COVID-19 FAQs for Obstetrician-Gynecologists, Telehealth

• Q: What resources and guidance are available to begin implementing telehealth?

  Last updated September 2023

  ACOG encourages practices and facilities that do not yet have the infrastructure to offer telehealth to strategize how telehealth could be integrated into their services as appropriate.

  The ACOG Presidential Task Force on Telehealth has published Committee Opinion 798, Implementing Telehealth in Practice, which focuses on billing, licensure, security, and technology considerations. It is important to refer to local departments of health and federal regulatory agencies because these policies are updated regularly (see Regulatory question below).

  Importantly, the ability of patients to access telehealth and the technology required to use it may vary. Some assessment of patient resources to access telehealth services is necessary to ensure equitable care. Alternatives for those unable to access standard telehealth modalities—for example, providing phone-only visits for those without internet or video capabilities— also should be considered as appropriate.

• Q: Are there evidence-based telehealth applications for obstetric and gynecologic care?

  Last updated September 2023

  A recent systematic review, Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes, examined low-risk and high-risk obstetrics, elements of postpartum care, contraception counseling, and family planning services. Beneficial applications of telehealth included:

  • Remote antenatal monitoring for blood pressure, glucose control, and asthma symptoms. These telehealth interventions achieved equivalent maternal and fetal outcomes with fewer in-person visits.
  • Telehealth interventions, such as text messages (SMS), were effective in increasing breastfeeding rates and decreasing tobacco use.
  • Telehealth interventions were effective for continuation of oral and injectable contraception.
  • Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion.

  Many of the studies on telehealth interventions, including those examined in the systematic review, were not designed to show improved outcomes but rather evaluated equivalency or noninferiority to standard of care.

  In this developing area of research, there also are a variety of telehealth interventions that have not yet been extensively studied but may be reasonable in an emergency response. For example, real-time virtual visits may allow for directed physical examination measurements during prenatal care, at the discretion of the obstetrician–gynecologist.

  Telehealth interventions may be considered as an adjunct to modified prenatal care schedules (See COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics). Many elements of a well-woman examination might be conducted with virtual counseling sessions, with the in-person physical examination deferred to a later date or performed on an as-needed basis.

• Q: Are there techniques to conduct telehealth visits to help reduce the risk of and exposure to COVID-19?

  Last updated April 14, 2020 at 12:00 p.m. EST.

  One important consideration for telehealth is the use of synchronous versus asynchronous interventions. Synchronous, or “real-time,” interventions include audio-visual consultations that allow the obstetrician–gynecologist to perform clinical counseling remotely in place of an in-person visit. Real-time audio-visual communication also has been used for clinical scenarios like peer-to-peer consultation, ultrasound imaging review, and directed physical examinations. Although there is no guidance on specific obstetric and gynecologic conditions, audio-visual consultations could be considered at the discretion of the obstetrician–gynecologist. For more guidance on providing effective communication with patients, see the ACOG Committee Opinion on Effective Patient–Physician Communication.

  For examples of basic telehealth etiquette when conducting a patient virtual visit or a peer-to-peer consultation, this video series presents expert recommendations on topics like Introduction to Telehealth Etiquette, Medical Consult, and Smart Interactions for the On-Call Provider. These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.

  In other scenarios, the use of asynchronous, or “store-and-forward,” telehealth interventions may be more applicable. Some examples of these techniques could include remote monitoring of patient-generated data such as maternal weight gain, blood glucose, or certain symptoms or medical screening questionnaires. These collected data could be reviewed at a later time during an in-person or virtual consultation. For example, depression screening and postpartum “check-in” questionnaires conducted with text or mobile apps have been used as an adjunct to in-person visits. Other examples can be found in the ACOG Committee Opinion, Optimizing Postpartum Care. 

   
• Q: Do any of the recent federal regulatory changes to telehealth requirements apply to obstetric and gynecologic care?

  Last updated September 2023

  As part of the COVID-19 emergency response, several new federal telehealth allowances were made. These may be subject to ongoing changes; see ACOG’s Managing Patients Remotely: Billing for Digital and Telehealth Services for the latest information on federal policy changes and coding advice. For further information on coding, please visit ACOG's Payment Advocacy and Policy Portal. Additionally, a recorded, free webinar for billing telehealth is available here. 

  In the beginning of the COVID-19 PHE, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced that it would exercise enforcement discretion and waive penalties for HIPAA violations for health care clinicians who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype. At the end of the PHE on May 11, 2023, OCR indicated they would continue to exercise this enforcement discretion and waive penalties through the 90-calendar day transition period. After this transition period, health care providers must become in compliance with the HIPAA Rules with respect to their provision of telehealth. Details can be found here.

  It is important for health care professionals to maintain patient privacy during telehealth visits on both the practitioner end and the patient end. This may include the use of headphones for both patients and health care professionals, asking patients to go to a private room in their place of shelter when possible, and showing the patient that the health care professional is in a private room with a closed door.

• Q: Are there specific considerations regarding telehealth reimbursement for Medicare and Medicaid patients?

