Use of Telemedicine During a Public Health Emergency

Use of Telemedicine During a Public Health Emergency

DISCLAIMER

This information and compliance guidance  has been gathered and interpreted by  No World Borders from various resources including CMS, Medicare Administrative Contractors (MACs)  and is provided for informational purposes. This should not be viewed as official policy of CMS or the MACs. It is always the provider’s responsibility to determine and comply with applicable CMS, MAC and other payer requirements.

  • 418.204(d) Special coverage requirements provides,

(d) Use of technology in furnishing services during a Public Health Emergency. When a patient is receiving routine home care, during a  Public Health Emergency as defined in § 400.200 of this chapter, hospices may provide services via a telecommunications system if it is feasible and appropriate to do so to ensure that Medicare patients can continue receiving services that are reasonable and necessary for the palliation and management of a  patients‘ terminal illness and related conditions.

The use of such technology in furnishing services must be included on the plan of care, meet the requirements at § 418.56, and must be tied to the  patient-specific needs as identified in the  comprehensive assessment and the plan of care must include a description of how the use of such technology will help to achieve the goals outlined on the plan of care.

Indeed, earlier in 2020 CMS issued a notice pursuant to the public health emergency

“This interim final rule with comment period (IFC) gives individuals and entities that provide services to Medicare beneficiaries needed flexibilities to respond effectively to the serious public health threats posed by the spread of the 2019 Novel Coronavirus (COVID-19).

Recognizing the urgency of this situation, and understanding that some pre-existing Medicare payment rules may inhibit innovative uses of technology and capacity that might otherwise be effective in the efforts to mitigate the impact of the pandemic on Medicare beneficiaries and the American public, we are changing Medicare payment rules during the Public Health Emergency (PHE) for the COVID-19 pandemic so that physicians and other practitioners, home health and hospice providers, inpatient rehabilitation facilities, rural health clinics (RHCs), and federally qualified health centers (FQHCs) are allowed broad flexibilities to furnish services using remote communications technology to avoid exposure risks to health care providers, patients, and the community.

We are also altering the applicable payment policies to provide specimen collection fees for independent laboratories collecting specimens from beneficiaries who are homebound or inpatients (not in a hospital) for COVID-19 testing.

We are also expanding, on an interim basis, the list of destinations for which Medicare covers ambulance transports under Medicare Part B. In addition, we are making programmatic changes to the Medicare Diabetes Prevention Program (MDPP) and the Comprehensive Care for Joint Replacement (CJR) Model in light of the PHE, and program-specific requirements for the Quality Payment Program to avoid inadvertently creating incentives to place cost considerations above patient safety.

This IFC will modify the calculation of the 2021 and 2022 Part C and D Star Ratings to address the expected disruption to data collection and measure scores posed by the COVID-19 pandemic and also to avoid inadvertently creating incentives to place cost considerations above patient safety.

This rule also amends the Medicaid home health regulations to allow other licensed practitioners to order home health services, for the period of this PHE for the COVID-19 pandemic in accordance with state scope of practice laws. We are also modifying our under arrangements policy during the PHE for the COVID-19 pandemic so that hospitals are allowed broader flexibilities to furnish inpatient services, including routine services outside the hospital.”

Telehealth Facility Fees

HCPCS code Q3014 – Telehealth originating site facility fee may be used.  No Medicare local coverage determinations (Medicare LCDs) were found for this code at the time this was published. 

Data Privacy guidelines are essential.  See our Data Privacy Capabilities for Healthcare

Related links: Telehealth bonuses, eligibility, modifiers and special provisions for substance use disorder prevention

Telehealth Services

Physician Bonuses 
Medicare Telehealth Payment Eligibility Analyzer
New Modifier for Expanding the Use of Telehealth for Individuals with Stroke
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

