Introduction
There's not a lot of strong evidence that suggests that in person is substantially better than telehealth, which is one of the things that I found really surprising in doing the research. It doesn't really matter what diagnosis you're talking about depression, anxiety, PTSD. It doesn't really matter what kind of treatment modality you're using CBT, ACT. They all seem to be pretty amenable to this particular strategy. And I found that really surprising. I had not anticipated seeing the research to be as strong as it was.
Center for Medicare Medicaid suggested that most codes should be covered by telemedicine. Various other payers allowed some codes, some procedures, psychological codes to be covered, and others were not included in the list of covered codes and that took a lot of advocacy to, to change. And in some cases that advocacy was successful and some cases not so much. In terms of challenges, it was getting education for ourselves and then educating our patients in terms of how can we do it so that it's still confidential. So it's still therapeutic.
And then, so it's still covered by insurance and fits, uh, all the guidelines that are provided for us telehealth is here to stay, but in what capacity and what volume or proportion, uh, that partially depends on us as a psychology community to advocate for that and support the APA in that advocacy. And then, uh, similarly insurance coverage for telehealth is also is quite fluid thing.
And we probably have a say there as well.
Most of us are now feeling pretty comfortable with the idea in a general premise that a virtual format can be a viable treatment format. I know that when I started in this work, I was heavily biased against telehealth. And, you know, we, we did this huge pivot, you know, we had a natural experiment. And the data that we're seeing is that it's gone a lot better than we thought it was going to.
Welcome to find empathy, a continuing education podcast for therapists, where we discuss the interaction between health and emotions. My name is Dr. Meghan Beier, a clinical psychologist who specializes in chronic illness and disability. Our current series is focused on using telepsychology to work with medical populations. While the topic stories and case studies are relevant for every therapist who uses telepsychology with medical populations, the topics covered were created specifically to meet the criteria needed to satisfy PSYPACT requirements for psychologists and American Psychological Association, the Association of State and Provincial Psychology Boards and APA insurance trust telepsychology guidelines.
I hope you enjoy this episode.
Mary Wells, PhD
This next conversation will be with Dr. Mary Wells. She is a licensed clinical psychologist and professor working as part of an interdisciplinary team at Virginia Commonwealth University Health System to provide services to patients with chronic pain due to a variety of medical conditions. She has a specialty interest and is certified through the American society of clinical hypnosis in the use of hypnosis with chronic pain. In 2021, she published an article entitled, "Telehealth in rehabilitation, psychology and neuropsychology," and has an upcoming comprehensive review of this topic in the book Handbook of Rehabilitation Psychology.
Dr. Wells, thank you so much for taking the time to discuss this topic with me today.
That's my pleasure.
So I just wanted to start off talking a little bit about telehealth. I think we tend to think about telehealth in the context of COVID, but it's been around quite a bit longer. So when did the use of phone or telehealth for psychology begin?
You know, the literature goes back as far as the 1970s. So it's been around for a long time. There's been a lot of articles published probably over the last 20 years or so. The VA was really the, um, organization that kind of took telehealth concepts to a higher level and began doing a tremendous amount of research in the area of the efficacy of, uh, the whole arena of, of telehealth services, primarily to be able to serve a population that is diverse and also widespread.
So there are multitudes of studies that have really looked at both psychological conditions and medical problems where a telehealth approach is really pretty effective. And there's not a lot of strong evidence that suggests that in person is substantially better than telehealth, which is one of the things that I found really surprising in doing the research, because my bias, as I think most of us had prior to the pandemic, was that in person was much better.
Hmm, absolutely. Yeah. You know, it's interesting cuz I worked with Dr. Dawn Ehde who does a lot of work with phone-based interventions in multiple sclerosis. And some of the things that she described even before the pandemic was that they were seeing sort of equivalent outcomes for the patients who went through both the, either virtual or telephone based, uh, intervention as well as kind of in person.
You know, I think that's absolutely true. The other thing that I found interesting was that it really didn't matter what type of treatment model you were using. My personal bias is that more of the cognitive behavioral strategies seem to be more in line with telehealth model, as opposed to some of the more experiential kinds of treatments.
But the research was pretty strong that, you know, if you're doing, um, CBT, if you're doing ACT, if you're using even mindfulness based stress reduction types of treatment programs, and there is some research on hypnosis and use of hypnosis via telehealth. Again, I'm a little biased against it. The communication degradation is real, but I think we'll talk about that a little bit farther down the, uh, in the conversation.
But again, it doesn't really matter what diagnosis you're talking about depression, anxiety, PTSD. It doesn't really matter what kind of treatment modality you're using CBT, ACT, mindfulness, hypnosis, crisis intervention. They all seem to be pretty amenable to this particular strategy. And I found that really surprising.
I had not anticipated seeing the research to be as strong as it was. So, um, that to me was one of the surprising nuggets of information that I got in doing the deep dive in the literature. And that it goes 50 years.
Yeah. And it is very surprising because I still hear a lot of people sharing that they feel that the in-person interventions feel much more effective. Um, but some of our research may be pointing in other directions.
Well, we can talk and I don't, if now's the time or a little bit. A colleague of mine, uh, in Minnesota, a guy named, uh, Dr. David Alter, who's also a clinical psychologist. Provided some information for our hypnosis organization regarding what's going on with communication when you're in person face to face versus telehealth versus telephone.
