Alaska does not give healthcare leaders much room for theoretical planning. Distance, weather, workforce shortages, and uneven broadband access turn every care model into an operational test. That is why understanding the pillars of the RHTP funding in the state of Alaska and the benefits of the Dr. Miltie N9+ matters for providers, administrators, and rural health decision-makers trying to build programs that can actually function outside a major urban center.

For organizations serving frontier communities, tribal populations, school-age children, families managing chronic conditions, and patients who cannot easily travel, funding is only useful when it supports care delivery that is clinically credible and sustainable. The best-aligned technologies are not generic video tools. They are platforms that help extend examination capability, improve care coordination, support reimbursement-aware workflows, and fit the realities of rural and community-based care.

What RHTP funding in Alaska is really trying to support

When healthcare teams talk about rural transformation funding, the conversation often drifts toward hardware purchases or one-time grant activity. That is too narrow. In Alaska, RHTP-related priorities are better understood as a set of practical pillars that shape whether a program can improve access and stay viable after the initial funding period.

The first pillar is access expansion. In Alaska, access is not just about adding appointments. It means reducing the need for long-distance travel, bringing care closer to schools and community clinics, and giving clinicians a way to evaluate patients who might otherwise delay care. A virtual care strategy that only adds a video visit without clinical examination tools may help with convenience, but it may not close the access gap in a meaningful way.

The second pillar is care model modernization. Rural transformation efforts increasingly favor technologies that let organizations redesign workflows rather than simply digitize old ones. That includes clinician-directed virtual exams, remote patient monitoring, care coordination, and support for distributed care settings such as homes, schools, pediatric practices, and satellite clinics. In Alaska, where workforce reach matters as much as workforce size, modernization is tied directly to operational resilience.

The third pillar is measurable community impact. Funding programs are more compelling when they can show improvements in follow-up rates, chronic disease oversight, pediatric access, reduced avoidable transfers, and better continuity of care. Leaders need tools that generate clinically relevant data and help document outcomes, not just activity.

The fourth pillar is financial sustainability. This is where many otherwise promising programs become fragile. Rural organizations need implementation models that recognize reimbursement, staffing constraints, and the realities of care delivery across multiple settings. A technology investment that requires extensive new labor or sits outside billable workflows can become difficult to defend, even if the clinical idea is strong.

The fifth pillar is equity for underserved populations. In Alaska, this includes rural communities, safety-net populations, and pediatric patients whose needs are amplified by travel burdens, caregiver limitations, sensory stress, or specialist scarcity. Programs that support care in familiar environments can be especially valuable for autistic children and pediatric patients with special healthcare needs.

The pillars of the RHTP funding in the state of Alaska in practice

If those pillars sound broad, that is because they are meant to guide real implementation decisions. The question for health systems, critical access hospitals, FQHCs, rural health clinics, and community-based organizations is what kind of platform can support all of them at once.

A standard telehealth setup may satisfy a narrow access goal, but it often falls short on exam depth, documentation quality, and care team integration. That trade-off matters more in Alaska than in denser markets. When patients face major travel barriers, a limited virtual encounter can still leave providers needing an in-person follow-up that is difficult to schedule and harder for families to attend.

A more capable model supports clinician-directed virtual physical exams, capture of objective patient data, remote monitoring, and pathways for follow-up care. This is where the benefits of the Dr. Miltie N9+ become operationally relevant rather than promotional.

Benefits of the Dr. Miltie N9+ for Alaska care delivery

The Dr. Miltie N9+ is not just a telehealth endpoint. It is a mobile, wireless virtual examination and patient monitoring system designed to extend clinical reach beyond the traditional exam room. For Alaska organizations, that distinction matters because the gap is rarely access to communication alone. The gap is access to clinically useful examination capability in places where patients already are.

One major benefit is stronger remote assessment. When a provider can conduct a more complete virtual physical exam and collect clinically relevant data, the virtual encounter becomes more actionable. That can improve triage decisions, support earlier intervention, and reduce unnecessary travel for cases that can be safely managed closer to home.

Another benefit is better fit for pediatric and family-centered care. Children, especially those with autism or special healthcare needs, may do better in familiar, lower-stress environments than in a distant clinic or hospital. A connected-care model that supports evaluation in homes, schools, or community settings can improve cooperation, caregiver participation, and follow-through. For families in Alaska, that also means fewer disruptions tied to weather, transportation, and missed work.

The platform also supports care continuity across distributed settings. That is valuable for chronic care management, post-discharge follow-up, school-based support, and ongoing monitoring for patients who do not need constant facility-based visits but do need structured oversight. In rural and frontier environments, continuity is often where outcomes are won or lost.

There is also an efficiency benefit for providers and administrators. A technology that combines connected medical devices, workflow customization, and care coordination support can help organizations extend limited clinical staff more effectively. That does not mean virtual care replaces hands-on care. It means the right patients can be seen in the right setting, with better use of specialist time and fewer low-value transfers.

Why the N9+ aligns with Alaska RHTP priorities

The clearest reason the N9+ aligns with the pillars of the RHTP funding in the state of Alaska is that it supports both clinical and administrative goals. On the clinical side, it helps organizations bring examination and monitoring capabilities into community-based settings. On the administrative side, it supports more scalable program design, especially when paired with reimbursement-aware deployment.