Medical Billing Expert Witness

CVE NumberVulnerability DescriptionPrior NSA Cybersecurity Guidance
(Some focused on other actors)
CVE-2019-11510In Pulse Secure VPNs,® 7 an unauthenticated remote attacker can send a specially crafted URI to perform an arbitrary file reading vulnerability. This may lead to exposure of keys or passwords.CSA – Mitigating Recent VPN Vulnerabilities U/OO/196888-19
CSA – Advisory - APT29 target COVID-19 research organizations U/OO/152680-20
Affects: Pulse Connect Secure® (PCS) 8.2 before 8.2R12.1, 8.3 before 8.3R7.1, and 9.0 before 9.0R3.4. [1]
1 T1190 and T1133 are MITRE® ATT&CK® techniques. MITRE and ATT&CK are registered trademarks of The MITRE Corporation. 2 Refer to CSI – Update and Upgrade Software Immediately U/OO/181147-19
3 Refer to CSI – Perform Out-of-Band Network Management U/OO/169570-20
4 Refer to ORN – Outdated Software and Protocols Continue to Result in Endpoint and Network Compromise U/OO/802041-16 5 Refer to CSI – Segment Networks and Deploy Application-Aware Defenses U/OO/184967-19
6 Refer to CSI – Continuously Hunt for Network Intrusions U/OO/181860-19
7 Pulse Secure VPN® is a registered trademark of Pulse Secure, LLC.
Additional Mitigations: Note that patching does not address credentials which may have been lost prior to patches being applied. NSA discourages the use of proprietary SSLVPN/TLSVPN protocols, which are not compliant with CNSS policy. Transition SSLVPN/TLSVPN deployments to either IETF standard-conformant TLS for single application use cases, or to IKE/IPsec VPNs, preferably using one of the evaluated TLS software applications or IPSec VPN gateways/clients listed on the National Information
Assurance Partnership (NIAP) Product Compliant List (PCL).
CVE-2020-5902In F5 BIG-IP® 8 proxy / load balancer devices, the Traffic Management User Interface (TMUI) - also referred to as the Configuration utility - has a Remote Code Execution (RCE) vulnerability in undisclosed pages.CSI – Harden Network Devices U/OO/171339-16
CSI – Perform Out-of-Band Network Management U/OO/169570-20
Affects: F5 BIG-IP versions 15.0.0-15.1.0.3, 14.1.0-14.1.2.5, 13.1.0-13.1.3.3, 12.1.0-12.1.5.1, and 11.6.1-11.6.5.1. [2]
Additional Mitigations: By default, the TMUI is accessible via the management interface on both the external and internal interface.
Best practice is to disable the external interface and configure an out-of-band management network. NSA released guidance for this in the Harden Network Devices CSI (U/OO/171339-16) and the Perform Out-of-Band Network Management CSI (U/OO/169570-20).
CVE-2019-19781An issue was discovered in Citrix® 9 Application Delivery Controller (ADC) and Gateway. They allow directory traversal, which can lead to remote code execution without credentials.CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
CSA – Advisory - APT29 target COVID-19 research organizations U/OO/152680-20
CSA – Mitigate CVE-2019-19781 U/OO/103100-20
Affects: Citrix ADC and Gateway versions before 13.0.47.24, 12.1.55.18, 12.0.63.13, 11.1.63.15 and 10.5.70.12 and SD-WAN
WANOP 4000-WO, 4100-WO, 5000-WO, and 5100-WO versions before 10.2.6b and 11.0.3b. [3]
CVE-2020-8193 CVE-2020-8195 CVE-2020-8196Improper access control and input validation, in Citrix® ADC and Citrix® Gateway and Citrix® SDWAN WAN-OP, allows unauthenticated access to certain URL endpoints
and information disclosure to low-privileged users.
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Citrix ADC and Gateway versions before 13.0-58.30, 12.1-57.18, 12.0-63.21, 11.1-64.14 and 10.5-70.18, ADC FIPS versions
before 12.1-55.179 and SD-WAN WAN-OP versions before 11.1.1a, 11.0.3d and 10.2.7. [4]
CVE-2019-0708A remote code execution vulnerability exists within Remote Desktop Services®10 when an unauthenticated attacker connects to the target system using RDP and sends specially crafted requests.CSA – Patch Remote Desktop Services on Legacy Versions of Windows U/OO/152674-19
ORN – Outdated Software and Protocols
Continue to Result in Endpoint and Network Compromise U/OO/802041-16
Affects: Microsoft Windows®11 XP - 7, Microsoft Windows Server®12 2003 - 2008.
Additional Mitigations: Block TCP Port 3389 at your firewalls, especially any perimeter firewalls exposed to the internet. This port is used by the Remote Desktop Protocol (RDP) and will block attempts to establish a connection. Disable Remote Desktop Services if they are not required. Disabling unused and unneeded services helps reduce exposure to security vulnerabilities overall and is a best practice even without the BlueKeep threat.
Enable Network Level Authentication. With NLA enabled, attackers would first have to authenticate to RDS in order to successfully exploit the vulnerability. NLA is available on the Windows® 7, Windows Server® 2008 and Windows Server® 2008 R2 operating
systems.
CVE-2020-15505A remote code execution vulnerability in the
MobileIron®13 mobile device management (MDM)
CSI – Update and Upgrade Software
Immediately U/OO/181147-19