And one of the things he talked about is the challenge of communication degradation. That human beings are designed and have been for, you know, as long as we've been in existence for face to face communication. There is a lot of communication that takes place nonverbally. And when you are using a, any type of device to facilitate communication, you lose some of the richness.
And when you're doing particularly psychological treatments, when so much of what we are attending to are those subtle shifts and changes and subtle cues, uh, there is a risk of losing some of that potency. Hmm. Now, you know, the, the research studies don't show that, but I think when you're looking at what the clinical experiences, you're gonna find that there is some loss of the richness.
The other thing that most clinicians, you know, now that we've been doing this for a little while, our finding is that doing these types of inter interactions with patients are much more fatiguing mm-hmm than one on one in person.
Yes. I've heard that even from patients that just being staring at a screen can be very fatiguing for long periods of time. And I've even had patients who turn their video cameras off, um, because it becomes so fatiguing during sessions or doing during group sessions. So I think that's a real phenomenon.
Yeah, I discourage that mainly because I'm relying on those visual cues that even though they're limited for the information that I can pull as a therapist, as a, as a practitioner, but I think it, it is a real challenge and it's one of the things that, um, I, I don't know if you have this on the question list, but I do have some information on that as well.
Yeah. That would be great to understand a little bit better. Can you expand on that?
Yeah. So, you know, as, as everybody knows, uh, the world dramatically changed in 2020, March of 2020 in particular. And we all rapidly pivoted from doing in person to almost exclusively virtual therapeutic interactions. Now our hospital setting dropped our, uh, ambulatory services from, you know, a hundred percent of, or almost a hundred percent in person to 80% virtual.
So, and that happened, you know, in our department, it happened within two weeks. So it was an almost immediate turnaround. And, you know, there were a lot of challenges in the front end trying to figure out how to do this. And I think there were, you know, I'm sure we all made some mistakes. But there was an article that came out in 2020 that provided some really nice information regarding how to optimize telehealth services.
Um, I think it came out of Harvard, uh, was Chen and, and his group. That talked about things that you need to pay attention to when you're working with, with folks from a telehealth perspective. And, you know, they talked about some very practical aspects. So I kind of wanna underline those.
The first being, what is your physical setup? You know, I think as we've learned the hard way from a number of major gaffes that showed up on our national TV and a wide variety of other areas that it's easy to screw this up, It's a physical setup standpoint. So having a place where you have, uh, pretty good lighting where you can be reasonably comfortable and also where you're limiting the risk of intrusion. You know, I have the advantage, uh, working from home at times to have an office with a door that closes, but, you know, I have critters and they all wanna come in and say, hello. Many of us have other family members, children, spouses, other people who, you know, certainly during the pandemic who came to move in because there was no other place to go mm-hmm and so we're all dealing with, how do you carve out a space of privacy, quiet, you know, so that you can really limit that risk of confidentiality loss.
So, you know, the other things that we talked a lot about were using a neutral background. I know for myself, I put a lot of effort into set up of where my camera is and where the lighting is, so that I have light on my face. But you know, the background is, is fairly neutral or is pleasing enough, you know, I'm a, I'm a shrink, I've got a bookshelf and a window, and I see you have the same kinds of things. Mm-hmm, , you know, setting up that space where it feels comfortable.
I think also recognizing that when you are doing these types of, of interactions with patients, that you're basically being invited into their personal space. And so there's a need to be incredibly respectful. About what that's like. I know in my own personal experience doing a lot of this, uh, work telehealth over the last few years, seeing where patients live and being really surprised in both directions. Mm-hmm as to what I see when an individual is in their home. So, you know, there are a whole lot of things about, you know, setting up sound and visual and lighting and comfort.
There's a lot about the technology set up. That's really challenging. Uh, I'm sure you, as most of us have struggled with figuring out which platforms to use. I think a lot of us sort of gravitated eventually towards zoom, because it has been a fairly robust platform.
Yeah. Our hospital system has started preferring us using our internal electronic health record access. So we, in our setting, we have EPIC and they have a MyChart video capacity that you can go directly through the chart to get in. The upside of that, is that all of your information's right in front of you. Uh, the downside is that their limit to the number of patients who can be involved. So, uh, I, I have not been able to do my small groups that way.
So, and we'll talk about groups. I know it's on the list, you know, again, finding ways of making sure that the tracking, you know, the visual tracking is okay, so is your camera in a place where you can see the other person, they can see you? And it looks at least some proximity of natural.
One of the things that I've found really helpful personally, is having two monitors so that I can put my chart up on one screen and have my patient on the other screen. And in most of our hospital setups. Now, if you go into a, a setup that's specific to telehealth, there's always two screens. Mm-hmm . That is one of those things that we found to be really helpful.
Doing the background checks. You know, the setups at the beginning of the day, I think is really important. I know at times I would get a little lax about that and then I'd find myself in a situation where, oh, I forgot to check my background. And you know, one of my doors was left open and it looked bad. Or my technology wasn't set up. I had a lot of trouble when I was going from one computer setup to another to make sure that the sound was working. Um, so those are things that become really important, you know, is just checking your system every single time you're accessing it, you know, on the patient side.
