A missed well-child visit in a rural county does not stay a missed visit for long. It can become a delayed developmental screening, an unmanaged asthma flare, a postponed behavioral health referral, or another month of travel strain for a working parent. That is why improving pediatric access to healthcare is not just a scheduling problem. It is a care delivery problem that reaches into operations, staffing, reimbursement, technology, and family experience.

For healthcare organizations, the challenge is rarely a lack of clinical intent. Pediatric practices, hospitals, FQHCs, rural health clinics, school-based programs, and community providers want to see children sooner and more consistently. The barrier is that traditional access models depend on the child, caregiver, clinician, and exam room all being in the same place at the same time. For many families, especially those navigating distance, transportation limits, work disruptions, language barriers, or special healthcare needs, that model leaves too many gaps.

What improving pediatric access to healthcare really requires

Access is often measured by appointment availability, but pediatric access is broader than open calendar slots. Children need care in ways that reflect how they actually live and how families actually manage care. A system can technically offer appointments and still be hard to reach.

That is especially true for children who need frequent follow-up, chronic disease monitoring, developmental observation, or lower-stress care environments. Autistic children and pediatric patients with special healthcare needs may do better in familiar settings such as home, school, or a trusted community clinic. In those cases, access improves not when organizations ask families to overcome more friction, but when care models reduce friction in the first place.

This is where healthcare leaders need a more operational view. Improving access means expanding the places where care can happen, the clinicians who can participate, and the clinically useful information available during a remote encounter. A video visit alone can help, but it does not always support a meaningful pediatric physical assessment. If clinicians cannot evaluate what they need to evaluate, access may increase on paper while clinical confidence stays limited.

Why pediatric access gaps persist

The root causes are familiar, but their impact is compounded in pediatrics. Workforce shortages limit appointment supply. Geographic distance affects families with fewer transportation options. Safety-net providers often carry high demand with constrained staffing. Children with chronic conditions need more touchpoints, not fewer, and those touchpoints are hard to sustain through office-based care alone.

Caregiver burden is another major factor. Pediatric care depends on parents, guardians, school staff, and sometimes multiple specialists. When follow-up requires taking unpaid time off, arranging childcare for siblings, and traveling long distances for a brief assessment, missed care becomes predictable. Organizations that want to improve access need to design around caregiver realities, not around ideal workflows.

There is also a clinical limitation that gets less attention. Standard telehealth can be useful for triage, medication follow-up, and certain consultations, but pediatric care often depends on direct observation and exam quality. Ear complaints, respiratory issues, skin conditions, and chronic disease follow-up may require more than conversation over video. That gap matters because children often need timely decisions, and providers need enough data to make them safely.

Improving pediatric access to healthcare with connected care

The strongest access strategies do not replace in-person care. They create a flexible care model where in-person, virtual, remote monitoring, and community-based services work together. That matters in pediatrics because needs vary widely. A healthy child due for routine follow-up is not the same as a child with asthma, diabetes, neurodevelopmental differences, or repeated transportation barriers.

Connected-care models give organizations more options. A child can be assessed from home, a school health office, a community clinic, or another distributed care site while a clinician remains elsewhere. If the encounter includes clinician-directed virtual examination tools and device-supported data capture, the remote visit becomes more than a convenience feature. It becomes a clinically relevant extension of the care team.

For pediatric populations, that flexibility can change adherence and continuity. Families are more likely to complete follow-up when travel is reduced, familiar caregivers can participate, and visits fit around school and work realities. Clinicians can also monitor trends over time rather than waiting for the next in-person visit to identify worsening symptoms or treatment drift.

The case for virtual physical exams in pediatrics

Not every pediatric encounter is appropriate for remote care, and that is an important distinction. Organizations should avoid treating virtual access as a universal substitute. But when virtual care includes structured workflows and the ability to collect clinically relevant data, it can support many high-value pediatric use cases.

Respiratory follow-up, chronic care management, post-discharge check-ins, school-based assessments, medication monitoring, and selected urgent complaints can all benefit from a stronger remote exam model. The key is whether the care team can gather enough information to evaluate the child appropriately and determine next steps with confidence.

That is where connected exam technology matters. A clinician who can guide a remote assessment using appropriate peripherals, patient monitoring data, and workflow support is operating in a very different environment than a clinician limited to basic video. The difference is not cosmetic. It affects clinical decision-making, documentation quality, escalation pathways, and the provider’s willingness to use virtual care as part of routine pediatric operations.

Special considerations for autistic children and children with complex needs

Improving access for pediatric populations means accounting for children who experience traditional care settings as disruptive, overstimulating, or difficult to tolerate. For autistic children and pediatric patients with special healthcare needs, access is closely tied to environment. A visit that is technically available may still be functionally inaccessible if the setting causes distress or makes examination difficult.

Lower-stress care environments can improve cooperation, caregiver communication, and follow-through. When clinicians can assess a child in a familiar setting, families may provide better history, children may regulate more easily, and care teams may gain a more realistic view of functional needs. That does not eliminate the need for specialty or in-person services, but it can reduce avoidable disruption and support more consistent touchpoints between higher-acuity visits.

