Telemedicine reimbursement is a notoriously complex topic. Policies tend to vary between states, payers, procedure codes and other factors; a variety of myths and misperceptions can complicate virtual health strategy even more. That’s one reason clarity is so important when it comes to telehealth reimbursement – not just because it impacts provider paychecks, but because it can shape the future of virtual health adoption. And with the onset of the COVID-19 outbreak, telehealth coverage policies are rapidly changing.
For these reasons, GlobalMed is putting a special spotlight on reimbursement in 2020. We’ll answer your questions, cover updates and new policies, and help you navigate the challenges that impact you most.
Today we’re going to address a confusing question that puzzles both patients and providers and can even stymie virtual care programs. We’re talking about “steering” – defined as when a payer announces that a virtual visit will only be covered if the patient and clinician use a specific telemedicine vendor. Some providers run into this so often that it halts their plans to offer telemedicine services. So what’s the truth? Do insurance plans really have the right to make this decision for their members and network physicians?
The answer is… It depends.
Policy vs. Preference
A payer’s power to restrict telemedicine vendor options does exist – in some cases. This depends largely on whether you’re the patient or the clinical practice. The type of service can also be relevant.
Let’s say you’re the patient and your insurance plan offers a type of telemedicine coverage. In today’s market, that often means that your plan will pay for you to access a certain product, such as a Direct-To-Consumer (DTC) app. If you want the negotiated rate offered by your plan, you don’t have much choice. You need to use the vendor your plan has chosen for you – you can’t just use any DTC app. While that might annoy you, it doesn’t qualify as steering.But wait. Now imagine you’re that patient’s primary care provider (PCP). The patient lets you know they’ve had a few visits by dialing up a doctor-of-the-day from that telehealth app covered by their benefits. You have zero idea what was said or discovered or treated during those visits, which hinders your ability to provide whole person care. Specific medical events are missing from the patient’s healthcare story. At the same time – the patient tells you they really liked the convenience of talking to a doctor without even leaving the house. They’d like to have that option with you, but they don’t think their insurance plan will pay for it.
And that’s where you as the provider can take back the power to choose the best telemedicine vendor for your practice.
Choosing Responsible Connected Care
At this point, your practice manager does their homework on parity laws and virtual care regulations in your state. They contact the patient’s insurance plan and announce that you will be offering virtual services to your patients. The plan representative suggests that your practice “must use” Vendor X if you want those claims paid.
That does qualify as steering and it’s not legal.
Your practice has the right to use any telemedicine platform or vendor that enables you to provide clinically responsible, evidence-based care. The vendor in question is irrelevant as long as you bill for those services using the correct codes.
While experienced billing departments and practice management groups are becoming aware of this, providers new to telemedicine sometimes don’t realize their own rights.A final point: remember that you can always call a payer and ask about telemedicine coverage. You’re not asking for a favor. You’re asking for clear reimbursement guidance on a valid care delivery model. Telemedicine isn’t just a modern convenience; it can advance patient outcomes. There’s also the fact that more and more payers are seeing the benefits of virtual care delivery, especially in terms of cost savings – but that’s a topic for another day.
Join the discussion One Comment
I don’t feel like they should be able to choose for patients and I think that should be up to the medical provider. Tom me, it seems like things would get unethical and quickly (that’s how that stuff generally goes in many industries, not just medical). Backroom deals and the like. I’ve been reading a number of your blog posts and your solution seems like a good one. I’ll refer you to some of our medical provider clients.