That balance is important. Some health technology performs well in a pilot but struggles in broad deployment because it requires too much customization, too many disconnected systems, or too much manual coordination. In Alaska, where operating conditions are already complex, healthcare organizations need platforms that reduce friction rather than add to it.

The N9+ also fits the needs of rural and safety-net organizations serving populations with uneven access to specialists. A rural clinic, critical access hospital, or pediatric program can use connected-care tools to bring more of the assessment process closer to the patient while still involving the broader care team. Through a Circle of Care approach, caregiver engagement and cross-setting coordination become part of the model instead of an afterthought.

Where healthcare leaders should be careful

Not every use case will deliver the same return. Organizations should avoid treating funding as a reason to buy technology first and define workflows later. The better approach is to start with service lines where travel burden, exam complexity, follow-up gaps, or pediatric access barriers are already clear.

It also depends on readiness. A strong virtual care platform still needs training, internal champions, clinical protocols, and attention to reimbursement and documentation. Leaders should assess staffing models, patient population needs, and site-level infrastructure before scaling broadly.

There is a practical middle ground here. The goal is not to virtualize everything. It is to identify where a clinician-directed remote exam and monitoring model can improve access, reduce friction, and preserve quality. In Alaska, that often means using technology to extend care intelligently, not universally.

A stronger case for rural transformation

For healthcare organizations pursuing rural transformation, the case for investment gets stronger when technology can speak to multiple funding pillars at once. Access, equity, pediatric support, operational efficiency, care continuity, and financial sustainability should not live in separate business cases.

That is why the benefits of the Dr. Miltie N9+ stand out for Alaska-based planning. It supports more complete virtual care, helps providers reach patients in community settings, reduces barriers for families, and gives organizations a more credible path from pilot activity to durable care delivery.

For Alaska leaders, the real opportunity is not to fund another isolated telehealth project. It is to build a care model that works where roads are long, specialists are scarce, and patients still deserve timely, clinician-directed care close to home.

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A pulse oximeter that gets used twice and left in a drawer is not a remote care strategy. For healthcare organizations building sustainable virtual programs, remote patient monitoring wearables need to do more than collect data. They need to fit clinical workflows, support reimbursement, reduce patient burden, and produce information a care team can actually act on.

That is where many RPM initiatives succeed or stall. The question is not whether wearables can generate more data. It is whether they can help clinicians extend care safely and efficiently into homes, schools, community settings, and rural environments where access gaps are real and follow-up is often harder than diagnosis.

What remote patient monitoring wearables need to solve

In practice, wearables sit at the intersection of patient engagement, chronic care management, clinical oversight, and operational design. A device may measure heart rate, oxygen saturation, blood pressure, temperature, activity, sleep, or glucose trends, but the value comes from what happens next. If readings are inconsistent, if transmission fails, or if staff cannot interpret data in context, the wearable becomes another disconnected technology layer.

For providers serving pediatric populations, rural communities, and medically underserved patients, the bar is even higher. Devices must be simple enough for caregivers to use correctly, dependable enough for distributed care models, and flexible enough to support clinician-directed follow-up. In many cases, comfort and familiarity matter just as much as technical capability. A child with sensory sensitivities or special healthcare needs may tolerate one form factor and reject another. That trade-off can determine adherence more than the spec sheet does.

Where remote patient monitoring wearables make the biggest impact

The strongest use cases tend to share one trait: they answer a specific clinical and operational need.

For chronic disease programs, wearables can help care teams identify deterioration earlier and intervene before a patient ends up in the emergency department. For post-discharge monitoring, they can support a safer transition home and reduce the risk of missed warning signs. For maternal and pediatric care, they can reduce travel demands on families who would otherwise need repeated in-person checks for relatively routine follow-up.

Rural health organizations often see another benefit. Remote monitoring can help stretch limited workforce capacity without lowering clinical oversight. When a specialist is far away, a connected care model can give local teams better visibility into patient status and help patients remain in their communities longer. That matters for access, but it also matters for equity. Travel time, missed work, childcare logistics, and transportation barriers are clinical barriers when they delay care.

In pediatrics, the value case is slightly different. Children are not simply smaller adults, and caregiver participation is central. Wearables that support remote observation in lower-stress environments can improve continuity for children who struggle with frequent clinic visits, including autistic children and those with special healthcare needs. The right model does not replace pediatric expertise. It helps bring that expertise closer to where the child is.

Why standalone wearables often underperform

A wearable on its own rarely fixes fragmented care. Many organizations learn this after purchasing devices before defining escalation protocols, staffing models, documentation pathways, or patient eligibility criteria.

The most common failure point is not hardware. It is workflow. If incoming data lands in a portal that no one checks consistently, alerts are too frequent to be useful, or readings cannot be tied to a virtual assessment, clinicians may not trust the program. Administrators may then see RPM as expensive monitoring rather than meaningful care delivery.

There is also a compliance and reimbursement layer. RPM programs need clear documentation standards, patient consent processes, device management protocols, and billing workflows aligned with applicable CMS and payer requirements. It depends on the care setting, patient population, and service mix, but organizations generally do better when RPM is implemented as part of a broader care model rather than a device rollout.

Choosing wearables for clinical relevance, not novelty

Healthcare leaders evaluating remote patient monitoring wearables should start with the clinical question, not the device catalog. What conditions are being monitored? Which metrics change care decisions? Who reviews the data? How quickly does the team need to respond? What level of patient or caregiver training is realistic?