This is also where caregiver inclusion becomes operationally significant. Pediatric care works better when caregivers are present, informed, and able to participate in follow-up. Flexible virtual care helps organizations bring parents, school personnel, and community-based staff into the same care pathway without requiring every interaction to happen inside a hospital or clinic.

Operational priorities for organizations expanding pediatric access

Healthcare leaders often ask the wrong first question. They ask which telehealth platform to buy before defining which access barriers they are trying to solve. A stronger starting point is to identify where pediatric leakage, delays, and missed follow-up are occurring.

For some organizations, the biggest issue is specialty reach across rural service areas. For others, it is post-discharge follow-up, chronic care management, or school-linked access. The right model depends on patient mix, staffing, reimbursement strategy, and clinical goals. What works for a children’s hospital hub may not fit a critical access hospital or FQHC network.

Implementation also needs to be reimbursement-aware. Virtual pediatric programs are more likely to last when clinical design, documentation, and workflows align with applicable billing pathways and compliance requirements. That includes HIPAA-conscious deployment, role clarity across care teams, and realistic training plans. Technology adoption tends to stall when organizations assume clinicians will adapt on their own.

The more durable approach is to pair technology with workflow customization, staff training, escalation protocols, and clear definitions of which encounters should remain in person. When organizations do that well, access expands without creating confusion or compromising care quality.

A more durable model for pediatric reach

Improving pediatric access to healthcare is ultimately about bringing clinically appropriate care closer to where children live, learn, and receive support. For provider organizations, that means thinking beyond the exam room and beyond basic telehealth. It means building a model that supports clinician-directed assessment, remote patient monitoring, caregiver participation, and continuity across distributed settings.

Platforms such as Dr. Miltie’s connected-care approach are relevant because they support this broader operational goal, not just a single virtual visit. When pediatric access is designed around the child, the caregiver, and the realities of community-based care, organizations can extend clinical reach without lowering clinical standards.

The next gains in pediatric access will not come from asking families to work harder to reach care. They will come from healthcare organizations that redesign care so it can reach families earlier, more consistently, and with greater clinical confidence.

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A pediatric patient misses a specialty follow-up because the nearest clinic is two hours away, a parent cannot leave work again, and the local team has limited backup. That is the daily reality telehealth solutions for rural healthcare are meant to change. For rural hospitals, community health centers, federally qualified health centers, and school-based programs, the issue is not whether virtual care matters. It is whether the model can support clinically relevant care, fit existing workflows, and hold up financially.

That distinction matters. Rural care delivery is rarely solved by video visits alone. A successful strategy has to account for workforce shortages, transportation barriers, broadband variability, caregiver availability, and the fact that many patients need more than a conversation on a screen. They need assessment, monitoring, follow-up, and coordination across settings that may include the home, the school nurse’s office, a primary care clinic, and a critical access hospital.

Why telehealth solutions for rural healthcare need more than video

Basic telehealth expanded access, but it also exposed its limits. When a provider cannot listen to heart and lung sounds, review oxygen saturation trends, or guide a more complete virtual physical exam, the visit may still end in a transfer, a repeat appointment, or delayed treatment. In rural settings, those gaps carry more weight because alternatives are farther away and local resources are often stretched.

That is why many organizations are shifting from simple teleconferencing to connected-care models. The stronger programs combine clinician-directed virtual examination, remote patient monitoring, chronic care management, and patient engagement tools in one operational framework. Instead of treating telehealth as a digital front door only, they use it as an extension of the care team.

For rural leaders, the practical question is not just what technology to buy. It is what clinical problems the technology should solve. If the goal is reducing avoidable travel for pediatric follow-up, the requirements look different than they do for managing COPD, hypertension, or post-discharge monitoring. If the organization serves autistic children or pediatric patients with special healthcare needs, care delivery may need to happen in lower-stress environments where caregivers can participate more fully.

What effective rural telehealth programs actually include

The most durable telehealth solutions for rural healthcare usually share a few traits. First, they support clinically useful data capture, not just face-to-face communication. Second, they fit distributed care settings, including homes, schools, outreach sites, and satellite clinics. Third, they align with reimbursement and staffing realities.

A connected virtual exam capability can make a major difference here. When clinicians can remotely guide assessments and capture medically relevant data, the virtual encounter becomes more actionable. This does not eliminate the need for in-person care. It helps organizations reserve in-person visits for cases that truly require them.

Remote patient monitoring also plays an important role, especially for chronic disease management and post-acute follow-up. Rural populations often face delayed intervention because symptom escalation is not identified early enough. Monitoring programs can help surface risk sooner, but only if the data flows into a workflow someone owns. Technology without clear clinical accountability tends to underperform.

Care coordination is the third piece that often determines success or failure. Rural patients frequently move between primary care, specialty care, emergency departments, schools, and home-based support. Telehealth works best when it strengthens that circle rather than creating one more disconnected platform. Organizations that define escalation pathways, documentation standards, and caregiver communication upfront usually see better adoption.

