Table 2.

Recommended Policy Changes

Barrier Addressed	Relevant Organization	Recommendation	Pros	Cons
Credentialing	The Joint Commission	Partner with the Federation of State Board of Medical Examiners, the Association of State and Provincial Psychology Boards, and other relevant licensing boards to develop a national telemedicine credentialing and privileging organization that can confirm the qualifications and clinical skills of telemedicine providers regardless of where they practice. Alternatively, CMS and The Joint Commission should work to streamline the credentialing by proxy process.	This would greatly reduce the costly, time‐consuming, and duplicative efforts of each FQHC having to conduct their own credentialing and privileging.	Would require a change in federal law to allow federal oversight of a process traditionally provided at the state level. Some health care systems may not be willing to accept the indemnity risk associated with a national organization's credentialing and privileging decisions.
Scope of project	HRSA	Revise policies and/or standardize the interpretation of current policies to facilitate the addition of TMH services into the FQHC Scope of Project. Current policy states that all patients must have access to the TMH providers regardless of location.	Removing this requirement may facilitate the expansion of TMH services even if all FQHC clinic sites do not have the capacity to offer TMH.	Creates an inequity for FQHC patients served in clinic sites without TMH.
Scope of project	HRSA	Allow FQHCs to request additional grant funding to support TMH programs when they expand their Scope of Project. Current policy states that the TMH programs must not require additional funding under the Section 330 Public Health Service Act Health Center Program grant.	Removing this requirement will create a more sustainable financial environment because state medical schools do not have the resources to provide services to more uninsured patients.	Requires additional resources
Remote EHR access	EHR Vendors	EHR vendors should develop products that offer site licenses at reduced rates for part‐time telemedicine providers. Alternatively, FQHCs, state primary care associations, and Health Center Controlled Networks should use collective bargaining to negotiate better rates for site licenses.	New products for part‐time providers will make the cost of site licenses less prohibitive and the return on investment more acceptable.	Offering less expensive site licenses for part‐time providers may reduce profit margins for EHR vendors.
Insurance credentialing	CMS	Should not require that TMH providers repeat the credentialing process to be empaneled when they practice in multiple health care organizations. Private insurers should also eliminate this redundant and burdensome requirement.	Reduces duplicate effort and costs.	None
Billing	State Medicaid Administrators	Should allow FQHCs to renegotiate their PPS rate when TMH services are added to the Scope of Project.	Increasing the PPS rate to account for the additional cost of contracting for TMH services creates a more sustainable financial environment.	Requires additional resources
Billing	CMS	Should require that all states and regions make TMH encounters eligible for the PPS rate. Some states (eg, MI) and CMS regional offices (eg, region 5) have determined that if the TMH provider is not physically located at the FQHC, the encounter is not eligible for supplemental PPS payments. Our recommendation is that all states adopt California's policy that if the distant providers are practicing within the “virtual walls” of the FQHC (ie, credentialed and privileged as an FQHC provider), that the encounter be eligible for PPS.42	Making TMH encounters eligible for the PPS rate creates a more sustainable financial environment.	Requires additional resources
Billing	CMS	Should allow FQHCs to bill as distant‐sites for Medicare patients.	Removing this restriction will allow TMH providers credentialed and privileged to practice at the FQHC to receive Medicare reimbursements. Otherwise, the FQHC and the medical school must have different arrangements for Medicaid and Medicare patients.	Requires additional resources
Billing	CMS	Should allow facility fees to reflect the indirect costs at the distant‐site, not just the originating‐site. The contracted rates offered by state medical schools reflect both the direct cost of providing patient care and the indirect costs associated with supporting the TMH provider at the distant‐site (eg, office, computer, electricity, heating).	Allowing billing for indirect costs at the distant‐site creates a more sustainable financial environment.	Requires additional resources
Indemnity	HRSA	Should allow TMH providers who are contracting and credentialed and privileged to practice at FQHCs to be covered under FTCA. This could be accomplished by either removing the stipulation that the TMH provider work full‐time at the FQHC or that mental health specialists be added to the list of provider type exceptions. HRSA should also eliminate the stipulation that the compensation that arises from contracted TMH services must be paid by the covered FQHC directly to the individual provider. Finally, HRSA should provide assurance that telehealth services are eligible for FTCA indemnity coverage.	Allowing TMH providers to be covered by FTCA will eliminate the need for FQHCs to purchase supplemental insurance. This will also allow FQHCs to contract with the state medical schools and for providers to be covered under their medical school's indemnity plan.	None