  Last updated September 2023

  During the COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) lifted several regulations to allow telehealth for Medicare patients, and encourages Medicaid and private insurers to do the same. Virtual check-ins were available regardless of the location of the patient and physician, and virtual visits were reimbursed by Medicare at the same rate as in-office evaluation and management visits.

  Since the official end of the PHE, some of these flexibilities around telehealth will be removed. For a detailed breakdown of how these changes will affect Medicare, Medicaid, and private payer populations, see ACOG’s PHE unwinding resources here.

• Q: What is telehealth?

  Last updated September 2023

  The term telehealth typically refers to using technology such as computers or phones to remotely provide health care to patients. However, definitions of telehealth and telemedicine vary by insurer, which influences which telehealth services are covered and reimbursed. 

• Q: What is the difference between synchronous and asynchronous telehealth visits?

  Last updated September 2023

  Synchronous telehealth is real-time, two-way communication between a patient and a health care professional.
   
  Asynchronous telehealth is sometimes known as “store-and-forward” telehealth. This is the method of acquiring medical data such as a patient transmission, upload, or communication through secure software or a secure server to a health care professional. The professional then reviews, interprets, or monitors the data and communicates back to the patient at a separate time. 

• Q: What are the different types of telehealth and virtual services?

  Last updated September 2023

  Here are some examples of different terms associated with telehealth services: 

  • Telehealth visit/virtual visit: A real-time two-way audio and video communication visit between a clinician and patient using a smartphone, webcam, or online chat. Also, it can be called Online Doctors Visits or video visits.
  • Telephone visit: Synchronous telephone conversation, telephone evaluation, and management of services. Note: Audio-only telephone encounters are only covered by certain states and insurers for the duration of the pandemic. Some state Medicaid programs are expanding their coverage of telehealth to include audio-only phone visits (see CCHP tracker), but this is on a state-by-state basis. Private health care plans make their own determinations (see AHIP tracker), but many are now allowing coverage of phone telehealth visits for a limited duration until the end of the emergency.
  • Virtual Check-ins/Digital Visits: A brief (5–10 minute) check-in with a health care professional via telephone or other telecommunication device, or a remote evaluation of recorded video or images submitted by an established patient.
  • E-visits: A communication between a patient and their health care professional through an online patient portal.
  • Remote Patient Monitoring: Collecting vitals and physiologic information by the patient that is then sent to the health care professional for interpretation and monitoring of the data.
• Q: Who is eligible to perform and bill for telehealth services and how do they get reimbursed?

  Last updated September 2023

  Most plans follow CMS rules and reimburse for telehealth services performed by a qualified health care professional such as a: physician, nurse practitioner, physician’s assistant, nurse-midwife, clinical nurse specialist, certified registered nurse anesthetists, registered dietician or nutritional professional, clinical psychologist, or clinical social worker. Individual states and insurers may define health care professionals eligible for reimbursement of telehealth services differently.

  Reimbursement for telehealth services depends both on the state and the insurer. Federal Medicare telehealth policies do not apply to Medicaid patients, and states may have separate legislation that addresses Medicaid coverage. Some states mandate payment parity for telehealth in their Medicaid or private health care plans, meaning that telehealth services are reimbursed at the same rate as the equivalent in-person service. In states without these mandates, telehealth is typically reimbursed at a lower rate than in-person care. Furthermore, state-level requirements only apply to fully-insured plans. They do not apply to self-insured plans.

  Both public and private health insurers have taken steps to increase access to telehealth services. For the most current status of telehealth reimbursement since the end of the COVID-19 PHE, please see here.

• Q: What resources and guidance are available to begin implementing telehealth?

  Last updated September 2023

  ACOG encourages practices and facilities that do not yet have the infrastructure to offer telehealth to strategize how telehealth could be integrated into their services as appropriate.

  The ACOG Presidential Task Force on Telehealth has published Committee Opinion 798, Implementing Telehealth in Practice, which focuses on billing, licensure, security, and technology considerations. It is important to refer to local departments of health and federal regulatory agencies because these policies are updated regularly (see Regulatory question below).

  Importantly, the ability of patients to access telehealth and the technology required to use it may vary. Some assessment of patient resources to access telehealth services is necessary to ensure equitable care. Alternatives for those unable to access standard telehealth modalities—for example, providing phone-only visits for those without internet or video capabilities— also should be considered as appropriate.

• Q: Are there evidence-based telehealth applications for obstetric and gynecologic care?

  Last updated September 2023

  A recent systematic review, Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes, examined low-risk and high-risk obstetrics, elements of postpartum care, contraception counseling, and family planning services. Beneficial applications of telehealth included:

  • Remote antenatal monitoring for blood pressure, glucose control, and asthma symptoms. These telehealth interventions achieved equivalent maternal and fetal outcomes with fewer in-person visits.
  • Telehealth interventions, such as text messages (SMS), were effective in increasing breastfeeding rates and decreasing tobacco use.
  • Telehealth interventions were effective for continuation of oral and injectable contraception.
  • Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion.

  Many of the studies on telehealth interventions, including those examined in the systematic review, were not designed to show improved outcomes but rather evaluated equivalency or noninferiority to standard of care.