Rural use cases where virtual care delivers real value

Pediatrics is one of the clearest examples. Rural families often travel long distances for specialist input, developmental follow-up, or recurring visits that could be handled closer to home if clinicians had better virtual exam tools. For children who are anxious in unfamiliar clinical environments, or for autistic children who do better in familiar settings, remote care can improve the quality of the encounter, not just convenience. The visit may be calmer, caregivers may provide better context, and follow-up is more likely to happen on time.

Chronic care is another area where telehealth can move the needle. Patients with hypertension, diabetes, CHF, or COPD often need regular touchpoints, trend review, and reinforcement of care plans more than they need frequent travel to a distant clinic. Remote monitoring paired with chronic care management can help rural organizations intervene earlier and use nurse care managers and clinical staff more efficiently.

Urgent assessment in community-based settings is also gaining traction. A rural clinic, school health program, or community site equipped for virtual examination can connect patients with a remote clinician who can assess the situation with more confidence than a standard video call allows. That can improve triage decisions and reduce unnecessary transfers while still escalating quickly when higher-acuity care is needed.

Behavioral health remains important, but it should not overshadow the value of hybrid physical and virtual care. Many rural organizations already offer telebehavioral health. The next step is building programs that also support physical assessment, longitudinal monitoring, and care coordination for medically complex patients.

The operational realities behind adoption

Rural executives and program leaders know the barrier is rarely interest. It is implementation. Broadband limitations, staffing constraints, onboarding burden, and uncertain reimbursement can all slow momentum. That is why enterprise-ready telehealth strategy has to be operational, not aspirational.

Workflow design should come before large-scale deployment. Who starts the visit? Who supports the patient at the originating site or in the home? What data is captured during the encounter? How is it documented in the record? What triggers escalation to in-person care, emergency transfer, or specialty referral? These questions sound basic, but they are where many programs either stabilize or stall.

Training matters just as much. Rural teams cannot afford technology that takes months to learn or depends on highly specialized staff to run every interaction. The best implementations support clinicians, nurses, medical assistants, and care coordinators in ways that match their actual day-to-day responsibilities. That usually means role-based workflows and practical education, not generic onboarding.

Reimbursement also has to be part of the design from the start. Rural telehealth programs are more likely to last when they align with CMS pathways, remote patient monitoring opportunities, chronic care management models, and payer requirements that make the service financially supportable. Not every use case reimburses the same way, and not every state or payer behaves alike. A reimbursement-aware deployment strategy is often the difference between a pilot and a durable service line.

Choosing the right technology partner

Healthcare organizations evaluating rural telehealth platforms should look beyond feature lists. The real test is whether the partner understands clinical workflows, distributed care environments, and the needs of underserved populations. A device alone is not a rural health strategy. A video platform alone is not a virtual care strategy.

It helps to ask harder questions early. Can the platform support clinician-directed virtual physical exams? Can it serve pediatric and adult populations? Can it adapt to care in schools, homes, outreach settings, and community clinics? Does the implementation model account for training, customization, and reimbursement planning? Can the organization scale from one use case to several without starting over each time?

This is where connected-care platforms stand apart. Solutions such as the Dr. Miltie N9+ are designed to support remote examination and patient monitoring in settings where access, staffing, and follow-up are ongoing challenges. That matters for rural providers because they need tools that extend clinical reach without reducing the quality of clinical decision-making.

A smarter way to think about rural virtual care

The strongest rural telehealth strategies do not try to replace local care. They strengthen it. They give rural clinicians more ways to assess, monitor, and coordinate. They help families stay engaged. They reduce avoidable miles on the road while making it easier to identify the patients who truly need escalation.

There are trade-offs, of course. Some visits will still require hands-on evaluation. Some communities will need infrastructure support before advanced virtual care can scale. Some service lines will justify investment faster than others. But that is normal. Rural transformation is rarely one big launch. It is usually a series of practical decisions that build a more flexible care model over time.

For organizations planning the next phase of virtual care, the opportunity is not simply to add telehealth. It is to build care pathways that bring clinically meaningful services closer to where patients live, learn, and recover. That is how access improves in a way patients can actually feel.

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CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Clinical Tab – Weights Vitals

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Clinical Tab

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Resident Dashboard – Admin – Misc Tab

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PointClickCare (PCC) Integration with Nonagon N9+ Device and Virtual Exam Platform – Patient Card

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§ 411.15 Particular services excluded from coverage.

Link to an amendment published at 88 FR 53345, Aug. 7, 2023.

The following services are excluded from coverage:

(a) Routine physical checkups such as:

(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in § 410.64 of this chapter, or annual wellness visits providing personalized prevention plan services.

(2) Examinations required by insurance companies, business establishments, government agencies, or other third parties.

(b) Low vision aid exclusion—(1) Scope. The scope of the eyeglass exclusion encompasses all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.

(2) Exceptions.

(i) Post-surgical prosthetic lenses customarily used during convalescence for eye surgery in which the lens of the eye was removed (for example, cataract surgery).

(ii) Prosthetic intraocular lenses and one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.

(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.

