Okay, well, folks are still rolling in, but in interest of everyone's time, we'll get started. Hi, and thank you so much for joining us. I'm Abby Worthen. I'm the Deputy Director of Digital Health here at the American Psychiatric Association. And next slide, please. So today we're going to be talking about what happens when the public health emergency ends, the COVID-19 public health emergency specifically, around telepsychiatry and hybrid psychiatry. So emerging topics webinars are ways that the APA supports members by providing updates on important topics and trends that are impacting your work. And you'll have the opportunity to see specialists and peers across your field during this webinar series like John and Shabana that we have with us today. Next slide, please. Thank you so much. This webinar does offer continuing education credits through your physician CME. Next slide, please. And handouts will be distributed in the follow-up email after the event. So the primary way that we're going to be interacting today is through the Q&A feature in Zoom. And what this will allow you to do is to ask questions directly to the panelists. So you might not see your question or response pop up immediately, but what we'll be doing is consolidating those questions on the back end so that Shabana and John can answer as many as possible. We will also be providing follow-up information, including a frequently asked questions document and the slides and recording after this as well. So if you don't see your question answered, have no fear. All right. So I have the pleasure of introducing Drs. Shabana Khan and John Torres today, who will be leading our discussion. Drs. Khan and Torres are respectively the chairs of APA's Committee on Telepsychiatry and Mental Health Information Technology. Dr. Khan is the Director of Child and Adolescent Telepsychiatry at NYU Lingo and Health and an Assistant Professor in the Department of Child and Adolescent Psychiatry at NYU Grossman School of Medicine. Dr. Torres is the Director of the Digital Psychiatry Division and Assistant Professor of Psychiatry in the Department of Psychiatry at Beth Israel Deaconess Medical Center. Next slide, please. So a quick disclaimer that this webinar likely will not cover every element of this topic related to your practice. This is a complex and quickly evolving field of both policy and practice. Federal, state, and facility policies differ and can change frequently and might interact with one another. We recommend that you keep in touch with your attorney, your facility attorneys if you have them, your APA district branch, and any other trusted advisor that you have to stay on top of legal and policy guidance in this area. And this presentation does not constitute legal advice and represents the views of the presenters. All right, next slide. Great. So first, some logistics. As we covered, please feel free to type in your questions for presenters throughout using a Q&A box. We will be looking at them on our side to make sure that we're able to get to as many as we possibly can. If your question is very specific to your situation or if it's very specific to coding, we may not be able to answer it live and encourage you to send your question to the Practice Management Helpline or we will follow up after the fact. We want to make sure that the presentation is valuable and generalizable to as many people as we can. So you may not see your exact question answered just due to time constraints, but we'll try to cover the overall scope of your question during our presentation. And as I said, we'll also be releasing a Frequently Asked Questions document after the fact for you to refer back to. So with that, I think we can get started and I'll pass it off to John. John, you are muted. Apologies. So thank you, everyone, for joining us today. I think this is a very relevant topic. It's why so many of us are here to learn about it. And I think I'll start with the caveat, of course, that Abby said that a lot of this is changing. And again, I think what's wonderful about being APA members and we have such great staff supporting us and you is we're going to keep on track of this. What is changing? And I think what we're going to tell you now is definitely accurate as of today. But again, I think we're all going to have to keep track of this together of what's changing and what's evolving. But let's jump into it by advancing to the next slide. So the outline of what we're going to be doing today is, again, Siobhan and I are going to be bouncing back some information we're going to share with you. I'm going to start off by setting the stage. Some of these terms you'll have heard of, some of them you may not have heard of, but it's really important that we get the terminology right. And you'll have this in references that we'll give to you afterwards because certain policies around what is an e-visit versus digital health visit versus telehealth visit make a very big difference. And sometimes getting the terminology right is important. Then we'll launch into a discussion of the comparison of the telehealth provisions before and after the public health emergency, what we're in now, but really what's coming next and what's going to change this year in 2024. We'll even look as far as 2025 on January 1st. That's as far as our horizon will go. We'll have a discussion with some cases. We'll take your questions and wrap up. And again, if some questions are very specialized, we'll get back to you. We don't want to give anyone, of course, incorrect information as we start. So let's advance to the next slide and really kind of set the stage with some common health terms. So again, I think this list at first pass is something we all know parts of it, but again, some of it may surprise. I think the one thing, at least from a legal point of view, if we think of what is an e-consultation, I think a lot of things are e-ed or online, but an e-consultation really is an interprofessional consult, right? This is where it's a clinician to clinician discussion. It could be, again, closer to you're talking to a colleague about what's happening around a plan. So there's different rules and regulations for e-consultation. E-consultation doesn't mean you consult or you meet with a patient online. So I think that's just one to note because sometimes it has different meanings, but for this purpose it has that. We're going to talk a lot about telehealth, which again is a very broad term. Our patients use it, we use it, insurance companies use it, Medicare use it. And under telehealth, right, we have telemedicine, which is a little bit more narrow as we see there, and sometimes it's used interchangeably with telehealth. Sometimes we can break it down to two things, synchronous versus asynchronous, and this will be important. Synchronous is what's happening if you're listening now, it's in real time. You're hearing me in real time. I can only do one synchronous visit at a time. I can't be doing multiple webinars even though I have the internet and telehealth capabilities. Asynchronous is a little bit different. This is something where it's kind of patients are doing it outside of sessions, the data comes to you, it may be stored forward, it may be messages coming to you. Remote monitoring clearly has become much more important during COVID. It's been hard. We can't always see our patients in person. And so remote monitoring can use different technologies that we can gather information from. We'll talk a little bit about remote monitoring. There's less sometimes regulation around remote monitoring, and we'll get to, and there's less direct reimbursement codes sometimes there are. This also, I'll jump down, it kind of fits with mobile health or mHealth, and there's a lot of excitement about apps, about wearables. Sometimes these are used for self-management. There's less direct regulation sometimes, and there's definitely less information on billing. There actually are not right now billing codes that directly often support mobile health. When we're going back to synchronous telehealth or telemedicine as we talked about here, there's audio only, right? Right now you can see me via video and you can hear me, of course, audio only can be done via phone or a system like this that we turn off the camera. We talked about e-consultation, again, a broad term, but it means between professionals. Face-to-face again, can be legally, it can be live, what you would do in an office if you had a person, or of course it could be with a video, it would not include audio only. So we have to keep that in mind with it. And then if some of you remember long before COVID began, we had these pesky terms of originating site and distant site, that never, rare terms, but originating site was where the patient is when they would receive telehealth services, and a distant site is where the clinician would be when they're offering those services. And the terms will come into play later because there are different regulations where you can see a patient if they're in your state, if they're in different states, where's the psychiatrist going to be located, and where's the patient. So originating and distant site are somewhat technical terms, but they'll be important. And again, we'll have a list of these terms for everyone afterwards, but keeping them in mind is very useful as you're reading legislation for what applies to remote monitoring, what applies to synchronous, what applies to telehealth. So a little bit of jargon, but I think again, very helpful to set the stage with it. So we'll jump to the next slide then. So where are we now? This is a question often my patients ask me too, and this is a question I ask myself, but if we're thinking where we are in terms of the public health emergency. So the public health emergency declared by the federal government, as we know, began in January of 2020, and it's