Hello! My name’s Michael Beebe. I’m an Executive Vice President at ADVI Health. I’m responsible for a reimbursement solution offering. I spend most of my time working with clients to identify and resolve coding coverage and payment problems in the device space and within diagnostics, both imaging diagnostics and laboratory diagnostics. I want to talk about some of the issues we’ve been working with clients on recently. The big issue right now is AI. It’s not just big in healthcare—it’s big across the country. In healthcare, it’s being applied to diagnostics and therapeutics.

One of the organizations we spend a lot of time with is the American Medical Association’s CPT editorial panel. The editorial panel has already been, I think, at the cutting edge of AI applications in medicine, and they’ve divided AI into 3 categories. One of the categories is the assisted category, and that is where AI provides additional clinical detail to assist the physician and their medical decision. The next higher level of AI is when the AI is actually making recommendations to the physician in the CPT. The editorial panel has characterized that as augmentative, when the AI is making recommendations to the physician. The most complicated complex version of AI is autonomous. This is when the AI will act on and tell the physician what is clinically going on with the patient. This has been applied, for example, in a diabetic retinopathy screening, where you can take a picture of the retina, and the AI will tell the physician whether or not the patient is likely to be experiencing diabetic retinopathy and then will make recommendations for a retina specialist. Even though the coding system is fairly advanced right now in how it is looking at AI, the payment system is less advanced and there are issues. AI software is encountering challenges as a result of the payment system. Traditionally, the Centers from Medicare Medicaid Services (CMS) who run the physician payment fee schedule have viewed AI as software and software that is really paid. You know, the way Microsoft would be paid. Microsoft, Word, or Excel are viewed by CMS currently not as a patient-by-patient expense but more of an indirect expense. A lot of the companies that are working on AI are not only developing better clinical products, but they’re also in a position of having to work with CMS to have their products paid differently. Because software that’s paid as a back office expense is really not appropriate for how this clinically focused software is being used. So payment right now has been a challenge for a lot of AI companies.

Moving on a little bit and getting away from AI software, I thought we could also talk about digital therapeutics and challenges in the digital therapeutic space. Increasingly, there are companies out there who are developing digital therapeutics, either a smartphone app or some other web-based application that will enable the patient to engage with the application to resolve mental health problems. For example, stress issues, potentially PTSD, or other mental health disorders where that would be amenable to a digital application. Among these are weight loss and smoking cessation programs that are oriented around a cognitive behavioral therapy type discipline and approach to resolving those issues. The difficulty with those is that CMS right now is not treating digital therapeutics as a benefit category. The FDA has identified pathways for these products to be approved with the presentation of clinical data. You have software as a medical device pathway or software as a service pathway through the FDA. CMS is struggling to identify a benefit category by which the Medicare program could pay for digital therapeutics. So that is a significant problem in the digital therapeutic space. One way companies can overcome that problem is by taking advantage of two existing categories of CPT codes: remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM), which provides a benefit under the physician fee schedule, or as a qualified healthcare professional to bill under professional, the professional component of the Medicare physician fee schedule. So, RPM or RTM, leveraging a digital therapeutic is a potential avenue for reimbursement in which the physician or the qualified healthcare professional (QHP) would prescribe the digital therapeutic, and then they would monitor the patient’s progress through that digital therapeutic. Thereby, they could build remote therapeutic monitoring codes. 

We are seeing a fair amount of interest in the digital therapeutic space to allow for a reimbursement to the practice, and then also reimbursement for the digital application itself, provided that there is involvement on the part of the physician or the QHP, professional and mental health is a big area where there is significant interest. We started working not too long ago with a client in this space who’s offering different take on cognitive behavioral therapy, where they allow the physician or the QHP in the face to face visits with the patient to extend those to a monitoring-type environment where the device provided by our client tracks the patient’s behavior, their eating, sleeping, energy level. Behavioral health mental health screening applications are standardized applications. All that information is provided to the physician or QHP as part of their cognitive behavioral therapy sessions to see whether or not the therapeutic recommendations that are being developed and worked on in those face-to-face or telemedicine sessions are benefiting the patient in their particular condition. So it’s a way to help the physician or QHP continue to engage with the patient while they’re on their own away from the seat cognitive behavioral therapy session to help benefit them and to develop the right tools to allow the patient to manage their conditions.

So, that’s just a brief update on the hot topics in CPT and reimbursement. It was good talking to you guys today. Take care.