For some programs, a simple connected device is enough. For others, wearable data needs to be paired with virtual physical assessment, symptom review, and care coordination. That distinction matters. A trend line can flag concern, but it may not explain the cause. Clinician-directed remote exams can add needed context when a number alone is not enough.

This is especially relevant in pediatric and community-based care. A child with respiratory symptoms may benefit from both monitoring and remote exam capabilities, particularly when travel to a specialty center is disruptive or impractical. The same is true in rural settings where local teams need tools that support assessment, not just passive tracking.

The operational case for connected care platforms

Organizations with the best RPM outcomes usually build around a connected-care framework. That means devices, data review, escalation, caregiver communication, and documentation are designed together.

When wearables are integrated into a larger platform, teams can standardize who gets monitored, how thresholds are set, and what happens when values change. That reduces avoidable variation. It also gives clinical leadership a clearer path to scale because the program is not dependent on ad hoc staff workarounds.

A connected approach is often more practical for safety-net providers and community-based organizations. These settings do not need technology that adds administrative burden. They need systems that support distributed care, make training manageable, and align with real reimbursement conditions. That is one reason enterprise buyers increasingly look beyond consumer-grade wearables toward solutions built for clinical use, workflow customization, and longitudinal care management.

Dr. Miltie approaches this need through a connected model that combines remote monitoring, virtual exam capability, and care coordination to help organizations extend clinician-directed care into homes, schools, clinics, and underserved community settings.

What matters most in pediatric and rural deployment

Pediatric and rural implementation introduces constraints that generic RPM strategies often miss. In pediatrics, device tolerance, caregiver confidence, and environment all shape adherence. A wearable may be technically accurate, but if it is difficult to place, intimidating for families, or poorly suited to a child with sensory challenges, utilization will drop.

Rural deployment brings different issues. Connectivity may be inconsistent. Staff may wear multiple hats. Patients may have long travel distances and fewer local specialty resources. In those settings, the right RPM program reduces unnecessary visits while preserving escalation pathways for patients who truly need in-person care.

This is why flexible deployment matters. Some organizations need school-based support, some need community clinic workflows, and some need home-based monitoring tied to chronic care management or post-acute follow-up. Wearables should fit the service model, not force the service model to adapt around the device.

Measuring success beyond device adoption

High enrollment numbers can look promising early, but they do not tell the full story. Better metrics include adherence over time, caregiver satisfaction, clinician response efficiency, reduced avoidable utilization, and whether the program expands access for patients who previously struggled to receive follow-up care.

Leadership teams should also ask whether wearable data is improving decision-making. Are clinicians identifying deterioration earlier? Are care coordinators able to intervene before issues escalate? Are families more engaged because monitoring happens in a familiar environment? Those are stronger indicators of value than shipment volume.

Financial sustainability matters too. Programs that ignore reimbursement, staffing costs, and device logistics can become difficult to maintain even when the clinical concept is sound. The most durable models balance patient-centered design with operational discipline.

The future of remote patient monitoring wearables

The next phase is not about adding more sensors for the sake of complexity. It is about making remote data more clinically meaningful and easier to use across real care pathways. That includes better integration with virtual exams, clearer escalation logic, and more tailored deployment for pediatric, chronic care, and rural health populations.

Healthcare organizations do not need wearables that simply collect more numbers. They need tools that support earlier intervention, broader access, and more confident care delivery outside the traditional exam room. When the technology is selected and deployed with that standard in mind, remote monitoring becomes less about devices and more about extending the reach of the care team.

The most effective programs start there: with the patient, the caregiver, and the clinician, all connected by a model that makes care easier to deliver and easier to receive.

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A blood pressure reading that trends upward over five days may not look urgent in isolation. To a remote patient monitoring nurse, it can be the early signal that keeps a patient out of the emergency department, prompts a medication review, or triggers a same-week follow-up before a chronic condition worsens. That is the practical value of this role. It sits at the point where clinical judgment, patient engagement, and connected-care infrastructure meet.

For healthcare organizations expanding virtual care, the remote patient monitoring nurse is no longer a niche position. It is becoming a core operational and clinical function, especially in programs serving chronic disease populations, rural communities, pediatric patients with ongoing monitoring needs, and patients who benefit from care delivered at home, school, or other lower-stress environments.

Why the remote patient monitoring nurse role matters now

Remote patient monitoring, or RPM, has matured beyond simple device distribution. Health systems and community-based providers are under pressure to improve access, manage staffing constraints, support value-based care goals, and create financially sustainable care pathways. That changes what organizations need from nursing teams.

A remote patient monitoring nurse does more than review incoming numbers. The role often includes triaging physiologic data, identifying when values fall outside patient-specific parameters, communicating with patients and caregivers, escalating concerns to prescribing clinicians, documenting interventions, and supporting adherence over time. In a strong program, the nurse helps turn data into action rather than letting dashboards become passive repositories of readings.

This matters even more in rural and safety-net settings. When patients face long travel distances, clinician shortages, or transportation barriers, the nurse becomes a clinically meaningful bridge between the patient and the broader care team. In pediatrics, the role can also reduce strain on families by supporting follow-up in familiar settings and involving caregivers more directly in monitoring routines.

What a remote patient monitoring nurse actually does

The day-to-day work varies by organization, patient population, and technology model. Still, several responsibilities define the role across most RPM programs.