  In this developing area of research, there also are a variety of telehealth interventions that have not yet been extensively studied but may be reasonable in an emergency response. For example, real-time virtual visits may allow for directed physical examination measurements during prenatal care, at the discretion of the obstetrician–gynecologist.

  Telehealth interventions may be considered as an adjunct to modified prenatal care schedules (See COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics). Many elements of a well-woman examination might be conducted with virtual counseling sessions, with the in-person physical examination deferred to a later date or performed on an as-needed basis.

• Q: Do any of the recent federal regulatory changes to telehealth requirements apply to obstetric and gynecologic care?

  Last updated September 2023

  As part of the COVID-19 emergency response, several new federal telehealth allowances were made. These may be subject to ongoing changes; see ACOG’s Managing Patients Remotely: Billing for Digital and Telehealth Services for the latest information on federal policy changes and coding advice. For further information on coding, please visit ACOG's Payment Advocacy and Policy Portal. Additionally, a recorded, free webinar for billing telehealth is available here. 

  In the beginning of the COVID-19 PHE, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced that it would exercise enforcement discretion and waive penalties for HIPAA violations for health care clinicians who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype. At the end of the PHE on May 11, 2023, OCR indicated they would continue to exercise this enforcement discretion and waive penalties through the 90-calendar day transition period. After this transition period, health care providers must become in compliance with the HIPAA Rules with respect to their provision of telehealth. Details can be found here.

  It is important for health care professionals to maintain patient privacy during telehealth visits on both the practitioner end and the patient end. This may include the use of headphones for both patients and health care professionals, asking patients to go to a private room in their place of shelter when possible, and showing the patient that the health care professional is in a private room with a closed door.

• Q: Are there specific considerations regarding telehealth reimbursement for Medicare and Medicaid patients?

  Last updated September 2023

  During the COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) lifted several regulations to allow telehealth for Medicare patients, and encourages Medicaid and private insurers to do the same. Virtual check-ins were available regardless of the location of the patient and physician, and virtual visits were reimbursed by Medicare at the same rate as in-office evaluation and management visits.

  Since the official end of the PHE, some of these flexibilities around telehealth will be removed. For a detailed breakdown of how these changes will affect Medicare, Medicaid, and private payer populations, see ACOG’s PHE unwinding resources here.

• Q: What preventive services for women can occur via telehealth modalities in the form of Well Woman preventive visits?

  Last updated September 2023

  Preventive services are critical to ensuring the health and well-being of women. Although some patients may face technology barriers to telehealth, the availability of virtual visits may increase accessibility for health care to many women who were previously unable to schedule routine preventive visits because of lack of transportation, childcare, or paid leave. A variety of preventive services can be provided via telehealth including anxiety and depression screening and referral, contraceptive counseling, interpersonal and domestic violence screening, urinary incontinence screening, HIV risk assessment, sexually transmitted infection prevention counseling, and breastfeeding services and supplies. For a full list of services, please see the WPSI recommendations here.

  Although many components of Well-Woman Care can be performed through telehealth, some preventive services require in-person evaluation, assessments, or collection of laboratory samples.

• Q: How do I select a telehealth platform for Well Woman preventive care?

  Last updated September 2023

  ACOG does not endorse any specific products or companies that provide the technology to deliver preventive services via telehealth. Products listed are meant to be examples and do not constitute an endorsement, certification, or recommendation of specific technology, software, applications, or products. When choosing a telehealth platform, take into consideration barriers that may exist for patients, such as access to the internet and availability of webcams or phone cameras. Some patients may not be able to access technology appropriate for telehealth services; practices and facilities are encouraged to explore ways to ensure those patients still have equitable access to care.

  • General use communication platforms: Some health care professionals may find it convenient to use applications that are available for general virtual communication or applications that their patient population may already be familiar with, such as Skype, Facetime, Duo, Hangouts, Zoom, GoToMeeting, WhatsApp, and more. Typically, these platforms employ end-to-end encryption, which allows only an individual and the person with whom the individual is communicating to see what is transmitted. The platforms also support individual user accounts, logins, and passcodes to help limit access and verify participants. In addition, participants are able to assert some degree of control over particular capabilities, such as choosing to record or not record the communication or to mute or turn off the video or audio signal at any point.
  • Specific telehealth platforms: There are telehealth platforms that require a contract or subscription fee per visit or per month. These are typically HIPAA compliant. Examples of vendors available can be found at the National Organization of State Offices of Rural Health telehealth resource.
• Q: Are there any communication platforms I should NOT use when delivering Well Woman preventive care services to patients?

  Last updated September 2023

  According to HHS and HIPAA, public-facing products such as TikTok, Facebook Live, Twitch, or chat rooms like Slack are not acceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide or indiscriminate access to the communication.

• Q: How does ACOG advocate for telehealth services?

  Last updated September 2023

  ACOG engages in a variety of advocacy efforts related to telehealth services including regulatory comment letters, legislative action, and payer-focused advocacy. These efforts are focused on ACOG’s telehealth advocacy principles including permanent coverage of telehealth services, payment parity to be at least at the level of Medicare payment and across settings, and proper payment for audio-only evaluation and management services.

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