been authorized multiple times. And it matters because we'll talk about coming up soon, it kind of has led to these changes that are happening and the changes in what we can do differently in the same. We expect it'll be authorized for at least another 90 days. We don't know exactly when it will end, and this is a little bit tricky for all of us and including you, because we want to know when it ends, when different policies will come into place, when we need to change our practice, when we need to change our billing or how we see patients. However, the federal government has given us a little bit of a clue. They said there'll be at least a 60 day notice when the public health emergency ends, which means that we would know around mid-February if they're going to renew it for April or not. Classically, they've kept renewing it for 90 days. There's no guarantee it would be updated or reviewed for 90 days, but I think checking around mid-February and clearly as the APA will send out updates, information for people, it's going to be extended. This, of course, is at the federal level. Most states have basically at this point expired the regulation. So before, during the height of COVID, you may remember that it was possible perhaps for you to see patients in different states, because different states have public health emergencies. We'll go into detail soon, but most of those regulations, those changes have not happened. What's interesting though, it's not just a federal public health emergency. In December, so right around Christmas time, we're thankful again, the APA staff was keeping on track of everything and Congress passed a Consolidated Appropriations Act, which extended many of the Medicare, so again, just Medicare telehealth flexibilities all the way through December 31st of 2024. So for Medicare patients, we actually have a pretty good indication of what could be happening through 2023 and 2024, and we'll talk about soon what was in that and what it means for what we can do with our patients. And of course, there are different regulatory timelines that are going to be from the state level, from what payers will demand regardless. So again, we're talking about the federal government is setting. It often does set a stage. One reason we want to keep our eyes on the end of the public health emergency is there's going to be some changes that as soon as that public health emergency switches off, that there's going to be differences to a law called Ryan Height that Shabana Khan will talk about in a second, about different things we can and can't do. So we do have to keep a very close eye and be sure on your practice of when the public health emergency ends, and we'll certainly talk about that one as well, of what will be different and what will be the same. And again, keeping in mind, just because some of these laws will continue, your state and your local policies may be slightly different. So we'll jump to the next slide with some polls. Thanks, John. So we wanted to poll our attendees. You're going to see a poll that pops up shortly on your screen. We'll give you a few moments to respond to these four questions. Please respond to share where you are in your telehealth or hybrid practice currently, and where you anticipate your practice will be in the future, particularly once the public health emergency expires. And then if you have any additional questions, responses, or ideas related to these questions, please post those in the Q&A. Okay, I think we're going to close the polling. So I'll let you start off, Shabana, on question one. Sure. So the question of what percentage of your practice is telehealth right now. So it looks like 43% of our attendees are saying that their practice is exclusively telehealth. 2% are saying that they're 100% in person at this point. So the vast majority are either mostly telehealth, 75%, or all telehealth, which is pretty striking. I think it speaks to how our field lends itself very well to this modality, and how there can be differences across specialties. And important for us to think about what factors to keep in mind as we look at a hybrid practice. When do we want to have patients come in person clinically, or due to regulatory or legal reasons or payment reasons, we would have to have someone come in person. So we'll talk about those factors. Question two is related. Again, we know in the last, since January 2020, there have been various federal regulations, as well as, again, temporary state ones that have made it definitely easier to have a virtual practice. So this question is looking at what happens in the post-public health emergency era, which is what we'll talk about those changes. And will you still want to do it? But we're seeing about a quarter of people saying they want to keep their practice 100% telehealth, which makes sense. And we'll cover ways to make sure you do that in the right way. Again, we're seeing 2% of people saying they don't want to do this anymore, which is perfectly fine. And then a good percentage of people saying, well, maybe it'll be half and half, a third, some, and then mostly. So I think it does make sense that we need to be very careful in what these changes will be in the post-PHE era. For 98% of us, it sounds like there's going to be some, we're going to need to follow these new regulations or keep up with them. So we're definitely glad you're all here. And the question of where do you think you and your practice still need support to successfully transition to a hybrid model? Vast majority, it looks like 79% indicated that an important factor will be understanding how laws and regulations will allow me to continue practicing telehealth where clinically appropriate. 10% indicated clinical best practices for telehealth, only 2% picking telehealth technology. And our last question, what components of transitioning away from the current telehealth flexibility is again, the current era that we're in, are you most concerned about? And it looks like about 35% maintaining cognitive care of patients. I think that makes a lot of sense. We all know the therapeutic relationship and the bond we can have for our patients is very therapeutic. It's very important. It certainly can be developed over telehealth. There's good evidence, but also having our patients switch between different care formats all the time is probably not ideal. I think we're also seeing right at 39%, can we reimburse? How is this going to work and be sustainable? And that's going to be what we're going to jump into right after this. And that makes sense. If you want to offer practice, we have to make sure it's sustainable and reimbursable. We're seeing other people concerned, 6% having the right technology to deliver hybrid care. We'll talk about exactly. So some systems you want to have in place is a good question. Can you do it? There were also flexibilities in a public health emergency that some telehealth systems didn't have to be HIPAA compliant in certain ways. Some things like say Facebook Messenger, you could never use, but there were kind of non-business associated agreements you could do with certain platforms that was allowed. And we will have to think about what technology now kind of does meet the legal limit for protecting HIPAA. The good news, and we can talk about the Q&A is it's not hard to do it. You just have to make sure you do find the right one. And there's a very good concern, of course, is certainly want to protect many of our patients have comorbidities, and we want to make sure everyone stays safe from COVID-19. With it, of course, if the federal government declares the public health emergency is over, it doesn't mean COVID eradicates, even though it would be a wonderful thing if it vanished. So I think it's helpful to see all of your responses and what you're doing. And again, I think the information we have now will be useful. It's also good for everyone to see, right, that we're all at different stages in this transition. And thinking about how the APA can support us, it's useful because there's not going to be one single right response or answer as we're each building our practices for the future to support these changing landscapes. So let's jump to the next slide. So we're going to compare really looking at kind of telehealth provisions during and, again, post a public health emergency. The pop quiz I'll answer is we don't know exactly when that's going to end. It could be as soon as we'll know in mid-February. It could be ending around April. It could be extended. But let's go to the next slide and look at some actual definite things that we do know. So we have a lot of text here. I'm going to go through it carefully because these details are very important. And again, our APA telehealth staff, Abby and Brooke, have done a wonderful job helping us really put this together in a simple manner. So you can continue billing Medicare for both video and audio. And again, that's important. Video and audio, tele-mental health services on a permanent basis, even after the public health emergency ends, which is a very big change. Every other field is not going to be allowed to do audio only. It is only in behavioral health and mental health that audio is going to be allowed to continue. So that's notable, right, that audio can continue on with it. So mental health, telehealth services, including substance use disorders, again, is the only category that's going to be eligible for audio only. We can have a different discussion. Is audio care as good as kind of synchronous care? We have video. There's some early data suggesting kind of if you can have patients on video, it may be higher quality care. We still don't fully know. But I think if you're given the preference, again, if a patient needs to do audio, you don't have to worry. It's going to be allowed to happen. My sense is we'll probably begin to show that video is useful