Reviewing and interpreting patient data

At the center of the role is the review of patient-generated health data. That may include blood pressure, pulse oximetry, weight, temperature, glucose values, or other condition-specific metrics. The nurse is not simply checking whether a number is high or low. Context matters. A mildly elevated reading in one patient may be less concerning than a smaller change in another patient with heart failure, complex pediatrics, or recent medication adjustments.

The best programs support this work with configurable alert thresholds and clinically relevant workflows. Even then, the nurse still applies judgment. False alarms, missing readings, and normal physiologic variation can all create noise. A useful RPM workflow helps nurses distinguish meaningful trends from device friction or one-off anomalies.

Engaging patients and caregivers

A remote patient monitoring program succeeds or fails on participation. Nurses often spend substantial time helping patients understand why readings matter, how and when to take them correctly, and what to do if symptoms change. In pediatric care, that engagement extends to parents, guardians, school staff, and other members of the care circle.

This is especially important for autistic children and pediatric patients with special healthcare needs. Monitoring may need to fit the child’s environment, communication style, and sensory preferences. The nurse’s role becomes part clinical support and part care coordination, with a strong emphasis on reducing disruption while preserving the quality of follow-up.

Escalating care at the right time

One of the most important functions of a remote patient monitoring nurse is timely escalation. Not every alert requires a physician call, and not every symptom can wait for the next scheduled visit. The nurse helps determine what needs education, what needs care coordination, and what needs immediate clinical review.

That middle layer is operationally valuable. It protects physician time, supports continuity, and creates a more responsive patient experience. It also reduces the risk that subtle deterioration goes unnoticed between visits.

Documenting for clinical and reimbursement integrity

RPM is a care model, but it is also a regulated service line. Nurses working in these programs often support documentation tied to care plans, patient communication, time-based service requirements, escalation pathways, and care coordination activities. If documentation is weak, the program may struggle clinically and financially.

That is why many healthcare leaders look for platforms and workflows that are reimbursement-aware from the start. A nurse should be able to focus on patient care without chasing fragmented data across systems.

Where this role creates the most value

Not every organization will structure RPM nursing the same way. The highest value usually appears where there is a combination of ongoing monitoring need, access friction, and a patient population that benefits from more frequent touchpoints.

Chronic disease management

Patients with hypertension, diabetes, heart failure, COPD, and other chronic conditions often benefit from trend-based monitoring rather than episodic office visits alone. The nurse helps identify deterioration earlier, reinforce treatment plans, and support adherence between appointments.

Pediatric and family-centered care

In pediatric programs, RPM nursing can support follow-up without requiring repeated travel or disrupting school and caregiver schedules. For children with special healthcare needs, the nurse may coordinate around developmental, behavioral, or environmental considerations that make in-person monitoring harder. That flexibility can improve participation and reduce missed follow-up.

Rural and community-based care

For rural health clinics, critical access hospitals, federally qualified health centers, and community-based organizations, the nurse can extend the reach of limited clinical teams. Instead of asking every patient to return for every concern, organizations can use remote monitoring to maintain visibility into patient status while reserving in-person capacity for those who truly need it.

What healthcare leaders should consider before hiring or scaling

It is tempting to think of the remote patient monitoring nurse as a staffing add-on. In practice, the role works best when it is designed into the care model from the beginning.

First, technology fit matters. If devices are difficult for patients to use, data transmission is inconsistent, or virtual exam tools are disconnected from nurse workflows, the burden falls back on staff. Nurse efficiency depends on clinically useful device integration, dependable data capture, and clear escalation logic.

Second, patient population fit matters just as much. A pediatric RPM workflow should not mirror an adult cardiac workflow. Rural programs may need more caregiver coaching and outreach persistence. Safety-net settings may need stronger support for language access, digital confidence, and care coordination across fragmented resources.

Third, organizations should be realistic about alert design. Too many alerts create fatigue. Too few can miss meaningful change. The right balance depends on condition, acuity, staffing model, and physician oversight.

Fourth, reimbursement and compliance cannot be afterthoughts. RPM programs require operational discipline around consent, documentation, time tracking where applicable, HIPAA-aligned workflows, and clinical oversight. A good nurse can strengthen the program, but no nurse should be expected to compensate for a weak implementation model.

The technology question: data alone is not enough

Many RPM programs start with connected devices and stop there. That can produce data, but not necessarily better care. Nurses need more than raw numbers. They need enough clinical context to assess what the reading means, enough communication capability to reach the patient or caregiver, and enough workflow support to move efficiently from observation to intervention.

This is where connected-care platforms can make a measurable difference. When remote monitoring is paired with virtual exam capability, care coordination tools, and customizable workflows, the nurse role becomes more clinically complete. In some settings, that means combining monitoring with clinician-directed virtual assessment rather than sending the patient to another site simply to confirm what a trend already suggests. For organizations building pediatric, rural, or distributed care models, that broader approach is often more practical than piecing together multiple disconnected tools.

A role that strengthens the whole care team

The remote patient monitoring nurse should not be viewed as a replacement for in-person nursing or physician care. The better way to see it is as a force multiplier for clinical teams trying to manage more patients across more settings with greater continuity.

When the role is well supported, nurses can identify change earlier, guide patients more consistently, improve caregiver participation, and help organizations use virtual care in a way that is clinically credible and operationally sustainable. That is particularly relevant for healthcare leaders building programs around chronic care management, pediatric access, and rural health equity.

For many organizations, the real question is no longer whether remote patient monitoring has value. It is whether the program has the nursing workflows, clinical tools, and care model design to turn that value into daily practice. Getting that part right is what makes virtual care feel less remote for the people who depend on it most.

