Telemedicine — How Do I Get Paid?

Most healthcare providers can understand the convenience benefit of telemedicine, but still get stumped on the question: does it pay?

By default, telemedicine can always be billed directly to payments and collected via cash or credit. There are no regulations preventing the delivery of services over video. And in many states, video visits will satisfy the requirement of a face to face needed to write a prescription.

However, there are still many reimbursement policies being drafted around this new form of healthcare delivery. There are also many payers updating policies to include video visits and other forms of virtual care. The purpose of this article is to offer a primer on the state of telehealth reimbursement and how healthcare providers can take advantage of what is available to them.

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Is Telehealth Reimbursable?

The short answer is, “Yes… in most cases.”

It is important to understand that telehealth is regulated differently for each state. You may have a telemedicine appointment with a patient located in a state where you are licensed, however, you must also consider that state’s rules for reimbursement in order to get paid.

For a comprehensive state by state breakdown of telehealth reimbursement SimpleVisit recommends checking out the 50 state analysis.

What about Private Insurance?

Commercial payers — that is, private insurers — have been most aggressive in reimbursement for telehealth visits. Many national plans embrace this healthcare innovation and want to pass along the savings telemedicine can bring into healthcare delivery.

A major thing to look for when determining how to bill for telemedicine is whether your patient is located in a “parity state”. Today, 29 states and the District of Columbia have parity laws that mandate commercial payers to provide comparable coverage and reimbursement for telemedicine services as is covered for in-person services.

This is a positive sign for providers, as it suggests that over time telemedicine will gain parity footing with in-person consultations across the board. Beyond these laws, the high potential for cost savings in the commercial sector — an average of $126 per visit for acute care — has incentivized many plans to cover telemedicine.

This is not to say that the commercial realm is without issue. Payers are not universally compliant with parity regulations, and few of these laws bear teeth in terms of required dates for compliance. Telehealth coverage has grown rapidly partly because of how inexpensive these types of visits cost. And commercial insurers are also still grappling with issues such as building telemedicine codes into claims systems and determining their level of coverage for various specialist services, from teledermatology to telepsychiatry.

Despite all this, reimbursement through private insurance companies is the least confusing and the most promising. With national health plans such as Unitedhealthcare, many Blue Plans, and Anthem advertising their telemedicine visits and coverage through aggressive marketing campaigns, it’s clear that some powerful players stand behind telemedicine and are dedicated to making it work as an integrated part of the healthcare system, not just for patients, but also for providers.

How About Medicaid Reimbursement?

Currently, 48 states have some form of reimbursement legislation outlined in their public healthcare program. The two states that contain absolutely no mention of telemedicine or telehealth in their public programs are Massachusetts and Rhode Island. For a complete look at the medicaid reimbursement available SimpleVisit recommends consulting The Center for Connected Health Policy’s State by State Scan.

Some additional restrictions to Medicaid reimbursement do exist in reference to location. Programs may place certain patient location requirements, specifically prohibiting reimbursement for services provided to a patient who is not at an established medical site when receiving telemedicine care. Medicaid may require practitioners to document that a patient has a barrier to receiving in-person care in order to receive reimbursement for delivery remote care in this instance.

Does Medicare Reimburse Telehealth?

With the exceptions of services provided through the Medicare Chronic Care Management program, videoconferencing is the only service that is reimbursable through Medicare. Store-and-forward technologies, such as email, will not be reimbursed by Medicare unless delivered to patients through the Medicare Chronic Care Management program.

CMS currently decides to approve a submitted Current Procedural Terminology (CPT) code based on the type of service that was provided over telehealth. There are certain services for which they will reimburse and others for which they will not. Essentially, Medicare attempts to determine two things:

  1. If the service was accurately described by the corresponding CPT code when delivered via telehealth.
  2. Whether the use of telemedicine to deliver telemedicine to deliver the service revealed a clinical benefit to the patient.

In addition to limiting services and methods of telemedicine care delivery, Medicare has several other requirements that patients and providers must meet in order to be reimbursed through Medicare for telemedicine. To learn more about these specific requirements and the existing CPT codes, visit the Medicare Telehealth Reimbursement page.

The aforementioned Medicare Chronic Care Management Program (CCM), which went into effect January 1, 2015, serves to reimburse providers for telemedicine services provided to patients with two or more chronic conditions. It is the first time the national government has made an exception to the originating site rule which mandates medicare patients must live in rural and physician shortage areas.

In conclusion, this primer certainly could not have provided all answers surrounding telehealth reimbursement. For more information, speak with a SimpleVisit consultant or contact your local Telehealth Resource Center with any additional questions.

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