when it's possible. There are many reasons why people may not be able to do video. They may be in a rural area, not have a strong internet connection. They may need help on using technology. But it's important to know that if you talk to other colleagues in other fields and they say, you cannot do audio anymore, you can go, no, in behavioral health, there's a very special exception to it. So the details is through basically 2023, all telehealth services should continue to be billed as the place of service that would be reported had the service been in person, so an office visit. What's a little bit different, we talked about that kind of around Christmas, the CMS 2023 Physician Fee Schedule establishes updated coding. So 151 days, about half a year after the PHE flexibilities end, you should transition from telephone codes, which some of you may be using, and we have our coding expert Becky Yao from the APA on the call for those questions, to new codes for E&M, for those modifiers, for 93, for FQ, which is basically audio services, and beginning to use those. So you don't have to change what codes you're using, but 151 days after the PHA flexibilities end, you should transition from those telephone codes towards kind of the appropriate E&M code with the modifiers, and again, those will still be reimbursed. For now, and the key word is now, there's no in-person visit requirement for Medicare patients. There may be in 2025, and again, I misspoke before, this gets to the Consolidated Act of Passed Around Christmas that said until December 31st of 2024, Medicare is going to extend the flexibilities that we don't have to have those in-person visits. Again, maybe different for patients and other insurance plans. State policies will be different. We'll talk soon if you're prescribing certain medications, it may be different, but on a broad level, this is important to know for Medicare patients. In 2025, which seems like a long time away, but again, in two years, there may be changes. It's probably too early to know what will happen. There'll be future rulemaking, but I think the main takeaways here are we can do audio visits for Medicare patients. Telephone, it'll be good. We should have 151 days after the billing, after the switch, we need to switch what the codes would be. For Medicare patients, we don't have to worry about in-person visits, again, with some caveats coming up around prescribing certain controlled substances of what we're doing. I will hand it off to Shabana Khan on the next slide. Thank you, John. We'll talk a little bit about controlled substance prescribing through telemedicine. I think before we talk about what the current state is and what the post-public health emergency situation may be, I think it's helpful to take a step back and look at prior to the pandemic, what were the requirements? The Ryan Height Online Pharmacy Consumer Protection Act, which passed in 2008, had the goal of combating rogue internet prescribing pharmacies. Around this time, these types of pharmacies were proliferating. They were dispensing controlled substances without any patient contact or without physician oversight. There were a lot of these websites that were available. While the Ryan Height Act was actually really helpful to combat these rogue pharmacies, it unfortunately limited the legitimate practice of telemedicine. The Act requires that we conduct at least one in-person medical evaluation before prescribing a controlled substance through telemedicine. Now, it does list seven practice of telemedicine exceptions. However, the exceptions are pretty narrow. They're technical. They don't account for much of our current clinical telemedicine practice. The other factor to keep in mind is Ryan Height is at the federal level. You also have to look at your state. The federal and state rules may not always align. Even if we have certain flexibilities at the federal level, currently, some states may have a more stringent approach to this. We have to look at both federal and state. What are some of these practice of telemedicine exceptions? Next slide. The Ryan Height Act says that the exceptions to this in-person requirement include if the patient at the time of the telehealth visit is in a DEA-registered hospital or clinic, if the patient is in the physical presence of a DEA-registered practitioner, which if they were in the physical presence of a DEA-registered practitioner, we wouldn't need the telemedicine practitioner to prescribe, but that's one of the exceptions. If the consult was conducted by a DEA- registered practitioner for Indian Health Service, that's another exception. If it's a consult that's done by a VA practitioner during a medical emergency, this exception, the next one, is what we currently have in place. As John mentioned, if the telehealth visit was conducted during a public health emergency declared by the Department of Health and Human Services, which was renewed today, and another exception is if the practitioner has obtained a DEA special registration. This act passed in 2008. Despite multiple advocacy efforts, outreach requirements by Congress and the administration, the DEA has yet to define the special registration. We're still waiting on this. Then the seventh exception is if the consult was done under circumstances specified by future DEA regulations. As you can see, we currently meet the exception for the public health emergency, but outside of that, these are pretty narrow exceptions. Next slide. Since March 16, 2020, the DEA has guidance in place during COVID-19, which states that DEA-registered practitioners can prescribe controlled substances to patients without that in-person examination if the following criteria are met. If the prescription is issued for a legitimate medical purpose, the practitioner is acting in their usual course of professional practice, communication is conducted via live interactive audio video, so it's a video interaction, and that the practitioner is acting in accordance with federal and state law. Next slide. Additional guidance that was issued and that has been in place since March 2020 is that the requirement for a separate DEA registration in each state is currently waived. Prior to the public health emergency, DEA regulations require that a practitioner obtain a separate DEA registration in each state in which the practitioner will be dispensing a controlled substance, and waived during the public health emergency. The public health emergency was just extended, as we mentioned today. We don't know exactly when it's going to expire. Unlike many federal flexibilities, including the ones that John discussed, many of them are extended for two years. Some were made permanent. This waiver of that in-person requirement before prescribing a controlled substance doesn't have any phase-out period as it stands. Unless there's specific rulemaking to extend it, as soon as the public health emergency expires, we are going to need to see patients in person if they haven't been seen in the past in person. Also, we are going to have to have a separate DEA registration in each state where patients are being prescribed controlled substances. Next slide. Just to summarize, Reinheit restrictions on the prescription of controlled substances without an in-person visit are going to resume the day the public health emergency ends. For all patients, not just Medicare beneficiaries, that in-person visit will be required before prescribing a controlled substance schedule 2 through 5 to any patients that have never been seen in person, including new patients or those that establish care via telehealth during the public health emergency. We are able to continue to prescribe controlled substances via telehealth to patients that were seen at least once in person, including those that were seen in person prior to the public health emergency or during, within clinical judgment. If it's clinically appropriate to continue that care virtually, as long as they have that one in-person assessment. While there may be regulatory action in 2023 that will make it easier to prescribe controlled substances through telehealth, including a possible availability of a telemedicine special registration that the DEA would define, those updates have not yet been made. As I mentioned, Congress and the administration through the SUPPORT Act had required that the DEA issue this guidance by October 2019, yet that deadline was missed. We're hearing from the DEA that they may have drafted the special registration and it has to go through multiple layers of review before it can be released. We are encouraging APA, ACAP, and other organizations are encouraging the DEA to open it up for comment once it is proposed rule is released. And we would absolutely welcome APA members to help us as we, once this does come out. So we don't know when it'll be, and we don't know exactly what the special registration will say, but we're hoping that it'll help with some of these issues. And as I mentioned, you are going to need a separate DEA registration in each state in which you are planning to prescribe. The DEA currently waived during the public health emergency, but the DEA would also like a practice address in each state or jurisdiction where controlled medicines are going to be prescribed. Next slide. So prescribing, or we'll shift from prescribing to practicing across state lines and some of the rules around licensure. So before, in general, before the public health emergency for any telemedicine care that's provided across state lines, the general rule is that a clinician must be licensed in the state where the patient is located at the time of the telehealth visit. In addition to licensure, we also must stay compliant with each state's medical practice act and practice standards. So those would include things like rules around patient examinations. How do you establish a doctor-patient