You know, I try to make sure every time I have a virtual session, a, a telehealth session, then I'm confirming with the patient that it's okay with them to do it virtually that I have obtained some type of formal consent. Mine is primarily verbal except in our first sessions. But that habit of just obtaining that consent every time I think is really important. It's a good habit.
The other thing that's really important is having a backup plan, you know, in session, the person's right there. When you're not in a session, a patient, you know, you may need to call them. So I usually start my session saying if for any reason we lose video contact, I will call you if the call drops, I will call you back.
If I'm doing any type of experiential work, I will make sure that the patient is not home alone. And that I have access to a backup number from someone else in the home. Um, again for purely safety reasons that you wanna make sure that there is access to someone else there. Um, if you're doing something that, for example, hypnosis or EMDR or any type of, of more intense, you know, memory re processing kinds of things, ego state therapy work, all of that is gonna require that additional level of safety on the patient end.
And I've had a couple of disasters with that and my, um, experience clinically. And, you know, it's pretty scary when you're talking to someone on the phone and they won't tell you where they are and they won't tell you what's going on. And then they're like, you know, don't think you're gonna send somebody out to check on me. And that's particularly important if you're doing any type of crisis stabilization work, you've got to have that backup. Hmm. Yeah.
And, and you need to teach your support staff on how to walk patients through the steps. Our electronic health record system has gotten better about that, but it's definitely a process. Yeah. That we're all learning. And you know, my experiences that as soon as I had it all figured out, they changed which platform they wanted us to use.
One of the disadvantages of working in a large academic medical center is that there's a lot of externally imposed decisions, um, in a private practice environment, in a small group practice. I think there's a lot more flexibility, but you also don't have the backup, um, it support that you do in a larger setting. Um, so these are all really important things to pay attention to.
I have found over the years that it's really helpful to let patients know what makes it easier for me. So a lot of us I'm sure have had the experience of a patient walking around in the room and you're getting dizzy with them walking around with their device in their hand.
And so I often say, can you be in a place where you can be not disturbed where you can set your phone down where we can really look at each other? I am super careful about individual's in vehicles. Yeah. I've certainly done a lot of those sessions with patients in their cars, but I always make sure that they are parked. And that if there's anyone else in the vehicle that they have given me permission directly, to continue this session with someone else in the vehicle.
Right. I think those are major, very important point points and definitely have had a few people join their session in the, in the car and have asked them to pull over to the side so that they're in a safe place, um, so that we can have a very safe and direct conversation that isn't distracted.
I had one recently where the woman was in the bathroom at the Walmart mm-hmm and she had been in there by herself. And then as soon as we started talking, everybody started coming in and I finally discontinue, I said, this is not the greatest place for this. Let's reschedule and get you, you know, get you back in, in the, in, off in person so we can have this conversation. So those are a lot of things that I think you pay attention to.
I think it's important to pay attention to your own needs in this process, my personal experience is that I had set up a schedule that was based on a fairly high level of cancellations mm-hmm and with the pandemic, that number has dropped. Yeah. And I also had mine set up on back to back 45 minute sessions, which in an office where you're getting up to go, you know, let someone out of the office, bring someone into a big office. You're not quite as locked into your chair.
And I'm actually revamping my schedule to give myself a little bit more room around each appointment so that I can get up so that I can move my eyes away from the screen because I, you know, my eyes get tired, we all get fatigued. And if you're doing a full telehealth day with, you know, anywhere from six to 10 patients, it's exhausting.
Mm-hmm . So how do you take care of your own needs in that process? Paying attention to your own physical demands, good self care. The reality that there are fewer cancellations that they can transition to telehealth, how do you build in breaks? How do you move your eyes away from the screen? So there are a lot of different components to that.
So those are kind of those details. So there are advantages to using the telehealth platforms and they include things like obviously preventing communicable diseases. There's a lot of decrease, uh, in loss of productivity because you, as the provider are not traveling and the patient is not traveling, uh, it's pretty easy to schedule again that decreased NoShow rates and definitely increased access to care.
There's also that reality of personal safety that, you know, when an individual is on the other side of a screen, they can't physically harm you. Mm-hmm . And some of us work with a relatively volatile population at times. And so those situations can be much less fearful if we are in a safer setup and telehealth provides that.
But it, you know, there are disadvantages and, and one is, you know, the whole reality of technology screwups and you know, all of a sudden you're in the middle of a very important piece of information in the screen freezes.
And loose connection. That degradation of communication that comes as just a natural result of using these types of environments. I think clinicians have to work a lot harder to establish and maintain rapport and connection. I just think it's part of the deal. There are a lot of challenges with patients who have limited access to technology.
And I think particularly in the rehabilitation population, that's a very real thing. Sometimes those limitations are because of limited internet access, internet access. Sometimes those are things more related to patient unfamiliarity or discomfort with a different types of technology options. And then there are sometimes the barriers associated with the disability population where someone might have difficulty manipulating the screen, manipulating the device. Being able to be heard clearly because of some type of dysarthric issues. Um, there are a lot of different aspects to that that make this, you know, potentially not as, as useful.
The reality for me still in a healthcare environment is that I'm still wearing a mask every day in my office. And so I find sometimes the communication can be better virtually mm-hmm I don't have a mask and I can see full face and they can see full face. But again, it's, it's specific to the situation that you're in and you have to be respectful of some of those aspects.