(c) Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only and procedures performed in the course of any eye examination to determine the refractive state of the eyes, without regard to the reason for the performance of the refractive procedures. Refractive procedures are excluded even when performed in connection with otherwise covered diagnosis or treatment of illness or injury.

(d) Hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids.

(1) Scope. The scope of the hearing aid exclusion encompasses all types of air conduction hearing aids that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound and bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.

(2) Devices not subject to the hearing aid exclusion. Paragraph (d)(1) of this section shall not apply to the following devices that produce the perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve:

(i) Osseointegrated implants in the skull bone that provide mechanical energy to the cochlea via a mechanical transducer, or

(ii) Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.

(e) Immunizations, except for—

(1) Vaccinations or inoculations directly related to the treatment of an injury or direct exposure such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenom sera, or immune globulin;

(2) Pneumococcal vaccinations that are reasonable and necessary for the prevention of illness;

(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in § 410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;

(4) Influenza vaccinations that are reasonable and necessary for the prevention of illness; and

(5) COVID–19 vaccinations that are reasonable and necessary for the prevention of illness.

(f) Orthopedic shoes or other supportive devices for the feet, except when shoes are integral parts of leg braces.

(g) Custodial care, except as necessary for the palliation or management of terminal illness, as provided in part 418 of this chapter. (Custodial care is any care that does not meet the requirements for coverage as SNF care as set forth in §§ 409.31 through 409.35 of this chapter.)

(h) Cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.

(i) Dental services—(1) Basic rule. Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.

(2) Exception. Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of—

(i) The individual’s underlying medical condition and clinical status; or

(ii) The severity of the dental procedures. 577

577 Before July 1981, inpatient hospital care in connection with dental procedures was covered only when required by the patient‘s underlying medical condition and clinical status.

(3) Inapplicability.

(i) Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service are not excluded; payment may be made under Medicare Parts A and B for services furnished in the inpatient or outpatient setting. Such services include, but are not limited to:

(A) Dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to Medicare-covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, the organ transplant, cardiac valve replacement, or valvuloplasty procedure.

(B) The reconstruction of a dental ridge performed as a result of and at the same time as the surgical removal of a tumor.

(C) The stabilization or immobilization of teeth in connection with the reduction of a jaw fracture, and dental splints only when used in conjunction with covered treatment of a covered medical condition such as dislocated jaw joints.

(D) The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

(ii) Ancillary services and supplies furnished incident to covered dental services are not excluded, and Medicare payment may be made under Part A or Part B, as applicable, whether the service is performed in the inpatient or outpatient setting, including, but not limited to the administration of anesthesia, diagnostic x-rays, use of operating room, and other related procedures.

(j) Personal comfort services, except as necessary for the palliation or management of terminal illness as provided in part 418 of this chapter. The use of a television set or a telephone are examples of personal comfort services.

(k) Any services that are not reasonable and necessary for one of the following purposes:

(1) For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

(2) In the case of hospice services, for the palliation or management of terminal illness, as provided in part 418 of this chapter.

(3) In the case of pneumococcal vaccine for the prevention of illness.

(4) In the case of the patient outcome assessment program established under section 1875(c) of the Act, for carrying out the purpose of that section.

(5) In the case of hepatitis B vaccine, for the prevention of illness for those individuals at high or intermediate risk of contracting hepatitis B. (Section 410.63(a) of this chapter sets forth criteria for identifying those individuals.)

(6) In the case of screening mammography, for the purpose of early detection of breast cancer subject to the conditions and limitations specified in § 410.34 of this chapter.

(7) In the case of colorectal cancer screening tests, for the purpose of early detection of colorectal cancer subject to the conditions and limitations specified in § 410.37 of this chapter.

(8) In the case of screening pelvic examinations, for the purpose of early detection of cervical or vaginal cancer subject to the conditions and limitations specified in § 410.56 of this chapter.

(9) In the case of prostate cancer screening tests, for the purpose of early detection of prostate cancer, subject to the conditions and limitations specified in § 410.39 of this chapter.

(10) In the case of screening exams for glaucoma, for the purpose of early detection of glaucoma, subject to the conditions and limitations specified in § 410.23 of this chapter.

(11) In the case of initial preventive physical examinations, with the goal of health promotion and disease prevention, subject to the conditions and limitations specified in § 410.16 of this chapter.

(12) In the case of ultrasound screening for abdominal aortic aneurysms, with the goal of early detection of abdominal aortic aneurysms, subject to the conditions and limitation specified in § 410.19 of this chapter.

(13) In the case of cardiovascular disease screening tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for that disease, subject to the conditions specified in § 410.17 of this chapter.

(14) In the case of diabetes screening tests furnished to an individual at risk for diabetes for the purpose of the early detection of that disease, subject to the conditions specified in § 410.18 of this chapter.

(15) In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter.

(16) In the case of an annual wellness visit providing a personalized prevention plan, subject to the conditions and limitations specified in § 410.15 of this subpart.