relationship? What are some of the rules around remote prescribing? So states vary on these issues. So in addition to being licensed in the state where the patient is, we also have to look at the medical practice act and standards of the state. There are some special rules for the VA, as well as for US military, when a patient is located on a base. So if a healthcare professional is providing services through the VA and they're licensed in one state, they don't necessarily have to be licensed in another state where the patient is located. It's due to something called federal preemption. So the VA has this exception. And then there's also an interstate medical licensure compact through the Federation of State Medical Boards. Currently, there are 37 states, DC and Guam that are part of this. Many professions have interstate medical licensure, sorry, many professions have interstate licensure compacts. They are different. Most of them are different from the medical licensure compact. With the medical licensure compact, you do have to be licensed in your home state, your principal state, but you also have to get the full license in the relevant compact states. So it's not a mutual recognition model where you would just have to be licensed in one. So you would still pay the full fee for each of the state's licensure. You would still have to keep up to date with education requirements, regulatory requirements of each state, and there's an additional $700 administrative fee. So it is a different model than some of the other licensure compacts, but it may reduce some of the paperwork with applying for licenses because states can share information. And it may, in some cases, be quicker to get a compact license. And then states have some exceptions that may be relevant to telemedicine, but there are state-specific nuances. So most, if not all, states have some kind of consultation exception for licensure, where if you're not taking on direct care of a patient in that state, but you're serving as a consultant to another physician who's licensed in that state, you wouldn't need to get a license. You can provide that consultation, but every state is different in terms of how to define that. They may have frequency limitations. They may have other kind of restrictions on this. The consultation would be another exception. Follow-up care, so a handful of states, not really used that often, but there's a handful of states that have a follow-up care exception. So for example, if a patient comes to a surgeon for a procedure, they go back to their home state. If that home state has a follow-up care exception, some follow-up visits could be done without a license. And then there are some states that have registration or a special telemedicine kind of registration, not used that commonly, but one that may be helpful. So Florida has an out-of-state telehealth registration. So as long as you're fully licensed in another state, you apply for this Florida out-of-state telehealth registration. As long as your malpractice covers that care, you may not need to get a full license in Florida. So this wouldn't apply to someone who wants to set up a physical practice in Florida, but let's say you have a patient that you were seeing in New York, they're in Florida, they want to conduct telehealth visits with you during that time. If you have that out-of-state registration and malpractice coverage, you would be able to do that. So there's some, very few exceptions like that as well. Next slide. During COVID-19, most states had some kind of temporary licensure flexibility. There was significant state-by-state variation, and they were often tied to state-specific executive orders or emergency declarations. As John mentioned, most of them have expired at this point. And it can be pretty challenging as I'm sure most if not all of us have experienced navigating these state-by-state flexibilities. Next slide. So here we wanted to share some Medicare telehealth codes. This is not the full list of codes that are covered for telehealth for Medicare beneficiaries. We are going to be sharing the slides and the recording for this webinar. And the link here above will show all of the codes that are covered currently. But we have the list here for codes that are most relevant to psychiatry. So the psychiatric evaluation codes, 90791, 90792, the psychotherapy codes, add-on psychotherapy codes to E&M. There's crisis intervention psychotherapy. I won't go through all of them, but I did want to mention the telephone E&M codes that John discussed, the 99441 to 99443, which were not covered before the public health emergency. They are currently covered, but after 151 days after the public health emergency expires, we will be transitioning to rather than using these codes, using the relevant E&M code, and then the appropriate audio-only modifier. Next slide. So this is a high-level overview of particular provisions relevant to telepsychiatry, what their status is during the public health emergency, and what the status will be after the public health emergency ends. Some of these will remain in place after the end of the public health flexibilities, and some will revert back to pre-pandemic status. So that removal of the in-person requirements specifically for Medicare, so this is different from controlled substances, this is the Medicare in-person requirement. During the public health emergency, Medicare patients can be seen in the home via telehealth without that in-person examination. After the public health emergency ends, an in-person examination, there'll be requirements for both new and established patients. Due to the Consolidated Appropriations Act of 2023, this in-person requirement for Medicare was delayed until at least 2025. So at some point, there will be that in-person requirement resuming. There's that initial visit that has to be done within six months of the first telehealth visit, and then there's, currently, there is going to be a requirement for every 12 months after that. There are some flexibilities with that every 12-month requirement, but not for that initial in-person. So there is legislation that is being proposed to try to repeal that, but at this time, we will have that in-person requirement in 2025. And then the removal of the originating site requirements for Medicare. So again, originating site where the patient is at the time of the visit. During the public health emergency, Medicare patients can be seen while they're in home without having to travel to a Medicare-designated originating site. And even after the public health emergency ends, home is acceptable as a telehealth originating site when providing mental health care. And that flexibility was made permanent. Coverage of audio-only services during the public health emergency, Medicare tele-mental health services may be conducted via audio-only, and that audio-only provision of mental health care is going to be made permanent. We talked about the Ryan Hyde Act and that currently waived in-person requirement. DEA still hasn't proposed ruling related to the special registration. So that waiver will expire on the last day of the public health emergency. Then the DEA registration requirements, as we discussed after the public health emergency ends, requiring a DEA registration in each state at a physical location in each state where a controlled medicine is prescribed. With virtual supervision during the public health emergency, CMS is allowing for supervision of residents via telehealth and general supervision can be virtual for behavioral health and Medicare on a permanent basis. Next slide. So the ability for us to provide telehealth and the modality that we will use is going to depend on factors including patient characteristics, state rules, payer rules, and also your particular practice or organization may have rules. And some elements are likely to change with additional federal action. One thing I wanted to mention was international telehealth. So I know this question does come up a lot. First, there's the issue of a patient being abroad in another country while you're located in the U.S. And then there's the scenario of a physician located internationally while the patient may be located in the U.S. in a state where you're licensed. So if we start with the first scenario of a patient in another country, generally similar to U.S. states, you would have to be licensed where the patient is. So whoever is regulating the practice of medicine in that country, they may have certain licensure requirements. We would have to be licensed. Also the technology that we're using. So there's data, privacy, and security considerations. So the technology that we use when we're providing care to patients within the U.S., we have to follow HIPAA, we have to follow high tech, other federal rules, we have to follow any state rules that may be relevant. So you also have to consider what are some of the data privacy regulations in that other country as well. They may sometimes be in some cases different or more strict than what we have here. So you have to look at that aspect as well. There's malpractice. So is my malpractice going to cover this care? Your malpractice provider may say, I didn't know you were doing this. This is not a covered service, you're not licensed. So they may not cover if there is an adverse event. So there's that factor as well. And then prescribing would, you know, depending on what the rules are, that would be another potential barrier. And then the question of whether a practitioner can be in another country. So it would depend certainly for CMS or if you're billing Medicare, Medicaid, you would have to be, the practitioner would have to be in the U.S. at the time of the visit. Certain payers may also, often other payers follow suit when Medicaid issues some guidance or requirement. So you would have to look at your individual payer as well, and then your