There is some very real difficulty with getting forms completed. Yes. And that's a real challenge for a lot of folks. I, I know I've relied pretty heavily on our front desk folks to make sure those things happen. So I don't get as involved, but certainly with, uh, paper and pencil testing for psychological like surgical pre-screening evaluations and things that gets more challenging.
And there is that potential loss of privacy. Again, that exposure of your personal space, your home environment, how comfortable are you on the practitioner end?
How comfortable is the patient on the, you know, receiving end of that? So those are all potential disadvantages that I think have to be paid attention to. Uh, we're in a place now where most of us have the option of doing one or the other, but I have a number of colleagues who have opted for total virtual visits. And it's not something I personally would be willing to do, but I think there are a lot of reasons why that becomes a very valid and viable decision to make. But it's a complicated one.
Yeah, definitely. I mean, I think I've actually gone totally virtual because all but one of my patients. Did not wanna come back in person. Um, and I think part of it is I work with people that have multiple sclerosis and they have mobility challenges. It was almost, uh, a mile round trip to walk from the parking garage to where our offices were.
Um, so for many reasons, I think mobility, transportation, um, all of these things, it ended up being easier for all, but one of my patients. And so it, you know, sometimes it's sort of the therapist and sometimes it's the patients and maybe it's a mix of both. I, I wanted to highlight, uh, one of the things you said earlier about kind of checking where people are and their location, and just sort of amplify that a little bit.
I, uh, especially working with medical populations. I had somebody have a seizure on screen in front of me. If I had not had her location or a family member's phone number, I would not have been able to get help to her. And I, I have experienced, uh, a particular patient who was moving and I was trying to refer her out and she said, oh, well, I'll just tell them that I'm in this location and really highlighting that.
That is not an okay solution and highlighting the reasons why it's important for people to share their actual location and ensure as much as we're able to, that that is accurate.
That comes with so many pieces attached to it. There's the reality. I have one patient who sees me in his car outside of his house because his connection is bad inside, but not bad outside.
Mm-hmm in that situation, I feel really comfortable seeing him there. I've had situations where folks have been. You know, a passenger in a vehicle mm-hmm, , there's also the issue. And because this is a PSYPACT conversation, there is definitely the issue of what your license allows you to do and what your organization allows you to do.
My particular academic medicine organization has opted not to provide any telehealth services out of the state. And they've made it very clear that if a patient is out of state, for any reason, even if they're just across the North Carolina border or just across, you know, the DC border, what it doesn't matter if they are out of state, our license stops at the end of that.
And it, they have not pro you know, offered the option of a PSYPACT exception. That may change. And I suspect over time it will change. But as of now, I think it's vitally important as a clinician to make sure that you are aware of what the regulations are, what the state and, and national requirements are and what the limits of your license are.
And being very respectful of how that works, because you can set yourself up for unintentional disasters if you're not careful.
Yeah. I'm, I, I think that's very true and being very clear with patients upfront that these are the limitations. Um, I've, I've had people who called in and they were on vacation in California.
And I said, we can't have this conversation today. I know that it feels very similar to any other day that you meet with me, but you are in a state where I cannot see you. It's outside of my license. Exactly. So I, I wanted to, um, just go back to highlighting group psychotherapy. So do you have any particular recommendations for, um, the evidence for group psychotherapy done via telehealth and also kind of what is the ideal setup for that based on your research?
The research as with many other areas is that it's pretty strong. There are some suggestions that you have to put more effort at the front end to create a therapeutic bond in order to make it viable. The studies, again, out of the, mostly out of the VA have been pretty consistently positive. That group psychotherapy can be provided very usefully and, and efficiently through a telehealth format, particularly with a disability population, being able to interact with other people with similar problems and not have to travel is really a gift.
I, I run a group for chronic pain patients and have for many, many years. And I have been doing it virtually since the beginning of the pandemic. We've attempted a couple of times to get back in person. And because of the effort changing circumstances that we're under, we have opted not to do that. We meet twice a month for an hour.
We do use a zoom platform because you can have more, more bodies on the, on the spot. And also I'm not tied to a single chart. And I think it's been pretty effective. I, I have, you know, there's some quotes in some of the literature that I wrote from some of my patients talking about how, you know, first and foremost, it's a heck of a lot better than nothing. Mm-hmm and that there is a loss of that personal connection.
I have two more questions for you. One is tele neuropsychology, and you don't have to dive too deeply into this because we have an entire episode on this that is gonna be, um, led by a neuropsychologist. Um, but I think the main question I had is, you know, there are some concern that test validity might be impacted by video versus in-person administration. What's your thoughts about the evidence that's out there about using tele neuropsychology?
I think the challenge with, you know, tele neuropsychology of course, is the reality that the testing materials cannot be manipulated in person mm-hmm . And so I think to some degree, it depends on what it is you're assessing and what the specific domains you're trying to tap into.
You know, how, how are you measuring those? Some of the, you know, memory based domains are fairly easy. To access using a telehealth format. I know when the VA was doing a lot of their early research in this area, their setup was very specific with someone there to facilitate the manipulation of materials.
So they had a technician on site and then neuropsychologist was not on site that I think has different implications than what we were dealing with. Particularly in the early months of the pandemic where our neuropsychology service essentially shut down, because we were unable to figure out how to do it and maintain the validity of the material.