(l) Foot care—(1) Basic rule. Except as provided in paragraph (l)(2) of this section, any services furnished in connection with the following:

(i) Routine foot care, such as the cutting or removal of corns, or calluses, the trimming of nails, routine hygienic care (preventive maintenance care ordinarily within the realm of self care), and any service performed in the absence of localized illness, injury, or symptoms involving the feet.

(ii) The evaluation or treatment of subluxations of the feet regardless of underlying pathology. (Subluxations are structural misalignments of the joints, other than fractures or complete dislocations, that require treatment only by nonsurgical methods.

(iii) The evaluation or treatment of flattened arches (including the prescription of supportive devices) regardless of the underlying pathology.

(2) Exceptions.

(i) Treatment of warts is not excluded.

(ii) Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment.

(iii) The services listed in paragraph (l)(1) of this section are not excluded if they are furnished—

(A) As an incident to, at the same time as, or as a necessary integral part of a primary covered procedure performed on the foot; or

(B) As initial diagnostic services (regardless of the resulting diagnosis) in connection with a specific symptom or complaint that might arise from a condition whose treatment would be covered.

(m) Services to hospital patients—(1) Basic rule. Except as provided in paragraph (m)(3) of this section, any service furnished to an inpatient of a hospital or to a hospital outpatient (as defined in § 410.2 of this chapter) during an encounter (as defined in § 410.2 of this chapter) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the hospital‘s patients. As used in this paragraph (m)(1), the term “hospital” includes a CAH.

(2) Scope of exclusion. Services subject to exclusion from coverage under the provisions of this paragraph (m) include, but are not limited to, clinical laboratory services; pacemakers and other prostheses and prosthetic devices (other than dental) that replace all or part of an internal body organ (for example, intraocular lenses); artificial limbs, knees, and hips; equipment and supplies covered under the prosthetic device benefits; and services incident to a physician service.

(3) Exceptions. The following services are not excluded from coverage:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a reasonable charge or fee schedule basis.

(ii) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act, that are furnished after December 31, 1990.

(iii) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.

(iv) Certified nurse-midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, 1990.

(v) Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, 1990.

(vi) Services of an anesthetist, as defined in § 410.69 of this chapter.

(n) Certain services of an assistant-at-surgery.

(1) Services of an assistant-at-surgery in a cataract operation (including subsequent insertion of an intraocular lens) unless, before the surgery is performed, the appropriate QIO or a carrier has approved the use of such an assistant in the surgical procedure based on the existence of a complicating medical condition.

(2) Services on an assistant-at-surgery in a surgical procedure (or class of surgical procedures) for which assistants-at-surgery on average are used in fewer than 5 percent of such procedures nationally.

(o) Experimental or investigational devices, except for certain devices.

(1) Categorized by the FDA as a Category B (Nonexperimental/investigational) device as defined in § 405.201(b) of the chapter; and

(2) Furnished in accordance with the coverage requirements in § 405.211(b).

(p) Services furnished to SNF residents—(1) Basic rule. Except as provided in paragraph (p)(2) of this section, any service furnished to a resident of an SNF during a covered Part A stay by an entity other than the SNF, unless the SNF has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the SNF‘s residents. Services subject to exclusion under this paragraph include, but are not limited to—

(i) Any physical, occupational, or speech-language therapy services, regardless of whether the services are furnished by (or under the supervision of) a physician or other health care professional, and regardless of whether the resident who receives the services is in a covered Part A stay; and

(ii) Services furnished as an incident to the professional services of a physician or other health care professional specified in paragraph (p)(2) of this section.

(2) Exceptions. The following services are not excluded from coverage, provided that the claim for payment includes the SNF‘s Medicare provider number in accordance with § 424.32(a)(5) of this chapter:

(i) Physicians’ services that meet the criteria of § 415.102(a) of this chapter for payment on a fee schedule basis.

(ii) Services performed under a physician‘s supervision by a physician assistant who meets the applicable definition in section 1861(aa)(5) of the Act.

(iii) Services performed by a nurse practitioner or clinical nurse specialist who meets the applicable definition in section 1861(aa)(5) of the Act and is working in collaboration (as defined in section 1861(aa)(6) of the Act) with a physician.

(iv) Services performed by a certified nurse-midwife, as defined in section 1861(gg) of the Act.

(v) Services performed by a qualified psychologist, as defined in section 1861(ii) of the Act.

(vi) Services performed by a certified registered nurse anesthetist, as defined in section 1861(bb) of the Act.

(vii) Dialysis services and supplies, as defined in section 1861(s)(2)(F) of the Act, and those ambulance services that are furnished in conjunction with them.

(viii) Erythropoietin (EPO) for dialysis patients, as defined in section 1861(s)(2)(O) of the Act.

(ix) Hospice care, as defined in section 1861(dd) of the Act.

(x) An ambulance trip that initially conveys an individual to the SNF to be admitted as a resident, or that conveys an individual from the SNF in connection with one of the circumstances specified in paragraphs (p)(3)(i) through (p)(3)(iv) of this section as ending the individual’s status as an SNF resident.

(xi) The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those electrocardiogram test services furnished during 1998.

