Reimbursement: Key to Telemedicine Success
Telemedicine offers providers, Next Generation ACOs, hospitals and others the ability to expand the reach of quality healthcare. Whether you are considering implementing a clinical telemedicine program for the first time or expanding the scope of your current services, one of the key elements of success will depend upon the availability of sources of reimbursement.
Generally speaking, within the United States, there are three sources other than cash payments from patients: Medicare, Medicaid and private insurance.
Medicare is the federally-run health insurance program for people 65 years and older, but it also covers certain younger individuals with disabilities. Coverage is the same for all states and the District of Columbia.
Medicare uses the term “telehealth” when referring to clinical telemedicine. Medicare pays for a limited number of Part B services furnished by a physician or healthcare provider to an eligible beneficiary via live, real-time videoconferencing. Not covered are the Direct-to-Consumer telehealth services in which a previously unknown consumer pays a fee to speak with a physician on the phone.
Telemedicine patients must be at “originating sites,” which include: doctors’ offices, hospitals, critical access hospitals, rural health clinics, federally qualified health centers, renal-dialysis centers, skilled-nursing facilities and community health centers. Under current law, Medicare will only reimburse providers for telemedicine visits if the originating sites and patients are in rural, medically undeserved areas.
The telemedicine visits must be done live. With the exception of Alaska and Hawaii, there is no reimbursement for “store-and-forward” – the capture of patient medical images for later viewing by a healthcare provider. Medicare does not reimburse for remote patient monitoring expenses. This is the link to the CY2016 Medicare Telehealth Services.
Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost healthcare coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly and people with disabilities.
Medicaid programs are managed by the individual states. There is no single recipe for what telemedicine services are covered because benefits vary from state to state. Most provide coverage for live, real-time clinical telemedicine visits, and they frequently mirror Medicare services, but not always. Some cover “store-and-forward”; others provide reimbursement for remote patient monitoring. Like Medicare, however, there is no coverage for Direct-to-Consumer Telehealth.
31 states and the District of Columbia have passed telemedicine parity laws to ensure that providers are reimbursed for virtual visits by private insurance at the same rate as in-person visits. In the remaining 19 states, private insurance (click to expand) carriers may or may not cover telemedicine visits. If they do, they do not have to pay the same rate as in-person visits. Some private insurers offer coverage for Direct-to-Consumer telehealth.
Contact: Roger Downey, Government Affairs Specialist, firstname.lastname@example.org, to learn more about the current telemedicine reimbursement policy in your state.