practice as well, on whether it would be okay to provide that care while you are abroad. So those are just some of the considerations at play. I'll click that. We're talking about a lot of changes in regulations. And I know before COVID, a public health emergency, clearly telehealth existed. Many of us tried it in some forms. I think what we knew overall though, there wasn't a lot of active regulation of what was happening. There were things, again, we shouldn't do things that are not permitted, but I think there was not very much enforcement. And I think that what we're seeing as, especially in behavioral health, is we're seeing this is gonna become permanent for audio. We're allowed to have exceptions. We're probably going to see that speculation more enforcement. So again, it may not be the right time to try to push boundaries, and we'll go over some cases of what those could be. But I think in essence, what we have to be careful about is, again, there's a lot more eyes, especially on behavioral health and psychiatrists as leading kind of what this new era of telehealth is gonna be. And again, so we've raised the federal investigations into some companies that were concerned about online prescribing. We have active DOJ investigations. We don't have to talk about company names here, but we've already seen issues being raised by the federal government. And again, so I think we will probably see some enforcement exercises that don't make sense. We're lucky we have the APA to track these to kind of help represent us. But I think some of it is also tricky. One thing as Dr. Kahn said is, you have to have a practice address for where you're located. And I think one thing we have to clarify is that practice address in theory is something that the government could come audit, right? You could, so it would not count as renting a mailbox. If you wanna put your children's address or something, it could be an address that gets audited, that gets coming to. So it's probably not best to have kind of an address just for the sake of an address, especially kind of in this period of change and with potential regulations around that as well. Maybe I think we have some cases that may answer some of the questions that were posed. And then I think we can jump in. So we're looking at the questions. You guys are all raising very good questions. We'll try to get some of them. But I think the cases may help. And whoever put the comment that your insurance may blow a gasket, they realize you're practicing psychiatry or medicine in a different state. This is the time to call your policies and say, am I covered for different telehealth ones? Because no one wants anyone to be blowing a gasket. So well said, whoever did that one. I agree. And we can advance to the next slide. I think we covered these points. Thank you all so much. We are going to move right along to talking through some of these scenarios. After the scenario portion, we're also moving into discussion. So as you've noticed a lot of opportunities to get your questions answered with Shabana and John's significant expertise. So as you read, as we get to each scenario, a poll will pop up and you can respond whether you think that the scenario can be done, can't be done, or whether it depends on the situation. And we'll discuss each possible response. So I'm going to start by asking Shabana, your patient, a 19-year-old student at a college in another state has gone back to school in person. Can you continue to provide them psychotherapy over HIPAA compliant Zoom? And I'll go ahead and launch the poll for your response. All right, to kind of split the majority of our attendees note that it depends or saying that it depends on whether or not we're able to provide this telehealth care 55%, 27% said yes. So I think it does depend on the situation. So let's say this patient was seeing me in my home state in my office or through telehealth where I'm licensed. Now they're back in college, would like to continue care. There aren't any other practitioners that they can connect with locally. So whether we can provide that care would depend on licensure. So am I licensed in the state where the patient is located? Is my malpractice going to cover that care across state lines? You mentioned here that we have HIPAA adherence technologies that we're using. So we're keeping that in mind as well. So it would depend on the situation and then a payer too if you're billing insurance is that, does that payer have any requirements for where the patient is located? Generally, we should be able to do it if we're licensed and have appropriate coverage for it. Thank you so much, Shabana. I have a quick follow-up question. What if the patient is just temporarily out of state and they're traveling and they call wanting to chat with you? What do you do then? Yeah, so this issue does come up a lot. So in general, let's say it's temporary if they're on campus for two months. So there's different levels of temporary, but if they're on campus for two months and their permanent address is where the psychiatrist is located, that state, some folks will say, well, can I just do it because it's temporary? No, the general rule is that you would still have to look at the state where the patient is located. And if they have a licensure requirement, we would have to be licensed even if the patient is there temporarily. If they have some kind of exception like the Florida out-of-state telehealth registration where you could apply for that, get that approval, then you may be able to do it, but otherwise you would have to be licensed. Patients do reach out to us often if they're on vacation. It's someone that knows, they know you very well. They trust you. They'll reach out to you with a clinical question. It becomes a little tricky, I think, if the state board is gonna view it differently if someone tries to set up a practice in another state through telehealth without a license versus I'm providing continuity of care for my patient, someone that I know really well. This prevents them possibly from having to go to the emergency room or a hospital locally. So I think that scenario may be viewed differently. So if we're taking a phone call from a patient out-of-state, that does happen often. So we are able to navigate those situations, but that telehealth visit, if we're providing a telehealth visit, we're billing, we're providing that care across state lines, generally we would have to be licensed. Thank you so much, Shabana, really helpful. And John, over to you. So the same patient in a different state than you, can you continue to prescribe that patient a controlled substance, a stimulant? This is a good question. It came up in many of the chats that people had. So let's quickly do a poll and see what people think, and then we'll see what the official answer is. So again, same patient as Shabana Khan explained to us, the question now is, you would like to provide them a stimulant or they're asking you for a stimulant. Can you do that? So your choices are yes, no, and depends. We'll let you guys get the last ones and let's see what our results are. So it looks like 60% depends, the majority. We have a third basically saying no, we have 8% saying yes. So what would happen is there's probably again, what Dr. Khan explained to us makes sense, there's probably three things we have to consider now that we're prescribing a controlled substance. This is where our friend, the Ryan Hite Act comes into place. So you would need to be DEA licensed in the state in which the patient is in college, right? Or again, we could say this is where your patient is on vacation. So you would have to have that DEA licensure in that state. You would likely have to have a physical practice in that state or the patient is seeing you in the home state. So in the East Coast where some of the states are smaller, if I have a patient in Rhode Island, they'd have to be coming to me in Massachusetts where I'm located. And again, that physical practice address should be a real address, it should not be a PO box. And again, as Dr. Khan said, you have had to at least have seen that person at least once in person kind of with that Ryan Hite Act. There's a little bit more flexibility in how often you have to see them going forward, but you would have had to see them at least once in person. It could be before COVID, for a college student that may have graduated, but or during COVID you saw them. So it's again, do you have a DEA license in that state? Do you, can you physically practice in that state? Do you have an address? And have you seen the person, person to person? Of course, some states may have additional laws. I saw some in the chat saying New Jersey may do things a little bit differently. This would again be at the federal level what you would need to do. And again, each state may be a little bit different or change things up, but this would hopefully be what you would need to meet. And again, as we said, this Ryan Hite Act, it's the one that as soon as that PHE changes on the stroke of midnight, this is the one that could come into effect, which is why we're lucky to have the APA kind of tracking this one with us. Thank you so much, John, really helpful. And again, a complicated area. So Shabana, back to you. If your patient is a Medicare beneficiary who you started seeing via telehealth during the pandemic, they live in your state. Can you continue to see them via telehealth only? And further, can you prescribe them controlled substances? And I need to watch the poll. All right, folks can go ahead and respond. All right, so we'll wait another moment. So this question addresses in-person requirement that relates to patient being a Medicare beneficiary, and then also prescribing a controlled medicine. So what would have happened after the public health emergency expires? So I'm going to go ahead and move on to the next question. So it looks like 58% of our attendees are saying yes, we can continue to prescribe the benzodiazepine. 