(xii) Services described in subparagraphs (p)(2)(i) through (vi) of this section when furnished via telehealth under section 1834(m)(4)(C)(ii)(VII) of the Act.

(xiii) Those chemotherapy items identified, as of July 1, 1999, by HCPCS codes J9000–J9020, J9040–J9151, J9170–J9185, J9200–J9201, J9206–J9208, J9211, J9230–J9245, and J9265–J9600, and as of January 1, 2004, by HCPCS codes A9522, A9523, A9533, and A9534 (as subsequently modified by CMS), and any additional chemotherapy items identified by CMS.

(xiv) Those chemotherapy administration services identified, as of July 1, 1999, by HCPCS codes 36260–36262, 36489, 36530–36535, 36640, 36823, and 96405–96542 (as subsequently modified by CMS), and any additional chemotherapy administration services identified by CMS.

(xv) Those radioisotope services identified, as of July 1, 1999, by HCPCS codes 79030–79440 (as subsequently modified by CMS), and any additional radioisotope services identified by CMS.

(xvi) Those customized prosthetic devices (including artificial limbs and their components) identified, as of July 1, 1999, by HCPCS codes L5050–L5340, L5500–L5611, L5613–L5986, L5988, L6050–L6370, L6400–6880, L6920–L7274, and L7362–L7366 (as subsequently modified by CMS) and any additional customized prosthetic devices identified by CMS, which are delivered for a resident’s use during a stay in the SNF and intended to be used by the resident after discharge from the SNF.

(xvii) Those blood clotting factors indicated for the treatment of patients with hemophilia and other bleeding disorders identified, as of July 1, 2020, by HCPCS codes J7170, J7175, J7177–J7183, J7185–J7190, J7192–J7195, J7198–J7203, J7205, and J7207–J7211 (as subsequently modified by CMS) and items and services related to the furnishing of such factors, and any additional blood clotting factors identified by CMS and items and services related to the furnishing of such factors.

(xviii) Those RHC and FQHC services that are described in § 405.2411(b)(2) of this chapter.

(3) SNF resident defined. For purposes of this paragraph, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF for the duration of the beneficiary‘s covered Part A stay. In addition, for purposes of the services described in paragraph (p)(1)(i) of this section, a beneficiary who is admitted to a Medicare-participating SNF is considered to be a resident of the SNF regardless of whether the beneficiary is in a covered Part A stay. Whenever the beneficiary leaves the facility, the beneficiary‘s status as an SNF resident for purposes of this paragraph (along with the SNF‘s responsibility to furnish or make arrangements for the services described in paragraph (p)(1) of this section) ends when one of the following events occurs—

(i) The beneficiary is admitted as an inpatient to a Medicare-participating hospital or CAH, or as a resident to another SNF;

(ii) The beneficiary receives services from a Medicare-participating home health agency under a plan of care;

(iii) The beneficiary receives outpatient services from a Medicare-participating hospital or CAH (but only for those services that CMS designates as being beyond the general scope of SNF comprehensive care plans, as required under § 483.21(b) of this chapter); or

(iv) The beneficiary is formally discharged (or otherwise departs) from the SNF, unless the beneficiary is readmitted (or returns) to that or another SNF before the following midnight.

(q) Assisted suicide. Any health care service used for the purpose of causing, or assisting to cause, the death of any individual. This does not pertain to the withholding or withdrawing of medical treatment or care, nutrition or hydration or to the provision of a service for the purpose of alleviating pain or discomfort, even if the use may increase the risk of death, so long as the service is not furnished for the specific purpose of causing death.

(r) A home health service (including medical supplies described in section 1861(m)(5) of the Act, but excluding durable medical equipment to the extent provided for in such section) as defined in section 1861(m) of the Act furnished to an individual who is under a plan of care of an HHA, unless that HHA has submitted a claim for payment for such services.

(s) Unless § 414.404(d) or § 414.408(e)(2) of this subchapter applies, Medicare does not make payment if an item or service that is included in a competitive bidding program (as described in part 414, subpart F of this subchapter) is furnished by a supplier other than a contract supplier (as defined in § 414.402 of this subchapter).

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The Centers for Medicare & Medicaid Services (CMS) issued a final rule Monday that updates Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment System for fiscal year 2024.

The federal agency estimates that the aggregate impact of the payment policies in the latest rule would result in a net increase of 4.0%, or approximately $1.4 billion, in Medicare Part A payments to SNFs in FY 2024. This estimate reflects a $2.2 billion increase resulting from the 6.4% net market basket update to the payment rates.

The final rule also brings forth updates to the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY 2024 and future years, including the adoption of a measure intended to address staff turnover.

Experts said that given the rising costs associated with labor and other expenses, the payment rate might be insufficient to meet the needs of the moment.

“While it is nice to see a more significant market basket increase (in the 6.2% range) than the prior years’ 2% and 3% adjustments, it is important to note that much of this increase is making up for last years’ significant under-reimbursement,” Brian Ellsworth, VP public policy and payment transformation for Health Dimensions Group, told Skilled Nursing News.