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Executive Summary

Digital health advocates believe remote monitoring—the use of digital technologies to collect and relay patient data to health care professionals—has the potential to transform disease management, health outcomes, and patient care, especially for individuals with multiple chronic conditions who lack convenient access to providers. Medicare, most state Medicaid agencies, and many private health insurance plans cover remote monitoring services.

For the purposes of this report, we define remote monitoring as an umbrella term for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). RPM refers to the monitoring of physiologic data—such as weight, blood glucose, or blood pressure—while RTM refers to the monitoring of patients’ self-reported non-physiologic data, such as pain levels or medication adherence. Currently, the Centers for Medicare & Medicaid Services (CMS) limits RTM reimbursement to cases involving the respiratory system, musculoskeletal system, and cognitive behavioral therapy.

Although the percentage of patients using RPM remains relatively low (594 monthly claims per 100,000 Medicare enrollees in 2021), the use of RPM increased among Medicare beneficiaries more than sixfold from 2018-2021. In part, this increase was due to CMS’ expanded coverage rules during the COVID-19 public health emergency. Thirty-four state Medicaid programs covered RPM services as of March 2023; however, many Medicaid programs restrict RPM use in some way. RTM uptake has also steadily increased since its introduction in 2022, yet billing and documentation requirements can hinder its widespread adoption.

The evidence base on remote monitoring, particularly for RPM tools, is growing. Yet some policy experts cite a lack of robust evidence on the optimal use of remote monitoring, including its duration and target patient groups. In the absence of such evidence, these experts question whether we are effectively “rightsizing” the use of these services. Underuse could limit access to beneficial care, while overuse could unnecessarily increase spending in federal health care programs. Additionally, providers cite the need for tools—such as generative artificial intelligence (AI)—to manage streams of data, otherwise the volume of patient-generated information can become overwhelming and unmanageable.

Over the past year, the Bipartisan Policy Center undertook an extensive effort to develop evidence-based, federal policy recommendations for the appropriate use and coverage of remote monitoring services. BPC assessed patients’ access to and use of remote monitoring technologies and their impact on health outcomes and cost. We conducted a series of interviews and hosted a private roundtable with health policy experts, federal officials, technology leaders, medical providers, payers, consumers, and academics to gain insight into the opportunities and challenges regarding remote monitoring.

This report looks broadly at ways to improve the use of remote monitoring services, ensure equitable access to these services across populations, and enhance data security and privacy standards. Now is the time for payers and providers to refine their approach and maximize appropriate adoption for patients who stand to benefit from remote monitoring.

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CMS recently released the CY 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule (Proposed Rule), which included many noteworthy proposals and clarifications related to Medicare telehealth services and other remote services. Since the COVID-19 Public Health Emergency (PHE) terminated on May 11, 2023, providers and practitioners have sought clarity on the end dates of various waivers and telehealth flexibilities. The Proposed Rule removes some ambiguity by extending certain telehealth flexibilities that were within CMS’s discretion and implementing statutory extensions that were included in the Consolidated Appropriations Act, 2023 (CAA, 2023). While CMS FAQ Guidance issued at the end of the PHE hinted at some of these extensions, the proposed rule provides more clarity – at least through the end of 2024.

As an overview, the Proposed Rule includes proposals to:

1. Implement all telehealth provisions of the CAA, 2023 which temporarily lifted statutory limitations on coverage of telehealth services through the end of 2024.
2. Pay all claims for telehealth services other than those for services furnished to patients in their homes at the lower MPFS facility rate beginning on January 1, 2024. This applies to any non-home originating sites such as physician offices. In contrast, all telehealth services provided to patients in their homes would paid at the non-facility rate.
3. Allow hospital outpatient departments to continue to bill for outpatient therapy, Diabetes Self-Management Training (DSMT), and Medical Nutritional Therapy (MNT) furnished remotely via telehealth by institutional staff to beneficiaries in urban areas (as opposed to only rural areas) and to beneficiaries in their homes (through the end of 2024).
4. Define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications (through the end of 2024).
5. Allow teaching physicians to be virtually present for key and critical portions of services performed with residents in all teaching settings in clinical instances when the service is furnished virtually through telehealth. CMS is exercising enforcement discretion through the end of 2024 to allow teaching physicians to be virtually present through telehealth in clinical instances where the service is not furnished via telehealth.
6. Remove frequency limitations on telehealth services applicable to subsequent inpatient visits, subsequent nursing facility visits, and critical care consultation services (through the end of 2024).
7. Modify its process for making changes to the Medicare Telehealth List. CMS also proposes to add a new code to the Medicare Telehealth List for the administration of a standardized evidence-based social determinants of health risk assessment.
8. Clarify policies and requirements for Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services. CMS also confirms that these services will only be available for established patients now that the PHE is over and codes that require data collection minimums will go back to requiring 16 days of data collected in a 30-day period.

Comments on the Proposed Rule are due at 5:00 p.m. on September 11, 2023.

Below is a more detailed summary of proposals related to telehealth and remote services including some context related to pre-existing policies and the implications of the proposals.