8 F5 BIG-IP® is a registered trademark of F5 Networks, Inc. 9 Citrix® is a registered trademark of Citrix Systems, Inc.
10 Remote Desktop Services® is a registered trademark of Microsoft Corporation in the United States and/or other countries. 11 Windows OS® is a registered trademark of Microsoft Corporation in the United States and/or other countries.
12 Windows Server® is a registered trademark of Microsoft Corporation in the United States and/or other countries.
13 MobileIron® is a registered trademark of MobileIron, Inc.
software that allows remote attackers to execute
arbitrary code via unspecified vectors.
Affects: MobileIron® Core and Connector versions 10.6 and earlier, and Sentry versions 9.8 and earlier. [5]
CVE-2020-1350A remote code execution vulnerability exists in Windows® Domain Name System servers when they fail
to properly handle requests.
CSA – Patch Critical Vulnerability in Windows Servers® using DNS Server Role
U/OO/152726-20
Affects: Microsoft Windows Server® 2008 - 2019
Additional Mitigations: Keep system and product updated and patched. In the event that an update cannot be applied immediately, the following workaround will prevent the vulnerability from being exploited, per Microsoft’s® recommendation. The workaround configures Windows® DNS servers to restrict the size of acceptable DNS message packets over TCP to 65,280 bytes (0xFF00).
Applying the workaround requires a restart of the DNS service. Apply the patch as soon as possible and remove the workaround once the patch is applied.
Launch an elevated PowerShell prompt:
Set-ItemProperty -Path HKLM:\SYSTEM\CurrentControlSet\Services\DNS\Parameters -Name TcpReceivePacketSize -Type DWord -Value 0xFF00
CVE-2020-1472An elevation of privilege vulnerability exists when an attacker establishes a vulnerable Netlogon secure channel connection to a domain controller, using the Netlogon Remote Protocol (MS-NRPC), aka 'Netlogon
Elevation of Privilege Vulnerability'.
CSI – Update and Upgrade Software Immediately U/OO/181147-19
Affects: Microsoft Windows Server® 2008 - 2019
Additional Mitigations: Install the patch and implement the additional instructions found in Microsoft article KB4557222.
CVE-2019-1040A tampering vulnerability exists in Microsoft Windows® when a man-in-the-middle attacker is able to successfully bypass the NTLM MIC (Message Integrity Check) protection.CSI – Update and Upgrade Software Immediately U/OO/181147-19
ORN – Outdated Software and Protocols
Continue to Result in Endpoint and Network Compromise U/OO/802041-16
Affects: Microsoft Windows® 7 - 10, Microsoft Windows Server® 2008 - 2019.
Additional Mitigations: Limit the use of NTLM as much as possible and stop the use of NTLMv1. [6] [7]
CVE-2018-6789Sending a handcrafted message to Exim mail transfer agent may cause a buffer overflow. This can be used to
execute code remotely.
CSI – Update and Upgrade Software Immediately U/OO/181147-19
Affects: Exim before 4.90.1. [8]
CVE-2020-0688A Microsoft Exchange® validation key remote code
execution vulnerability exists when the software fails to properly handle objects in memory.
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Microsoft Exchange Server® 2010 Service Pack 3 Update Rollup 29 and earlier, 2013 Cumulative Update 22 and earlier,
2016 Cumulative Update 13 and earlier and 2019 Cumulative Update 2 and earlier. [9]
CVE-2018-4939Certain Adobe ColdFusion®14 versions have an exploitable Deserialization of Untrusted Data vulnerability. Successful exploitation could lead to
arbitrary code execution.
CSI – Update and Upgrade Software Immediately U/OO/181147-19
Affects: Adobe ColdFusion (2016 release) Update 5 and earlier versions, ColdFusion 11 Update 13 and earlier versions. [10]
CVE-2015-4852The WLS Security component in Oracle WebLogic®15 Server allows remote attackers to execute arbitrary commands via a crafted serialized Java®16 object.CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Oracle WebLogic Server 10.3.6.0, 12.1.2.0, 12.1.3.0, and 12.2.1.0. [11]
CVE-2020-2555A vulnerability exists in the Oracle® Coherence product
of Oracle Fusion® Middleware. This easily exploitable
CSI – Detect and Prevent Web Shell
Malware U/OO/134094-20
14 Adobe ColdFusion® is a registered trademark of Adobe Systems, Inc. 15 Oracle WebLogic® is a registered trademark of Oracle Corporation.
16 Java® is a registered trademark of Oracle Corporation.
vulnerability allows unauthenticated attacker with network access via T3 to compromise Oracle®
Coherence.
Affects: Oracle Coherence 3.7.1.0, 12.1.3.0.0, 12.2.1.3.0 and 12.2.1.4.0. [12]
CVE-2019-3396The Widget Connector macro in Atlassian Confluence®17 Server allows remote attackers to achieve path traversal and remote code execution on a Confluence® Server or Data Center instance via server-side template injection.CSA – Patch Critical Vulnerability In Atlassian Confluence
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Atlassian Confluence before 6.6.12, 6.7.0 to before 6.12.3, 6.13.0 to before 6.13.3, and 6.14.0 to before 6.14.2. [13]