Moreover, Ellsworth noted that the expenses for the nursing home Industry have gone up. “[The] average hourly nursing wage went up by 17% between 2019 and 2021, so CMS had ample indication that the market basket update needed to be adjusted upward. Adequate payment for nursing staff is of vital importance and will need to be factored into the staffing standards when they come out,” he said.

Ellsworth also recommends that CMS revisit consolidated billing policy to better ensure that patients with high-cost medications get more timely access to skilled nursing. “It is long past due to make some adjustments to that policy,” he said.

Meanwhile, this expert view is backed by nursing home advocates as well, who said that even though they welcome the payment rate increase, it doesn’t go far enough to ensure quality given the tough labor and economic environment.

“The final rule released today does not address the reality of providers’ operating environments, and will, ultimately, limit older adults’ access to much-needed care and services,” said Katie Smith Sloan, president and CEO of LeadingAge, the largest association of nonprofit providers of aging services, including nursing homes. “[The] 4% provided in this rule will surely be offset by the increasing costs of care, which will most certainly continue to rise in the coming year – on top of the expected staffing standards.”

And, Martin Allen, senior vice president of Reimbursement Policy at the American Health Care Association (AHCA), acknowledged that while the Medicare increase will help nursing homes enhance their services and support their caregivers, more must be done, especially if the Biden Administration implements a federal staffing mandate – an effort that AHCA estimates could cost tens of billions of dollars each year. “It is vital to fund government mandates and to ensure Medicare remains a viable program to ensure our nation’s seniors can access the care they need,” Allen said.

Moreover, advocates pointed out that several of the measures stand out as “concerning” on quality reporting and value-based purchasing. Among these measures, they especially noted the staff and resident vaccination measure and the total Nurse Staffing Turnover measure for the VBP as not being practical.

LeadingAge also said that it disagreed with how CMS was defining gaps in employment with a 60 day-timeframe, saying that it was contradictory to the Department of Labor’s guarantee of 12 weeks per year of family/medical leave (FMLA).

“These measures aren’t fair, reasonable or within providers’ control,” Smith Sloan said.

The final 2024 payment rule is expected to be published in the Federal Register on Aug. 7.

Updates to payment rates

The market basket update is based on a 3.0% SNF market basket increase plus a 3.6% market basket forecast error adjustment and minus a 0.2% productivity adjustment, as well as a negative 2.3%, or approximately $789 million, decrease in the FY 2024 SNF PPS rates as a result of the second phase of the Patient Driven Payment Model (PDPM) parity adjustment recalibration, CMS said in its press release.

“After considering the stakeholder feedback received on the FY 2023 SNF PPS proposed rule and to balance mitigating the financial impact on providers of recalibrating the PDPM parity adjustment with ensuring accurate Medicare Part A SNF payments, CMS finalized a PDPM parity adjustment factor of 4.6% in the FY 2023 SNF PPS final rule with a two-year phase-in period, resulting in a 2.3% reduction in FY 2023 and a 2.3% reduction in FY 2024 to the SNF PPS payment rates,” CMS said.

CMS also noted that the impact figures do not incorporate the VBP reductions for certain SNFs subject to the net reduction in payments under the VBP. Those adjustments are estimated to total $184.85 million in FY 2024.

CMS’ other changes include those made to the PDPM ICD-10 Code Mappings, in response to stakeholder feedback.

The federal agency also announced changes to the SNF QRP by adopting two measures in the QRP, removing three measures from the SNF QRP, and modifying one measure in the QRP. In addition, this rule makes policy changes to the QRP and begins public reporting of four measures.

And CMS said that it is also adopting the Discharge Function Score (DC Function) measure beginning with the FY 2025 SNF QRP. This measure assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score and uses mobility and self-care items already collected on the Minimum Data Set (MDS).

CMS is removing certain measures as well beginning in FY 2025, including one pertaining to self care score for medical rehab measure. 

Changes to the VBP Program

CMS had also proposed initially to gauge patient satisfaction as part of quality reporting and VBP programs through the CoreQ: Short Stay Discharge measure but decided to nix it in the final rule given that it lacked support during the comment period.

“While we and our members support this type of reporting, the measure as proposed did not provide adequate funding to ensure its success – so it was rightly excluded in the final rule,” Smith Sloan said.

CMS is adopting four new quality measures, replacing one quality measure, and finalizing several policy changes in the SNF VBP Program. The new quality measures are as follows:

• CMS is adopting the Nursing Staff Turnover measure for the SNF VBP program beginning with the FY 2026 program year. This is a structural measure that has been collected and publicly reported on Care Compare and assesses the stability of the staffing within an SNF using nursing staff turnover. Facilities would begin reporting for this measure in FY 2024, with payment effects beginning in FY 2026.
• CMS is adopting the Discharge Function Score Measure beginning with the FY 2027 program year. This measure is also being adopted for the SNF QRP and assesses functional status by assessing the percentage of SNF residents who meet or exceed an expected discharge function score and use mobility and self-care items already collected on the MDS.
• CMS is adopting the Long Stay Hospitalization Measure per 1,000 Resident Days beginning with the FY 2027 program year. This measure assesses the hospitalization rate of long-stay residents.
• CMS is adopting the Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) beginning with the FY 2027 program year. This measure assesses the falls with major injury rates of long-stay residents.
• CMS is replacing the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) with the Skilled Nursing Facility Within Stay Potentially

The rule also finalizes a constructive waiver process to ease administrative burdens for CMS related to processing Civil Monetary Penalty (CMP) appeals, the federal agency said in a press release. CMS publishes the final rule consistent with the legal requirements to update Medicare payment policies for SNFs annually.