1. CAA, 2023 Extensions

The Proposed Rule implements all telehealth provisions extended through the end of 2024 by the Consolidated Appropriations Act, 2023. This includes:

• Lifting geographic restrictions and maintaining the expanded list of originating sites including patient’s homes.
• Expanding the list of distant site practitioners to include Physical Therapists (PTs), Occupational Therapist (OTs), Speech Language Pathologists (SLPs), and Audiologists. Marriage and family therapists (MFT) and mental health counselors (MHC) will be recognized as telehealth practitioners effective January 1, 2024.
• Extending telehealth to FQHCs and RHCs.
• Delaying until January 1, 2025, the required in-person visit for telehealth mental health services.
• Extending audio-only telehealth.

2. Place of Service for Medicare Telehealth Services

Under COVID-19 PHE flexibilities, physicians and other practitioners have reported the place of service (POS) that would have been reported had the service been furnished in-person. Services were reported with modifier 95 to effectuate this change. The payment impact was services that would have been furnished in person in an office setting could be paid at a higher MPFS non-facility rate when furnished via telehealth. This was never the case before the PHE where all telehealth services were reported with POS 02 and paid at the lower facility rate.

In the CY 2023 MPFS final rule, CMS finalized that following the end of the calendar year in which the PHE ends, practitioners will no longer be able to bill telehealth claims with modifier 95 along with the POS code that would have been applied if the service were furnished in person. Instead, telehealth claims would have to be billed with the following POS indicators:

• POS 02 – Telehealth Provided Other Than in Patient’s Home (Descriptor: Patient is not located in their home when receiving health services or health-related services through telecommunication technology).
• POS 10 – Telehealth Provided in Patient’s Home (Descriptor: the location where health services and health-related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence when receiving health services or health-related services through telecommunication technology).

Beginning on January 1, 2024, claims billed with POS 10 will be paid at the non-facility telehealth rate, but all other telehealth claims billed with POS 02 will be paid at the facility rate. This would mean that POS 02 would be reported for any non-home originating site such as physician offices. Accordingly, telehealth services furnished to patients receiving the services in physician offices would be paid at the lower facility rate (i.e., at a rate that is less than if they were furnished in person).

CMS decided that behavioral health services provided to patients when they are in their homes should be valued at the office setting rate even if provided to patients at home because many mental health practitioners see patients in their office and at home so they have to maintain an office as practice expenses even if a significant portion of the practice’s visits are conducted via telehealth. As such, CMS decided the practice expenses for these practices are more accurately reflected by the non-facility rate.

In sum, CMS is proposing that all telehealth services provided to patients who are not in the home (including patients in physician’s offices) will be paid at the facility rate starting at the beginning of CY 2024. In contrast, all telehealth services provided to patients in their homes should be reported with POS 10 and paid at the non-facility rate. This could include all Medicare-eligible telehealth services for the period of time that the home is still an originating site for all services (through the end of 2024). Without further legislative changes, when the CAA, 2023 extension of the flexibilities related to originating sites end, the patient’s home will not be a Medicare-eligible originating site for services other than mental health and other very limited exceptions. Therefore, most all telehealth claims other than mental health telehealth would be paid at the facility rate. Mental health telehealth services will continue to be paid at the non-facility rate when provided to patients in their homes, but if a mental health practitioner provides telehealth services to a patient in a hospital or facility setting, that would be reported as POS 02 and paid at the facility rate.

3. Extension of Virtual Presence for Direct Supervision

During the PHE, CMS allowed “immediate availability” required for direct supervision of diagnostic tests, physicians’ services, and certain outpatient services to allow the supervising professional to be immediately available through virtual presence using two-way, real-time audio/video technology, instead of requiring their physical presence. CMS also allowed immediate availability for direct supervision through virtual presence for purposes of meeting incident-to-billing requirements.

To prevent abrupt changes to practice patterns that CMS acknowledged could limit access to certain services, CMS is proposing to continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2024. CMS believes this will align the timeframe of this policy with the extension of many other telehealth flexibilities. During this extension, CMS is seeking comments on a more permanent extension.

CMS suggests that one potential approach would be to extend or permanently establish the virtual presence flexibility for services that are valued under the MPFS based on the presumption that they are nearly always performed in entirety by auxiliary personnel. This could include any service wholly furnished incident to a physician’s or practitioner’s professional services as well as Level I office or other outpatient E/M visits for established patients and Level I emergency visits.

4. Virtual Presence of Teaching Physicians

During the PHE, teaching physicians could satisfy teaching physician billing requirements by being virtually present through real-time audio-video telehealth technology for key and critical portions of services performed with a resident. Outside the PHE this was only allowed in rural teaching settings.

CMS is now proposing to allow teaching physicians to continue to have virtual presence in all teaching settings in clinical instances when the service is furnished virtually through telehealth (e.g., a three-way telehealth visit with parties in different locations). This virtual presence policy continues to require real-time observation (not mere availability) by the teaching physician, and excludes audio-only technology.

CMS is exercising enforcement discretion to allow teaching physicians in all residency sites to be present through audio/video real-time communications technology for purposes of billing under the MPFS for services they furnish involving residents through the end of the CY 2024 rulemaking process.

CMS seeks comment on how telehealth services can be furnished in all residency training locations beyond Dec. 31, 2023. This includes other clinical treatment situations that are appropriate to permit the virtual presence of a teaching physician.

5. Extension of Flexibilities that Allow Hospital Outpatient Departments to Bill for Certain Telehealth Services Furnished by Institutional Staff

CMS proposes to allow hospital outpatient departments to bill for telehealth services furnished by therapists through the end of 2024. This includes continuing to allow outpatient therapy, Diabetes Self-Management Training (DSMT) and Medical Nutritional Therapy (MNT) services to be furnished remotely by institutional staff to beneficiaries in their homes when furnished by institutional providers via telehealth.

