy test from a CLIA-certified lab after the PHE. However, the AADA is actively advocating with the FDA and the Isotretinoin Products Manufacturers Groups (IPMG) to maintain the at-home pregnancy flexibility and other critical changes to the program.
How does this impact dermatologists?
Dermatologists should plan to go back to pre-pandemic requirements for pregnancy testing in preparation for the end of the PHE and watch for incoming updates from the AADA’s ongoing conversations with the FDA and IPMG to improve the program.
Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS)
Due to the pandemic, the MIPS Automatic Extreme and Uncontrollable Circumstances (EUC) policy was applied to individual eligible clinicians who did not submit any data for the performance year 2021, and therefore received a neutral payment adjustment for the payment year 2023. This automatic exemption is not being applied universally for the performance year of 2022 and 2023. However, individual physicians, groups, virtual groups, and APM entities have the option to submit a MIPS EUC application and request reweighting.
How does this impact dermatologists?
If you are required to participate in MIPS and are seeking the EUC exemption, be sure to complete your application. Otherwise, you may be subject to a penalty for not submitting data for the required performance period. Visit the AAD MIPS step-by-step guide to keep abreast of the new requirements each year: staging.aad.org/mips.
Stark Law
The physician self-referral law prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which they (or an immediate family member) have a financial relationship and prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payer) for any improperly referred designated health services unless you meet one of the many exceptions. During the PHE, CMS permitted certain referrals and the submission of related claims that would otherwise violate the Stark Law, if all requirements of the waivers were met. These waivers are set to end at the end of the PHE.
How does this impact dermatologists?
While these COVID-19 waivers may not apply to most dermatologists, if you were operating under any of these provisions, plan to go back to pre-pandemic requirements under the Stark Law or ensure you qualify for one of the exemptions.
The COVID-19 pandemic shed light on many vulnerabilities, inefficiencies, and shortcomings within the patient and physician care system. While tragic on many fronts, the silver lining was that patient access to care expanded, some bureaucratic obstacles were reduced, and the magnitude of physician and staff burnout gained the attention it deserved. These gains should not be limited to the pandemic era alone as they are strides in the right direction but also just the tip of the iceberg. Much work remains and though we may have fixed one or two points in the system, we might have weakened others. So, members should rest assured that the Academy will continue to advocate on behalf of dermatologists to push for greater reduction in administrative and regulatory burdens and urge our leaders to do what is right for patients and physicians, during a public health emergency or not.
Additional information on the end of the COVID-19 PHE
Additional DermWorld Resources
In this issue
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