CVE-2019-11580Attackers who can send requests to an Atlassian® Crowd or Crowd Data Center instance can exploit this vulnerability to install arbitrary plugins, which permits
remote code execution.
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Atlassian Crowd from 2.1.0 to before 3.0.5, 3.1.0 to before 3.1.6, 3.2.0 to before 3.2.8, 3.3.0 to before 3.3.5, and 3.4.0 to
before 3.4.4. [14]
CVE-2020-10189Zoho ManageEngine®18 Desktop Central allows remote
code execution because of deserialization of untrusted data.
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Zoho ManageEngine Desktop Central before 10.0.479. [15]
CVE-2019-18935Progress Telerik®19 UI for ASP.NET AJAX contains a .NET deserialization vulnerability. Exploitation can result in
remote code execution.
CSI – Detect and Prevent Web Shell Malware U/OO/134094-20
Affects: Progress Telerik UI for ASP.NET AJAX through 2019.3.1023. [16]
Additional Mitigations: NSA concurs with Tenable’s®20 recommendations: “This is exploitable when the encryption keys are known due to the presence of CVE-2017-11317 or CVE-2017-11357, or other means. Exploitation can result in remote code execution. (As of 2020.1.114, a default setting prevents the exploit. In 2019.3.1023, but not earlier versions, a non-default setting can prevent
exploitation.)” [16]
CVE-2020-0601A spoofing vulnerability exists in the way Windows® CryptoAPI (Crypt32.dll) validates Elliptic Curve Cryptography (ECC) certificates. An attacker could exploit the vulnerability by using a spoofed code-signing certificate to sign a malicious executable, making it
appear that the file was from a trusted, legitimate source.
CSA – Patch Critical Cryptographic Vulnerability in Microsoft Windows® Clients and Servers U/OO/104201-20
Affects: Microsoft Windows® 10, Server® 2016 - 2019.
Additional Mitigations: In addition, the Windows® certificate utility (certutil) and the OpenSSL®21 utility can be used to inspect a certificate for explicitly defined or non-standard elliptic curve parameters if a suspect certificate is encountered.
CVE-2019-0803An elevation of privilege vulnerability exists in Windows®
when the Win32k component fails to properly handle objects in memory.
CSI – Update and Upgrade Software Immediately U/OO/181147-19
Affects: Microsoft Windows® 7 - 10, Microsoft Windows Server® 2008 - 2019.
CVE-2017-6327The Symantec®22 Messaging Gateway can encounter a
remote code execution issue.
CSI – Update and Upgrade Software
Immediately U/OO/181147-19
Affects: Symantec Messaging Gateway before 10.6.3-267. [17]
Additional Mitigations: Run under the principle of least privilege, where possible, to limit the impact of potential exploit.
CVE-2020-3118A vulnerability in the Cisco® Discovery Protocol implementation for Cisco IOS®23 XR Software could allowCSI – Harden Network Devices U/OO/171339-16
17 Atlassian Confluence® is a registered trademark of Atlassian, Inc. 18 ManageEngine® is a registered trademark of Zoho Corporation. 19 Telerik UI® is a registered trademark of Telerik AD.
20 Tenable® is a registered trademark of Tenable, Inc.
21 OpenSSL® is a registered trademark of OpenSSL Software Foundation. 22 Symantec® is a registered trademark of Broadcom Corporation.
23 Cisco IOS® is a registered trademark of Cisco Systems, Inc. in the United States and other countries.
an unauthenticated, adjacent attacker to execute
arbitrary code or cause a reload on an affected device.
Affects: Cisco IOS XR 5.2.5, 6.5.2, 6.5.3, 6.6.25, 7.0.1. [18]
Additional Mitigations: On many devices, Cisco® Discovery Protocol is enabled by default. NSA recommends disabling discovery
protocols, per our Harden Network Devices CSI. To determine if CDP is enabled, use the “show running-config | include cdp” command.
CVE-2020-8515DrayTek Vigor®24 devices allow remote code execution as
root (without authentication) via shell metacharacters.
CSI – Update and Upgrade Software
Immediately U/OO/181147-19
Affects: Vigor2960® 1.3.1_Beta, Vigor3900® 1.4.4_Beta, and Vigor300B® 1.3.3_Beta, 1.4.2.1_Beta, and 1.4.4_Beta devices. [19]
Additional Mitigations: After patching the system, check to make sure that no additional admin users or remote access profiles have been added. Verify that no changes have been made to Access Control Lists.
NSA is aware that National Security Systems, Defense Industrial Base, and Department of Defense networks are consistently scanned, targeted, and exploited by Chinese state-sponsored cyber actors. NSA recommends that critical system owners consider these actions a priority, in order to mitigate the loss of sensitive information that could impact
U.S. policies, strategies, plans, and competitive advantage. Additionally, due to the various systems and networks that could be impacted by the information in this product outside of these sectors, NSA recommends that the CVEs above be prioritized for action by all network defenders.

 

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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