29% are saying it depends. So right now, during the public health emergency, and for another two years, there was recent legislation that's putting off that requirement for an in-person assessment for Medicare patients. And that's, like I said, through the end of 2024. So you can continue to see the patient virtually and bill Medicare until 2025, either via video or audio-only modalities. But in order to continue to prescribe the benzodiazepine, as John mentioned, once that public health emergency expires, right at that moment, we are going to lose that flexibility. So if you want to continue the benzodiazepine, you would need to have the patient come in person. Yeah, so that one was a little bit of a trick question, because the answer to the first one is different than the answer to the second. All right. So John, we're going to go back to you for the last scenario. So if you've seen a, you saw a Medicare patient in person right after, you will see a Medicare patient in person right after the flexibilities end. Can you deliver care to that Medicare patient via audio-only modalities after that, or are you required to use a video platform? Yeah, perfect, we'll vote. And while we're voting on this, I'm looking at some of the chat and questions. And again, if some of these rules are a little bit confusing or don't make sense, especially with a shortage of clinicians, we agree with you. I think the APA, I think Siobhan and I get a good view chairing committees. The APA staff is working extremely hard to lobby for changes that would make these rules better so we can provide access to more people. I think everyone wants these rules to be more streamlined. Everyone, it would make sense if we can treat more people and deliver high quality care. So I think there's lots of lobbying efforts that the APA is doing. I would say almost, we have Abby and Brooke looking at every piece of federal legislation that comes out, writing responses to it, educating lawmakers, because no, this will take some change. So if you're looking at this goal and some of these policies are absurd, I can't have offices in every state. It doesn't make sense. You are correct. And again, I think it's the advantage when we have groups like the APA that we can advocate for it. We're not, no one on this, we're saying not always policies make sense. It's better we understand them and can kind of not get ourselves in trouble as we do work on a larger basis to make these more logical. So I just want to acknowledge everyone's, I'll say shared frustration about some of these. But as to scenario four, it looks like 80% say yes, 9% say no, and 11% say depends. And in this case, the yeses are correct as we started out kind of saying, audio only tele-mental health and mental health care is allowable on a permanent basis in Medicare after all these flexibilities end. So again, it wasn't allowed. It wasn't reimbursed. There was a lot of trouble to even do it before. So there's one win we've had out of this that audio can work. And again, as we said, we're not here to talk about is audio better than video? There's different cases, but if you need to do audio, in that case, you certainly can do it. And that's important to know. So we've certainly had some wins. And again, I think we'll continue to build off those. But again, as I said, some of these policies are not perfectly logical. Some of them are, do kind of require double speak or thinking if you try to balance it. But I think we're doing the best we can to at least interpret them so we know what they are and what we want to advocate for with it. And we'll jump to questions. I'll say, if you guys come across interesting policies that change, let APA staff know, letting us know about what's happening, what rules happened. If you get contacted by the DEA, if pharmacies say they won't do something, many of you have asked the question, I'll jump to it. Can I prescribe it in my state and let the pharmacy transfer the medication to someone out of state? Technically, that's a decision that's up to the pharmacy. We are getting reports that a lot of pharmacies are now saying no to transferring things and doing things. Pharmacies are getting worried about being more regulated. We saw that many pharmacies are actually now for some of these online prescription, especially stimulants for companies that started in the pandemic, the pharmacies actually refused to fill their scripts. And again, we've seen some cases where pharmacists have been willing to transfer scripts to people in different states. In some cases where they're just going, no, we're not going to do that. So I wouldn't rely on that as a way to deliver care to your patients. It certainly has been a sort of loophole before. It may work in some cases, it may not work in some cases, but it wouldn't be something that you would want to, again, be relying on for your practice. That said, again, sometimes pharmacies will transfer medications for patients as one broad thing. Thank you so much, John. And a follow-up on that is if the patient is, if the patient is originally seen in the state in which you are licensed, and then the patient tries to pick up a prescription out of state, we've touched on this a little bit, but just to be clear, in general, the expectation is that the prescriber will have a DEA license, prescriber will have a DEA license in the state in which they're, in which the patient is getting the prescription. Is that true, Dr. Torres and Dr. Kahn, or any nuances to add? I think that would be the by-the-book response. So again, they could legally say, we're not going to do it because we don't have a DEA there. Again, and again, they may start doing it more because just overall, the regulatory enforcement mechanisms of just all healthcare are focusing more on digital health and unfortunately, as a field, we had some knock with the DOJ investigation into a stimulant company. There's more focus, especially on stimulants being prescribed by online pharmacies. So it may be a little bit rougher at the beginning. Yeah, I agree. And this scenario does come up a lot. I think someone had asked a question about border states. So let's say I'm in New York. I have a lot of patients that live in New Jersey, which is 30 minutes away, but they do come to my practice to see me in New York. And I happen to send the prescription to their New Jersey pharmacy. It gets filled, not a problem. It might be pharmacy specific. It might be state dependent, whether or not it's going to be filled, but the practice of medicine is occurring in New York. I'm not licensed in New Jersey, but during COVID, New Jersey had significant flexibility, which has since expired. So I was able to continue seeing them through telehealth while they were in New Jersey. I had already seen them once in person in my New York practice. I'm still prescribing the controlled medicine. So those bordering states, this scenario comes up a lot. But if it's, let's say you're providing this care to another state, you're not licensed, patients, they're long-term, they're not coming regularly to your practice in your home state, that can become an issue where you wouldn't need that physical address and you wouldn't need that separate DEA registration. So always good to contact your risk management, maybe the DEA field office as well, just to get clarifications, because there's no like 100% right answer in some of these situations, it gets complicated. And I saw a question as well from a psychiatrist working at the VA, and just a reminder that your facility may also have rules that are relevant to you as well. So with that, I think we can move on to the next phase, which is an open discussion. And so what you'll see in the next few minutes, we have about 25 minutes for discussion, and we've been collecting and consolidating the questions that have come in through Q&A, and we'll be posing them to Drs. Kahn and Torres, but feel free to continue adding questions in or clarifications as we go, because we can always jump in and say, what about this situation? So I want to start with a really kind of level setting question. If you have been operating a virtual practice successfully throughout the pandemic, as we saw in our initial poll, where a lot of folks have been delivering care virtually and are happy with it, can you continue to maintain your practice completely virtually going forward? And what about if you're prescribing controlled substances? So it depends on the factors that we mentioned, we have to look at state rules, state legislation, we have to look at the payer, the particular payer, licensure, if the patient happens to be in another state, controlled substance rules at the federal level, what the current state is at the federal level, and then also what that specific state says about it. So I think those are some of the considerations to determine and then sometimes if payers aren't very explicit about some of these rules, it may be good practice to follow what Medicare, the guidance that Medicare has, or some payers may just follow what Medicare says. So if there isn't that clarity, contact risk management, or maybe it may help to kind of follow Medicare rules to make sure you're in compliance, even if you're not billing Medicare or not billing insurance, unless you have a clear answer from the relevant payer. Yeah, so I think you can continue to have a completely virtual practice. A lot of the issues around prescribing across state lines have been issues for some time now, because right, each state has kind of removed issues of do you have reciprocity in the height of COVID. If you have any questions about prescribing across state lines, there's a website, as we said, FSMB, the Federation of State Medical Boards.org. They do a pretty good job of maintaining a list of