So I think this is an ongoing question. I think there is a lot of debate right now about what we can do and how we might update and. Enhance the testing materials that we're using, taking advantage of the telehealth formats, and also looking at, you know, can you do, you know, different types of remote test manipulations using a computer instead of a person?
I think we're on our way, but we're not there yet. Right?
Absolutely. I agree with that. And final question here. I know many providers have been using telehealth, so this isn't something new, but I think it's helpful for us to remind ourselves about, you know, the basic competencies or what we should be paying attention to.
So from your perspective, what are some of the provider competencies that are needed for using telepsychology, especially, you know, if there are any unique considerations when working with rehab or medical
populations, I think first and foremost, you know, guiding light in any type of professional work, is that.
You only do what you know, how to do mm-hmm that we really look at the difference between what the license says we can do versus what our state of competency says we should be doing. And I think that's true across the board. You know, we talk a lot in the hypnosis training about, you know, you wouldn't use hypnosis to do dental work unless you're a brain dentist.
Right. So, you know, I think there's a lot of overlap in that concept that you really wanna make sure that you are not attempting to do more than you would normally do within the framework of telehealth that you would do in your office. So that would be the first thing. The second thing is I think you have to be more tech savvy than most of us have been required to be in the, in the past, particularly those of us on the older end of the spectrum.
The other thing I think that's really important is paying attention to bias. I know that when I started in this work, I was heavily biased against telehealth. And, you know, we, we did this huge pivot, you know, we had a natural experiment and the data that we're seeing is that it's gone a lot better than we thought it was going to.
Mm-hmm I think there was a study that came out in American Psychologist, looking at attitudes about telehealth pre and post pandemic and how they changed. And most of us are now feeling pretty comfortable with the idea and a general premise that a virtual format can be a viable treatment format.
Having to set that if you're gonna do it, talk to somebody who's doing it, mm-hmm, find out what the challenges are. Read my book chapter, read other people's book chapters, get a sense of how you need to approach particular problems, because it does bring up some weird ethical challenges. One story, I was doing a, a telephone session with someone who did not have access to the, to a video.
I had seen her only once before she had been referred specifically for health psychology, pain management type strategies, but had a clear and much more complex psychiatric history that was being treated elsewhere. I get on the phone with her. She starts in almost immediately with this download of emotional torrent of mess, family issues, arguments with family members, blah, blah, blah, blah, blah.
It kept escalating. And the next thing I know, I'm trying to say, can you tell me where you are? Mm-hmm I'm not telling you where I am. You're gonna send me to the crazy house. And I went, oh my, okay. So, you know, as a relatively skilled clinician, I felt comfortable essentially talking her off the ledge. And I felt okay, when I got off the phone that she was gonna be right, but I also thought I'm never doing this.
And those are the kinds of experiences that if you can talk to your colleagues or read some articles or get some hands on ideas about how you can avoid those kinds of problems, then it's much easier. So these kinds of conversations doing this type of, of continuing education is really important to, you know, keep your chops up in the area of telehealth.
The other thing that's, you know, this is a rapidly changing area and the rules around how we are allowed to use telehealth and bill for telehealth and get reimbursed for telehealth. Are going to be changing over the next several years. They already have. They already are. A lot of these things are still premised on us being in an emergency setting.
Yeah. And emergency declarations are starting to expire and they're gonna change the landscape. And so if you're going to be doing this, particularly if you're doing this exclusively, you have to stay on top of what that landscape looks like, so that you can protect both yourself and your patients for unexpected bills and a patient come in and said, I have to see you in person because Medicare allows me to see you.
But my secondary doesn't. Mm,
mm-hmm yeah, that's a, that's a really great segue. We're gonna have somebody talking about billing, but we've seen that already, that things are shifting rapidly and certain codes are approved or not approved. Um, and that, that changes over time. So we have to be really aware of that.
So patients are not getting hit with massive bills. They didn't expect. I wanna thank you so much for your time and expertise in doing this conversation with me today. If people wanna follow some of your research or, or look for other, uh, your, your research articles or your book chapter, or anything else that you're doing, where might they find you or what's the best place for them to look for that information?
Well, I, I will say I've come out of a solely clinical life for over 20 years and I am just playing around in the academic medicine world just for the last few years. So at the moment I have two book chapters and that's about all the research I have out there. If people have specific questions, uh, I, I do presentations with the American society of clinical hypnosis on ethics and telehealth.
So, uh, you know, there's a presentation through their website with more, you know, conversational information about how to tie in ethical practice to telehealth. And, you know, I think it's mostly just. Popping into Google scholar or PubMed and, and looking at what's come out in the last year or two from a wide variety of folks all around the country and all around the world.
Look beyond just what we're doing in the us to get a, a really good sense of how folks are figuring this stuff out.
Thank you so much. This is really wonderful and lots of great information.
Thanks. It's been an absolute pleasure.
Anna Agranovich, PhD
I hope you enjoyed that conversation with Dr. Mary Wells. Remember if you would like continuing education credits for listening to this episode, click on the link in the show notes.
If you're enjoying Find Empathy, please share the podcast with your friends and colleagues.