During the PHE, CMS allowed outpatient therapy services to be furnished and billed by therapists in private practice and also allowed for outpatient therapy services, DSMT, and MNT to be furnished via Medicare telehealth to beneficiaries in urban areas (as opposed to only rural area) and to beneficiaries in their homes.

CMS originally took the position that institutions billing for services furnished remotely by their employed practitioners (where the practitioners do not bill for their own services), would end when the PHE ends along with the end of the Hospitals Without Walls waivers. CMS is now considering whether certain institutions should be able to bill for certain remotely furnished services personally performed by employed practitioners.

While CMS considers how it would implement a more permanent policy, CMS will continue to allow outpatient therapy, DSMT, and MNT services to be furnished remotely by institutional staff to beneficiaries in their homes when furnished by institutional providers via telehealth. To effectuate this, institutional providers will be able to continue to bill for these services when furnished remotely in the same manner they have during the COVID-19 PHE through the end of CY 2024.

CMS also stated that it is exercising enforcement discretion to allow practitioners who would not otherwise qualify as Medicare distant site practitioners to continue to remotely furnish DSMT services as long as they are otherwise qualified to provide the services.

CMS seeks comment on current practice for these services when billed including how and to what degree they continue to be provided remotely to beneficiaries in their homes, as well as relevant authorities to continue to permit billing for these services in future rulemaking. Moreover, CMS has indicated that it plans to broadly consider billing and payment for telehealth services in institutional settings, including when these services are furnished by practitioners who have reassigned their billing rights to an institution (this would include billing arrangements where practitioners reassign billing rights to Critical Access Hospitals (CAHs), and CMS makes payment for the practitioner’s services under CAH method II).

6. Frequency Limitations on Telehealth Services

Before the PHE, the following frequency limitations were in place:

• Limit of one telehealth visit every three days for subsequent inpatients visits.
• Limit of one telehealth visit every 14 days for subsequent nursing facility visits.
• Limit on critical care consultations to one telehealth visit per day.

CMS waived the frequency limitations for subsequent inpatient visits, subsequent NF visits, and critical care consultations for the duration of the PHE. Even though the frequency limitations resumed effect beginning on May 12, 2023 (upon expiration of the PHE), CMS used waiver authority to exercise enforcement discretion with respect to these frequency limitations through December 31, 2023.

In the CY 2024 MPFS proposed rule, CMS is proposing to remove telehealth frequency limitations for the duration of CY 2024 for the following codes:

• Subsequent inpatient visit CPT codes (99231, 99232, 99233)
• Subsequent nursing facility visit CPT codes (99307, 99308, 99309, 99310)
• Critical Care Consultation Services – HCPCs Codes: G0508, G0509

CMS is gathering data and seeking comments on a more permanent policy with a focus on ensuring that Medicare beneficiaries are receiving subsequent inpatient and nursing facility visits and critical care services while the temporary policy remains in place post-expiration of the PHE.

7. Telehealth Services List

CMS proposes to clarify and modify its process for making changes to the Medicare Telehealth List. In previous years services were added on a Category 1, Category 2, or Category 3 basis. Now that the PHE is over, CMS proposes to clarify and modify its process for making changes to the Medicare Telehealth List. One goal is to distinguish services that were added to the telehealth list on the basis of COVID-19 PHE-related authorities versus services that were added temporarily on a Category 3 basis, which do not rely on a PHE-related authority.

CMS will assign permanent or provisional status to any service that maps to the service elements of a permanent telehealth service or has evidence of clinical benefit when delivered via telehealth. Once provisional services have enough evidence of clinical benefit, they will be assigned permanent status. For FY 2024, CMS proposes that services currently added on a “temporary Category 2” or Category 3 basis will be assigned to the “provisional” category. Our prior article provides further guidance on the Category assignments for various services on the telehealth list.

CMS proposes to temporarily add health and well-being coaching services to the Medicare Telehealth List for CY 2024. Additionally, CMS proposes to permanently add a new code to the Medicare Telehealth List for the Administration of a standardized evidence-based Social Determinants of Health Risk Assessment as long as the broader proposal for Medicare to pay for such risk assessments is finalized. More specifically, CMS is allowing a face-to-face encounter element of the social determinants of health (SDOH) risk assessment service to be permitted to be performed via two-way interactive audio-video technology as a substitute to in-person interaction as long as the telehealth modality does not affect the accuracy or validity of the results gathered via a standardized screening tool. CMS is also proposing that this service must be furnished by the practitioner on the same date they furnish an E/M visit as the SDOH assessment would be reasonable and necessary when used to inform the patient’s diagnosis, and treatment plan established during the visit.

8. Remote Monitoring Services

In the proposed rule, CMS reiterated its longstanding policy that there is a range of services delivered using telecommunications technology that do not fall within the scope of Medicare telehealth services but are separately payable under the MPFS. These include, but are not limited to services that use telemedicine technology to facilitate interactions between the practitioner and the patient, but do not substitute for an in-person encounter. One example of such services includes remote patient monitoring.