what are the policies in each state of what you can and can't do. But in general, as we said, most of them kind of say you would need to be to practice medicine in our state, like before the public health emergency, you would need to be registered in our state. And as Dr. Kahn said, there are these kind of new things where Florida will kind of have a slightly easier registration to just say practice telehealth for people in the state. So there are some evolving exceptions. It really is thinking about what's going to be different with the Ryan Height as soon as the public health emergency ends. We're not here to speculate. As we said, the APA is doing a lot of advocacy because we think that Ryan Height, it does stop some very bad rogue actors from doing bad things. We, of course, we think most psychiatrists as a field would be beneficial if we could prescribe across state lines. And so we're certainly advocating and trying to lobby for reasonable changes that would make it better. But it does seem that since the end of the PHE, the declaration, right, seems it'll come rather soon, be it in 90 days, be in 120 days. I think that's the thing to keep most in mind if you're doing a virtual practice is what are you going to do with those folks and patients? Is there a way that you can at least be seeing them and then thinking about these different DEA issues, which again, some of them are very challenging to meet. It's hard to be registered in all 50 states and have a physical address in all 50 states. You would have to have a lot of startup capital to build a practice like that. Yeah. And then there were also questions about safety considerations, a few questions on this. So another factor to consider, if you're going to have a completely remote practice, it's easier to navigate safety situations. It can be easier for patients in the room with you, you know exactly where they are, but with telehealth, it can be helpful to kind of lay the groundwork with patients ahead of time that at this time you are appropriate for telehealth care. If in the future clinically, it may be indicated for you to either come back, come in person to see me or to someone locally, then we may make that recommendation. So kind of doing that safety assessment, which we clinically should be doing anyway, but even more important here, if a patient's in another state, in another county, do we know what the local resources are? Because if we call 911, we're going to mobilize our local police. So do you know the numbers for like the police department, where the patient is located? We don't have, I know there was a question of how can we confirm where the patient is? We don't use like GPS or geolocation. We do have to go by what patients tell us. If a patient says that they're in the state where I'm located, that's what I'm documenting. So making sure that you have good documentation as well for a telehealth visit. What's the parameter that was used? What state is the patient in? You may, for billing purposes or for other regulatory reasons, you may want to also indicate where the physician is at the time of the visit. So those safety considerations become even more important when a patient is not physically located with us. So it's not that we can't provide that care completely virtually, but having a plan of where's the patient going to go if we do need to have them seen in person as soon as possible. Yeah. I see some questions saying, what are the efforts that individual psychiatrists or any mental health practitioner can do around if we want these things to be changed permanently? I would send the APA any stories of hardships that you're having. Again, delete any personal health information about cases where you've not been able to care for a patient or it's been restrictive. Sometimes having those cases, again, de-identify and anonymize it are very helpful for going to legislators to lobby with. Sometimes we can present people facts about there's this much lack of access to care. But if you have good stories, you're seeing personal cases impacting your ability to deliver high quality care, let the APA know. And I think that's just very, very helpful for us building the case and having the stories to tell legislatures, this is what these restrictions are doing to us. So every case is very useful to report into us. And again, we can work with you to make sure it's de-identified and you're not sharing information with it. But I think that would be very, very helpful for any of these changes going forward of how it makes a difference. And part that's how audio only got approved as people shared many stories personal of how audio only was really helping patients. And that's actually probably what helped with making it permanent for behavioral health. So these things can change. They're not permanent if you're not happy with it, but please, please do share with the APA. Thank you so much. Really helpful. And apologies, I lost my internet there for a moment, but we're back. Just a quick follow up a little bit. So recognizing that I appreciate the conversation around advocacy, recognizing that psychiatrists play a critical role in communicating to the federal government what is necessary to achieve their own objectives around clinical care and outcomes. So what are some of the options given that the DEA has not yet issued the special registration? And while we do plan on commenting on and supporting the issuing of a telemedicine special registration when the DEA comes out with it, what can providers do in the meantime with some of their patients to whom they prescribe controlled substances? So I think important to have that plan in place start now. We should be getting at least 60 days notice before the public health emergency expires. Is there anyone locally in a lot of the telehealth companies that had started during the pandemic that were prescribing these controlled medicines without an in-person exam proliferated? And now many of them are pulling back and saying, we know that eventually, probably sooner rather than later, we're not going to be able to continue prescribing this stimulant or other medicine. So they're like stopping prescribing, which can also become an issue for other practitioners locally because these patients who were being prescribed these medicines through these telehealth companies or other venues may end up coming to our practice. But just thinking through a plan of, we know this is coming. What is our plan to make sure that you are able, if you are able to continue this medicine, can you come in to see me in person? Can your primary care doctor, if they may not be willing to or want to, but is there someone else involved in the care that can take over prescribing? Or what are the options locally? And starting to have that discussion with patients as well. Thank you. So helpful. And we had a related question that I thought was really interesting. I'm curious for either of your insight. How do you verify a patient's location when you're doing telehealth to make sure that they are in a state where you're able to practice and prescribe? As Dr. Khan said, it is self-report. I mean, for safety reasons, best practices are you want to ask a patient where they're located and often have an alternative mode to contact them just in case there is a need to send emergency services, something happens in a way to reach them. But certainly there's no federal or state requirements. We've seen where it says, again, you need to be verifying or enforcing where a patient is. Again, we would consider it just best telehealth practices. And the APA is a very good telehealth blog and telehealth best practices on psychiatry.org with videos. It was built actually by Dr. Khan and luminaries like Jay Shore and Stephen Chan. It's good fun to watch, but it really would be you ask a patient where they are and as Dr. Khan said, you document that just as good documentation in your safety procedures. So you don't need to have people send you coordinates, I guess is what I'm saying of where they are. Thank you. That's really, really helpful. I think somebody did suggest, should they send you a screenshot of their pin on a map? But I think that makes a lot of sense. So moving to a little bit more of the policy side and away from the practice considerations, what do we know about how commercial and Medicaid plans are likely to cover telehealth in 2023? It's hard to predict the future. I'll just say that much. And I think usually we see again, Medicare sets the example. And if we look to the past, usually the examples set by Medicare generally get implemented in similar ways, not always. And again, so I think it does make sense to certainly if you're taking private insurance to check with your plans about what they're reimbursing and what they're not reimbursing. But I think there are unknown questions there. I don't know. How do you read the future, Dr. Khan? I agree. So commercial payers, Medicaid are state-based, but depending on the state, they may even cover certain services more in some states and not in others. Most of them have already started pulling back the flexibilities they had during COVID. Dr. Torres mentioned the Federation of State Medical Boards has that great resource. There's also the Center for Connected Health Policy, which we have listed in the slides, which we'll share, that also goes state by state and at the federal level. Most states have commercial insurance coverage laws, which say that commercial payers have to cover telehealth, but there's only a handful of states that have not just commercial insurance coverage laws, but true payment parity, meaning not only do you have to cover it, but you have to pay the same rate. So it's just helpful to kind of know your state laws, contact individual payers for what they are covering. Hard to predict. And like that, there's the question, someone said, for different premium