Dr. Wells mentioned the changing landscape of billing in the context of telepsychology. We will pick up on this topic with Dr. Anna Agranovich she provides some helpful information and even more important resources to keep current and aware of shifting laws or changes in insurance and reimbursement. She is a board certified rehabilitation, neuropsychologist and director of outpatient psychology services at the Johns Hopkins department of physical medicine and rehabilitation.
As director of the outpatient psychology services, she was a key leader in the fast switch to telehealth at the start of COVID and has monitored billing or insurance changes throughout the course of the pandemic. Anna, thank you so much for discussing this topic with me today. I wanted to start with what were some of the biggest challenges or hurdles from an insurance perspective?
You, your team, your patients had to overcome when switching to telemedicine,
I am happy to, uh, to have this conversation. So there, there were a lot of challenges initially, and as we all know, the switch to telemedicine had to happen very quickly, uh, and without much preparation, uh, on grand, uh, scheme. And, uh, so.
Initially, I guess the thought was that most of the things we couldn't do and many clinics were closed. And then we tried to convert follow ups, uh, in form of psychotherapy or health and behavior interventions to telehealth. And then eventually, so as public, uh, health emergency were declared, uh, center for Medicare and Medicaid issued the guidelines that for insurances starting with Medicare and then the private payers to follow that telemedicine services should be covered in the same way as if we seen patients in person.
And that applied for many medical codes, as well as most of psychology codes. So ideally we would, would be able to do the same thing we were doing in person through telehealth, you know, as, as much as possible, uh, as long as we had the video and audio connection. And initially. The requirement was that we had to have both.
So if a patient didn't have a way to connect through video, we weren't able to see them. Then those restrictions were lifted for many insurances for some time. And then for some put back in place and for some have not, but I'm getting ahead of myself a little bit. There. Other challenges were that whereas Center for Medicare, Medicaid suggested that most codes should be covered by telemedicine whereas other payers allowed some codes, some procedures on psychological codes to be covered, and others were not included in the list of covered codes.
And that took a lot of advocacy to, to change. And in some cases that advocacy was successful and some cases not so much. So I guess. In terms of challenges, it was a to figure out how to do it in terms of doing it virtually and getting, you know, education for ourselves and then education, our patients, uh, educating our patients in terms of how can we do it?
Uh, so that it's still confidential. So, uh, it's still therapeutic. And then, so it's still covered by insurance and fits, uh, all the guidelines that are provided for us.
Yeah. There was a lot of hurdles that we had to overcome quickly, and I think you were a big part in sort of guiding us through all of that.
I wanted to start very basic regarding billing, um, because you know, I sometimes think that billing for. Psychological services with medical patients can be a little bit different than your typical psychotherapy patient. Um, so can you share a little bit more about that? How is billing or how can billing be different for medical patients as opposed to a typical psychotherapy patient that might be coming to a community mental health center?
So there's two buckets. If you wish of codes and type of services that psychologists could provide and, uh, typical, uh, mental health services. So think diagnostic clinical interview, psychiatric interview and psychotherapy codes of various various length, but then working was, uh, people with primary medical diagnosis who may need psychological services due to coping with their illness and various symptoms, uh, that accompany that be that chronic pain, or be that fatigue, or be that cognitive, uh, challenges associated with medical condition or injury or illness.
Uh, oftentimes what we do is we assess and treat people using their medical insurance on the medical benefits. And there are two sort of two types of codes that we use there for one set of codes for more neurological conditions and the other set for general health, which, which are called health and behavior assessment and intervention codes.
And so now practice, we use a lot of those codes, which don't require that the patient has a mental health diagnosis. They might see psychologists because they have multiple sclerosis and various, uh, struggles associated with them because they have a brain injury or a stroke or chronic pain, uh, but not necessarily a primary mental health concern such as a depression or anxiety.
So, uh, going back to billing, then we, we choose to build, uh, those codes and the medical diagnosis using assessment and intervention codes within the health and behavior domain.
So the next question is really focused on billing for telemedicine. So from your perspective, or from your experience, how is billing a telemedicine code different from in person?
Is there anything in particular that providers should be aware of when they start switching to telemedicine and thinking about how billing might be different?
Well, generally speaking, under the current, uh, state of national health emergency, there shouldn't be any difference. We should build the same codes as with what would be if we see people in person and they should be reimbursed at the same level as if we were seeing them in person.
So in. Ideal case scenario, there shouldn't be any difference. Only difference is that when we do services through telemedicine, we need to add a certain modifier in initially when telehealth just started the spring of 2020, there were a whole lot of those modifiers you could drown in. But I think by now it's only one "-95," which means services provided by telehealth.
So they should be added so that billing code. So this is, uh, if we lived in the, uh, ideal world, what actually happens is that some insurances don't cover certain codes by telemedicine. And there is no good explanation as to why, but it just the case, certain codes, for example, those health and behavior codes that I was referring to earlier are not covered by telemedicine, by blue cross blue shield and most flavors of, of, of that blue.
And there's no way around it. So there's probably the best way to. To figure out if, you know, wanting to build under medical benefits through health and behavior codes is to have regular patients reach out to their insurance and find out what the insurance representative tells them in terms of their coverage.
So there's those exceptions. Similarly, uh, for example, neuropsychological testing codes, actual testing that and scoring, uh, are covered by telemedicine by some insurances, but not others. And there's no formula to figure it out other than, uh, going on website of the insurance and, and learning what this, what the current opinion on the topic.