2024 projected Medicare Part D coverage

CMS also announced that the average total monthly premium for Medicare Part D coverage is projected to be approximately $55.50 in 2024. This expected amount is a decrease of 1.8% from $56.49 in 2023. Stable premiums for Medicare prescription drug coverage in 2024 are supported by improvements to the Part D program in the Inflation Reduction Act that allow people with Medicare to benefit from reduced costs.

The post [UPDATED] CMS’ 2024 SNF Final Rule Seen as Insufficient for Payment Rates While Advancing Unfair Measures appeared first on Dr. Miltie.

Brian Carpenter, MD 1/31/2023

TELEMEDICINE

ADVERTORIAL

As we move forward in 2023, it’s uplifting to see census returning to near pre-pandemic levels for many providers. Unfortunately, many of these same facilities are still experiencing staffing challenges and the daunting reality of higher-acuity residents. With over 50 percent of U.S. hospitals operating in the red, the trend to discharge patients from the acute setting faster and sicker will surely continue.

An increase in acuity requires more physician access.

Skilled nursing facilities (SNFs) are increasingly shouldering the responsibility of complex hospital discharges, which test staff capabilities and negatively affect quality scores. Some providers have welcomed a higher-acuity strategy as an opportunity to build census, but physician access for these patients remains limited. Newly admitted patients may not see a physician for an assessment on the first day, and long-term care residents may only see a physician once a month. Physician access differs vastly from the acute-care setting, where doctors can be at the bedside 24/7 when needed.

Telemedicine is the only cost-effective means to increase access to physician services.

If the pandemic had a silver lining, it was telemedicine. The U.S. Department of Health and Human Services reported a 63-fold increase in Medicare telehealth utilization in 2020. Better technology, the need for infection control, and regulatory changes in the Coronavirus Aid, Relief, and Economic Security (CARES) Act expanded the opportunity to positively impact SNF outcomes. When deployed correctly, telemedicine is the most effective and affordable way to place a physician at the bedside 24 hours a day. Video-enabled virtual care provides the means to assess, manage, and treat changes in condition, in partnership with an attending nurse. It’s especially effective for nights and weekends.

Today it’s about more, not less.

Despite its promising potential, SNF telemedicine was initially met with a hefty dose of skepticism. Medical directors and attending physicians feared their billable encounters—or even their jobs—could be at risk. Nurses worried physicians would spend less time in the building. Providers worried about liability. And families assumed that telemedicine would replace in-person care for their loved ones.

Fortunately for long term and post-acute care residents, attitudes have shifted dramatically over the past few years. Today, there is broad and growing acknowledgment of telemedicine’s value and data to prove clinical efficacy and improved outcomes.

Telemedicine assists in managing transfers to and from acute settings.

One of the biggest challenges happens when residents need hospital-level services. Transfers at night create the most risk because understaffed emergency departments (EDs) don’t always prioritize SNF residents for treatment. We’ve seen a dramatic difference when an ED transfer workflow includes a tele-physician consult followed by direct communication from the tele-physician to the ED. When an engaged physician speaks directly to an ED physician to advocate on the patient’s behalf, the scenario for the patient changes. Telemedicine makes this possible, even overnight. The result is faster care, appropriate utilization, and less time in the hospital. We manage hundreds of ED transfers each month, and 39 percent of residents return to the SNF without hospital readmission.

Likewise, when patients arrive or return to the SNF, seeing a physician within a few hours can significantly improve the transition of care. Patients and families have shared how comforting it is to see a physician and have questions answered on day one. A video encounter can address medications, pain management, and a care plan to set the patient up for success until they can be seen in person by a physician.

Integration makes a difference.

SNF telemedicine is a two-way conversation initiated by a nurse at the bedside. Nurses use telemedicine more often when the process is easy, integrated into their existing workflow, and intuitive. Our partnership with PointClickCare makes telemedicine accessible directly in the patient chart, and utilization has skyrocketed. One regional organization saw a remarkable 300 percent increase in consultations—94 percent of which resulted in residents receiving treatment without having to leave their facility.

Telemedicine has a positive impact on SNF operations.

For SNFs, the return on investment from telemedicine shows up in myriad ways. Revenue is saved by reducing hospital readmissions and lost bed days. Administrative costs go down with uninterrupted care and fewer expenses tied to hospital transfers. Additional value accrues with improved quality scores, better hospital relationships, and more referrals through high-quality SNF networks. Additionally, numerous organizations see increased nursing satisfaction from this additional level of responsive support, even using their program to help recruit nurses.

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