for different insurers, it likely will change depending on what state you may be operating, what diagnoses you're covering. So you may certainly want to check about what premiums you're paying for your malpractice coverage. And certainly, certainly, there's one thing we say is do check your malpractice coverage now about what they will and won't cover, because sometimes you may not realize there's very little telehealth coverage. You may be pleased to find there's very good telehealth coverage, but I think we have seen there's not a great standard for what is telehealth coverage and different insurers are learning along all of us. So if you are planning to keep your practice all virtual, it really is a good time to reach out to your malpractice coverage and at least check in on what you have. Thank you. Really, really helpful. And I think another resource there is your APA district branch who may have a little bit of a lay of the land around coverage for the major insurers in your state. Another thing to be aware of is differences in modality. So while some payers, whether it's Medicaid or commercial insurers, may cover video-based telehealth, there's certainly been discussion around coverage of audio-only that may vary. And to recap a question that I believe we answered in written format, Medicare Advantage should more closely match Medicare, but also may vary, especially in modality, by payer. So we are developing resources around this right now because we understand that it's a significant priority as about half of our country's Medicare members are covered by Medicare Advantage plans rather than traditional Medicare. So like they both said, Medicare and CMS policies offer really good benchmark, both for coverage and for compliance, but generally don't tell the whole picture. So relatedly, what rules and policies are members obligated to if they do not take insurance or if they're not billing insurance for a specific encounter? How does that play in? So I'll start. Most of us are based in America. So even if there are federal laws around what you're going to be doing in the practice of medicine, so payment may be different, but some of the federal laws you may not be able to get away from. But I think I'm going to hand this over to Dr. Khan to go into some of those details. I agree. So there's some rules related to HIPAA that we would still have to follow, like you mentioned, at the federal level. And then again, just the licensure, prescriptive authority, other requirements that we've discussed. So it's not just about payment. Often we think, well, if I'm not billing, I can do this, right? But there are other considerations there. You still can't likely practice medicine in a different state unless you have, again, state or unless you have licensure to practice in that state, regardless of who is paying the bill, whether it's the federal government or not. So much of this may unfortunately still apply to you, whether you're doing a private practice or you're part of a group practice, you're a part of, say, a federal qualified health center that's doing more of it. So it's certainly a relevance. And even if you're not accepting insurance patients, accepting insurance patients may submit the claim. So these issues may still come up indirectly. Thank you. That makes a lot of sense. So moving back into the practice of telepsychiatry, we know that during the COVID-19 related flexibilities, telehealth in some instances reduced no-kill rates because it increases the convenience with which patients can just hop on a call with you. However, it might also decrease the sort of the stickiness of that encounter, and people may be having situations where patients are not showing up for follow-ups. What are some strategies for maintaining that continuity of the relationship in a virtual environment? I think it's helpful to think about what are the barriers? What are the reasons for this particular patient? So if we think about from an access and equity perspective, telehealth can be so helpful to address a lot of the inequities that we have. But if we aren't implementing telehealth thoughtfully, then we may actually further widen these gaps. So is it that this patient doesn't have the network connectivity? Does my patient not have the devices that are needed for telehealth? Am I not providing instructions for how to set up telehealth in different languages? Is there appropriate IT support? So just thinking through what are the barriers for this particular patient? And then there's other kind of logistical things similar to in-person care, whether it's setting up reminders for appointments, what could be helpful to kind of have patients engaged? Are there other means that we can enhance that patient engagement? So I think thinking through what are the reasons? Is it that the patient can't find a private space or they're working two jobs? Even if it's telehealth, they're not able to make it to the appointment. Thinking through all of those and then offering solutions as appropriate and making sure we are providing whatever necessary guidance, help in setting up technologies, assistive technologies that are needed to ensure that our patients are able to connect. Yeah, I think initially during all this call to height of COVID, we saw no-show rates were very low and there's a lot of excitement about that. I think we have seen the no-show rates beginning to climb up. They're still less than perhaps before COVID, but the trend seems to be that I think the same no-show policies we had are keeping kind of a very strict frame of what is in scope of care, how do we show up to appointments, may become very important certainly for doing it. So I think all of the things we're doing to help patients come to appointments in person, we really don't have to think about it. As Dr. Khan said, digital literacy is probably going to become more and more, it's not a buzzword, but it's going to become a very important topic because we do know that it's harder for some patients to connect. There are new projects like Project Lifeline. If your patient is low income, if they're qualified Medicare, they actually can now get very subsidized high-speed Wi-Fi by the federal government for less than $30. There's programs the FCC has to help them get free smartphones. So I would actually look into if there's a care manager or case manager, you can email us at the APA, but there are good federal programs to get low-income patients, really good internet connectivity, data plans, phones, and services. So it's part of the Broadband Infrastructure Act. And again, we've signed our patients up and some of them have faster internet than I have and I probably pay much, much more, which is appropriate, but these programs do work from the federal government to help your patients get connected. So really, really good note to take us out on. With that, Drs. Khan or Torres, do you have any last words that you want to say for your peers and colleagues? I'll say thank you for joining us. I'll say keep looking at the telehealth blog on the APA website. Again, we know most of you are on this call are psychiatrists and APA members. It's still a publicly accessible website. Anyone can come and look at it. And we'll try to post updates about when the PHE may end. We know we couldn't answer every question. There's more coming in, and they're good ones. So we'll try to consolidate them and have some broad responses in general that we can put up our information about this because these are all good questions. But I think we'll keep following this with you would be my concluding remarks. I agree with Dr. Torres. Appreciate everyone joining. And as we mentioned, please reach out to the APA from an advocacy perspective. So helpful for us to hear what barriers psychiatrists are facing. And then also a shout out to the APA team and just their amazing work on keeping us up to date and making sure that we are practicing appropriately. Yes. If you all haven't seen Abby's energy for this, it's impressive. Pretty good. Well, as you can all tell, this is a fascinating area to work in. And we're so, so thankful to have Dr. Khan, Dr. Torres, and all of you with us today. It's wonderful to hear your expertise, your questions, your deep care and commitment for your patients. So if we want to go to the next slide, we touched during this on a few resources that we think might be helpful. As a reminder, these slides, the recording and a frequently asked questions document will be released in follow-up to this. So none of this information goes away. Keep an eye on the APA website, especially the telepsychiatry toolkit. On the APA website, you'll also be able to find information about the practice management helpline, which any APA member can contact with questions related to today's discussion or anything else. And then our colleague here also involved in SMI advisor, which provides critical guidance around the treatment of serious mental illness. We also released psychiatric news, which can provide really good hot off the presses updates about psychiatry and psychiatric policy. And then finally, we're linking to two external resources, first from the Federation of State Medical Boards and second from the Center for Connected Health Policy, which both of which Dr. Khan mentioned throughout this presentation, which pull out some of the telemedicine policies by state. While they may not be perfectly up to date all the time, they're a really good way to help get your hands around this, especially with specific states and specific payers. And with that, I think we're going to say goodbye to everyone. Thank you so much for joining.

telepsychiatry

hybrid psychiatry

COVID-19 pandemic

controlled substance prescribing

telemedicine

licensure requirements

telehealth coding

state-by-state variations

advocacy efforts

telehealth regulations

enforcement

continuity of care