And that has changed over the course of pandemic as well. And can, might continue changing month by month, year by year, season by season.
Right. And as some of those emergency, some of those, yeah. How, how they might be lifted over time, that might have an impact. I, I would imagine.
So for now, we still, I just checked the most recently the national state of health emergency has been, uh, continued effective July 15th for 90 days.
It could be terminated earlier, but there is no signs that that may happen. And then there is a hope that coverage telehealth coverage will continue a bit longer. But I guess I'm getting ahead of myself again.
that's okay. So in terms of assessment codes, you, you kind of touched on, uh, neuropsychological testing.
Is there any difference for, let's say a, uh, psychometrist or a, a technician that might be helping with some of those assessments versus a provider?
Difference in terms of telehealth
mm-hmm in terms of billing.
So, uh, on sort of air on the side of caution, I would recommend that any testing by psychometrist is done in, in person.
There may be that Medicare might still be covering, but other insurances, I seriously doubt. I don't want to be, you know, be quoted as an expert on that. But many, many of the private payers, uh, stopped covering actual testing and scoring, uh, through telemedicine, but they do cover it in person. So again, there's, there's no, you know, hard and fast rule, uh, it's best to check for each particular state for each particular insurance.
Cause those guidelines are very specific and there are where this information is provided through APA through American psychological association, uh, practice association. So Dr. Beier shared a couple of links with you and one of them is about. Policies for national payers and one for state payers in terms of covering of different codes and covering telemedicine and state of emergency by state, et cetera.
So the federal state of emergency is still in place, but each state has an opportunity to create their own, their own guidelines, which they of course do.
Okay, great. Thank you so much. I'll link that in the show notes, as well as, um, in a kind of PowerPoint document that I'm putting together so that people can look up some of this information as it changes over time.
So I know we've been talking a lot about insurance, but there are many people in the community that are, um, maybe only private pay. Uh, and so they are really looking at patients paying out of pocket for their services. Is there any difference that people that providers need to be aware of in terms of doing telemedicine for people paying out of pocket versus people who are paying with insurance?
All except for Medicare and Medicaid patients, any other, uh, for any other insurances, you know, it's totally fine to, to build out of pocket, uh, with Medicare and Medicaid patients by law, you either take this insurance or you don't see those patients in person or by telemedicine.
Okay. So in those cases, you're really just looking at what are the licensing laws regarding telehealth in whatever state you're living in, if you're part of PSYPACT et cetera, correct?
Correct.
Okay. And you've kind of touched on this a little bit, but is there anything else that you think would be helpful or interesting to know about how insurance or billing has shifted over the course of the pandemic?
So, yeah, it has evolved in a bit and it con uh, continues evolving or devolve in whichever way you . So, uh, initially there was a lot of shift in the direction of inclusion and now many insurances selectively start, stop, cover in certain services by telemedicine. But again, it's so specific and could vary by specific payer in a specific state, not just national.
So it's very important to consult with those sites that, uh, we share to make sure what's covered. And what's not.
And I know that you kind of follow the landscape through APA and practice guidelines. So now that we're transitioning out of the initial state of emergency, and maybe some of these states of emergencies might be lifted in the next couple months or who knows, but what do you think, or what are you hearing is sort of the landscape looking towards the future with telepsychology?
Um, number one, do you think it's gonna stick around number two, do you see any upcoming changes that providers should be aware of other than kind of just checking back with their state and APA?
Yeah, it's a great question. And I keep looking for my crystal ball but, uh, jokes aside, I think it looks quite promising as far as mental health coverage is concerned because, uh, Medicare has already ruled that telehealth benefits for psychology for mental health codes specifically, uh, will remain permanently quote unquote, but that's gonna be the same for private payers like blue cross and Aetna and Cigna.
So on, so forth that we don't know. But, uh, also I think Medicare. Uh, just to quote, uh, recent, recent policies that Medicare has permanently removed geographic restrictions for mental health and substance use services, and permanently allows beneficiaries to receive those services at home. Uh, and another thing that Medicare also permanently covers audio only visits for mental health and substance use services.
So it can be done by by phone. So what's permanent in our world. I don't know, but that's what current regulations, uh, say. So what's likely that psychotherapy as well as, uh, initial diagnostic interview, uh, will remain covered by most insurances through telehealth, even after public health emergency has been lifted as far as the rest of the codes.
So think neuropsychological assessment, psychological assessment, health, and behavior interventions, uh, that. Depends. Uh, so for now, what we know that public health state of, uh, public health emergency has been continued for 90 days. And there have been, uh, a lot of, uh, lobbying by American psychological association, as well as other to allow telehealth health coverage to remain active for another year after, uh, public health emergency has passed.
So we haven't reached that threshold after reach the year gonna start yet. And I don't know when it's gonna start and what, what else gonna evolve during the time? So most likely telehealth will remain in some form or fashion, whether it will be as widely used as it is now, or there will be certain procedures, certain codes that we only could offer in person, uh, that I don't know, but most likely the mental health coverage psychotherapy will remain available through telehealth.