In the 2024 proposed MPFS rule, CMS proposes to clarify its payment policies for certain remote monitoring services, specifically remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). By way of background, in the CY 2020 MPFS final rule, CMS confirmed that the RPM code family (CPT codes 99453,99454, 99457, and 99458) describes chronic care RPM services that involve the collection, analysis, and interpretation of digitally collected physiologic data, followed by a treatment plan and management of the patient under the treatment plan. In the 2024 proposed rule, CMS reiterates that the code family for RTM services includes CPT codes 98975, 98976, 98977, 98978, 98980, and 98981 which involve the monitoring of program or therapy adherence through a scheduled recording, or program alert, or an interactive communication with the patient or caregiver. In previous rulemaking, CMS confirmed that remote monitoring codes are designated as care management services and the rules for general supervision apply.

New v. Established Patients:

Following the expiration of the PHE, RPM services may be furnished only to established patients, meaning that an initiating visit is required for patients not seen by the practitioner within the last year. During the PHE, CMS waived the requirement of an established patient relationship and allowed practitioners to provide RPM services to both new and established patients without an initiating visit. In the proposed rule, CMS clarifies that patients who received RPM services during the PHE are considered established patients.

Data Collection Requirements:

CMS reminds practitioners that following the end of the PHE on May 11, 2023, the 16-day monitoring requirement for RPM and RTM services was reinstated. This means that monitoring must occur over, at least, 16 days of a 30-day period. The proposed rule seeks to clarify the data collection minimums apply to existing RPM and RTM code families for CY 2024 (the existing RPM and RTM codes are identified above). CMS further seeks to clarify that the following codes require the collection of a minimum of 16 days of data in a 30-day period: 98976, 98977, 98978, 98980, and 98981.

CMS proposes to further clarify that:

• RPM services should be reported once during a 30-day period and only when reasonable and necessary.
• Only one practitioner may bill for CPT codes 99453-99454 and CPT codes 98976, 98977, 98980, and 98981, during a 30-day period, and only when at least 16 days of data have been collected on at least one medical device. This is consistent with CMS’s analysis as set forth in the CY 2021 MPFS final rule which provides that even when multiple medical devices are provided to a patient, the services associated with those devices can only be billed once per patient in a 30-day period and only when a minimum of 16 days of data is collected.

Use of RPM, RTM, in Conjunction with Other Services:

CMS reminds practitioners that they may bill for RPM or RTM services, but not both. Either RPM or RTM services may be billed concurrently with certain care management services for the same patient as long as time or effort are not counted twice. Care management services include CCM/TCM/BHI, PCM, and CPM. While the proposed rule seeks to clarify that RPM and RTM may not be billed together, CMS requests feedback regarding practitioner experience with different code sets and services to develop and clarify its payment policies for these services.

Other Clarifications for Appropriate Billing:

CMS is proposing that practitioners may separately furnish and be paid for RPM or RTM services to a beneficiary that received a procedure or surgery which is covered under a payment for a global period. Payment for RTM or RPM services would be separate from the global payment. Similarly, for beneficiaries already receiving RTM or RPM services during a global period, practitioners may receive separate payments for those services as long as they are unrelated to the diagnosis for which the global procedure was performed. In other words, the remote monitoring must relate to an episode of care that is separate and distinct from the episode of care for the global procedure, i.e., the remote services do not pertain to or address the condition that is related to the global procedure or service.

RPM and RTM Services Provided by RHCs and FQHCs:

Finally, CMS is proposing a policy to include RPM, RTM, Community Health Integration (CHI), and Principal Illness Navigation (PIN) services in the general care management HCPCS code G0511 when these services are provided by RHCs and FQHCs.

Conclusion

The CY 2024 Proposed Rule includes a number of important extensions to telehealth flexibilities and clarifies existing policies related to telehealth and other remote services. While these proposals align with the CAA, 2023 extensions to continue to allow payment for many telehealth arrangements structured during the PHE, most policies allowing significant expansions in Medicare payment (e.g., for services furnished to patients in their homes or by institutional staff of outpatient departments) are only extended through the end of 2024. It will take further legislative action and agency rulemaking to gain more certainty regarding the permanency of these policies. In the meantime, CMS seems open to comments regarding these policies and stakeholder input regarding how to extend flexibilities that would continue to provide expanded access to services through telehealth without compromising clinical care.

The post CY 2024 Medicare Physician Fee Schedule: Extending Telehealth Flexibilities and Seeking Future Policy Input appeared first on Dr. Miltie.

Over the past several years, the Centers for Medicare and Medicaid Services (CMS) has expanded payment for care management and remote monitoring services in an effort to recognize and pay for non-face-to-face services that improve care coordination for Medicare beneficiaries. In connection with the calendar year 2024 Medicare Physician Fee Schedule (MPFS) proposed rule, CMS clarifies its existing guidance for remote monitoring services, including both remote physiological monitoring (RPM) and remote therapeutic monitoring (RTM) services, and proposed several additional clarifications. CMS requests additional information from healthcare providers and other stakeholders regarding the use of remote monitoring, remote cognitive behavioral therapy (CBT) and other digital therapeutic modalities.

CMS also proposes modifications to the way rural health centers (RHCs) and federally qualified health centers (FQHCs) are reimbursed for care management services, and proposed to establish reimbursement for remote monitoring services furnished by RHCs and FQHCs. Comments and responses to the requests for information included in the proposed rule are due to CMS by September 11, 2023.

The post Remote Monitoring: CMS Clarifies Guidance, Proposes Rural Provider Payment, Requests Information on Digital Therapeutics appeared first on Dr. Miltie.