Yeah, that's, that's kind of the, the landscape that I thought as well. And maybe a year ago that I had a lunch with one of the deans at Johns Hopkins. I won't say which one. And I, um, cause I, I don't want to say anything I shouldn't, but you know, uh, what, one of the things that he said was that he doesn't think that this genie will get put back in the bottle.
Like it's very hard to completely reverse this now that we've all experienced it and our patients have experienced it and benefited from it. Although, as you said, there's probably gonna be shifts and changes over time that we all have to maintain and be aware of.
Um, the hybrid version will likely be longstanding.
Uh, I personally am not planning to ever have a full time in person clinic, but most likely it will be hybrid. Mm. Yeah,
absolutely. That's
dictated by needs of the patients as well as, uh, insurance limitations.
Right. Absolutely. And, and we'll be talking about that in some of the other episodes, too, kind of how to determine what's helpful for the patient, as well as the provider.
I, I also wanted to talk about crossing state lines. You had kind of brought that up and we know that insurance can vary based on what state the person is residing in, or maybe even where their employer is. Um, if they are working remotely, but their employer is located in a particular state. So what are the things, uh, maybe challenges or things that providers need to keep in mind when they're working with patients who are in a different state than they are, as it pertains to insurance.
So, well, first and foremost, we only can practice, right? So if we're talking about PSYPACT only in those states that, uh, have enacted the, the PSYPACT in, into law, right. It's very important to check, uh, and be compliant with laws and regulations, particular state. So not only where you are, but where you are seeing patients or clients, uh, and be familiar with whatever the rules in those specific jurisdictions, uh, across state borders or any other borders, uh, the best approach as far as insurance goes, because there are just so many variations there is to ask the patient to confirm was their insurance, uh, give them specific codes and, uh, ask them to verify their own coverage because insurances tend to be much more receptive to questions from their clients than questions from providers.
So that, that would be my, uh, recommendation, but, you know, again, going back to those websites, we share, uh, there is a lot of information that AP tries to update, uh, as much as possible in terms of various insurances and what their rules and regulations in terms of practicing across state lines and what codes they cover and whether they cover telehealth.
And, but as this is a constantly moving target, it's good to verify specifically,
that's, that's really good information. And you know what, my last question is really focused around maybe an ethical question. Uh, so recently we had, oh, a major insurance company who was no longer accepting some of our telehealth codes and, and that kind of prompted a lot of us to think about how we could transfer some of our patients so they could continue getting care.
Um, but maybe in a, in a different way. And so. You know, what do you think providers should keep in mind, you know, any guidance or, or ethical considerations, um, when we're having to transfer patients because maybe their insurance shifts or they move out of a PSYPACT state, you know, what are some of those ethical things that, you know, we've had conversations around that you think would be helpful and important for providers to be aware of?
Well, that's, that's tricky, right? Because it's, uh, ideally, you know, would be wonderful to find the different provider who a accepts their insurance or practices within that particular jurisdiction and does exactly the thing that the patient needs or the client needs. And. But it's always possible or not.
We know that there are fewer and fewer providers outside of hospital settings that accept insurance of any kind. We know that there's shortage of those who work with people with specific medical conditions, that diagnosis. So there's, there's a lot to think about. So whether when the issue is related to telehealth coverage versus just coverage for in person services, I guess one of the options is to bring people into the clinic, right.
And offer them the services that they need and be covered for that. When that is not, not possible, I guess it's our task to try to do, do our best, to find, find some continuity of care where people could get the help that they need.
Hmm. It's a real challenge. I know that we've come up against. Numerous times and something that we'll have to keep thinking about, but I clearly hear you saying, you know, we need to keep our patients in the loop and help them to advocate for themselves as well as us advocating as much as we can for what might be most helpful for them.
Exactly. And this is actually a great point because again, you know, insurances tend to listen to their clients more so than to, to ask providers. So, uh, empowering, uh, our patients to advocate for themselves and get the coverage that they need is also an important task to pursue.
Absolutely. I just had, um, the other day I'm part of, I have a, an Ms group and a few of the, uh, individuals who are part of that group decided together that they were going to put together a little mini advocacy group outside of my hands.
It was their own decision. And it just seems like, you know, that's really maybe the direction that. Um, sometimes we, we can encourage,
yes. It's important to have that conversation with your patients, you know, on their, or their families, you know, whoever can support them in that advocacy role because they need us there.
And oftentimes we are between the rock and a hard place in terms of offering the service that needed and not having any coverage for that.
Yeah, absolutely. Now one final question you can say no to this, but is, is there anything else that I didn't ask you that you think would be important for community providers or psychologists to know about.
Well, I don't know if there's anything you didn't ask about, but sort of maybe to reiterate, so A. Telehealth is here to stay, right. Um, but in what capacity and what volume or proportion, uh, that probably partially depends on us as a psychology community to advocate for that and support the APA in that advocacy.
And then, uh, similarly insurance coverage for telehealth is also is quite fluid thing. And we probably have a say there as well. Uh, so as a community, as a professional community, to ensure that our patients have access to telehealth services, which have proved to be quite helpful over the past two years.
So we, we, we can also affect that landscape and how it develops it's it's not just happening to us. It should be happening with us.
That's a wonderful note to end on. So thank you so much, Dr. Agranovich for all of your insight and information about billing and insurance. And I'm, I'm really happy that you spent the time to talk with me about this.
My pleasure.
Conclusion
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