Telemedicine reimbursement is always changing. Regulations and rules fluctuate between states, payers and services; ambiguity seems the norm rather than the exception, which can create a significant barrier to virtual care adoption. At the same time, telehealth has become embedded in the healthcare landscape and many providers find the advantages outweigh any headaches in securing payment.
It’s also true that reimbursement laws matter in ways that go beyond an individual physician’s paycheck. Generous policies can drive telehealth offerings, just as restrictions can create a financial disincentive. Specific statutes can shape telemedicine growth as well, such as encouraging specialty consults but not remote patient monitoring – depending on which service is best compensated.
So what can we expect for 2020? Nate Lacktman, partner at the Foley & Lardner law firm and Chair of its national Telemedicine & Digital Health Industry Team, has a positive outlook. “With 42 states enacting telehealth commercial insurance laws, coupled with notable expansions in Medicare and Medicaid coverage, the reimbursement landscape looks promising for virtual care services,” he told GlobalMed. “Plus, I anticipate 2020 will bring more efforts among states to update their prior telehealth coverage laws to keep pace with the industry’s growth.”
Let’s take a look at what to expect this year.
A recent Foley & Lardner survey, 50-State Survey of Telehealth Commercial Payer Statutes, examined telehealth commercial payer statutes across all U.S. states and District of Columbia as of October 2019. The authors concluded that the reimbursement landscape has notably improved in the last two years, but policies vary wildly from state to state. For instance, just 13 states require commercial health plans to cover remote patient monitoring services, while 24 states require coverage for store-and-forward (asynchronous) telemedicine.
42 states and Washington, D.C., have some type of telehealth commercial payer statute in place – but only Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, Utah and Virginia offer true parity for in-person and telehealth services, in which a health plan must reimburse at the same rate for virtual and in-person care. Other states have similar bills under development.
- There are three reimbursable new codes for a bundled episode of care for treatment of opioid use disorder. These services can be delivered at any telehealth originating site (including the patient’s home) with no geographic requirement. The bundled payment structure for opioid use disorder (OUD) treatment allows for counseling and therapy components to be delivered via live interactive video.
- Federally qualified health centers (FQHCs) and rural health clinics (RHCs) will no longer be reimbursed for remote physiologic monitoring codes. The reason: those services are included in their RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS) sum.
- For remote patient monitoring (RPM) services, CMS expanded reimbursement for RPM services with a new code that lets patients receive more virtual care time in one month. CPT code 99457 now covers the first 20 minutes per month of RPM services, while CPT code 99458 is used for an additional 20 minutes.
- Finally, there’s welcome news for providers who’ve complained that obtaining consent for each and every digital technology-based healthcare service is unreasonable. As of 2020, CMS only requires consent once a year for virtual services.
Curious how new codes and services get added to CMS rules? You – or anyone else – can send CMS a request, whether you’re a patient, clinician, medical society, state agency director or telemedicine vendor. Just visit the CMS telehealth site for instructions on emailing your request to [email protected] and put “Telehealth Review Process” in the subject line. The deadline for 2021 consideration is Feb. 10, 2020.
Since Medicaid consists of state-specific programs, reimbursement guidelines change depending on where services are provided. All state programs cover live video telemedicine but payment for services like store-and-forward or remote patient monitoring isn’t as consistent. Just 14 states reimburse for store-and-forward, while 22 reimburse RPM services.
The Center for Connected Health Policy’s recent report State Telehealth Laws & Reimbursement Policies notes a few trends. Virtual substance use disorder services and teledentistry now qualify for Medicaid reimbursement; some new policies require documentation and security controls for telemedicine services.
A few updates:
- Providers participating in California’s Medi-Cal program can choose their modality – live video or store-and-forward – to deliver virtual services to eligible members, as long as the CPT or HCPCS code is covered. Virtual consultations are now considered a subset of store-and-forward.
- Colorado passed a law requiring Medicaid to reimburse telemedicine services at the same rate as in-person services.
- Some states now allow patient homes as an eligible originating site, including California, Colorado, Kentucky, New Hampshire and Ohio. Some states now consider schools and/or federally qualified health centers and rural health centers to their eligible originating sites.
Turning Expanded Reimbursement into Expanded Care
As always, remember that telemedicine reimbursement is complex and contextually dependent on a number of factors. Before interpreting a broad state or payer policy as guaranteeing (or ruling out) coverage and reimbursement, check directly to see if a specific service in a specific location for a specific patient will be paid. But even if the reimbursement in your area is not what you hoped, take heart in the reality that policies are steadily – if gradually – expanding payment in most regions. Telemedicine ROI is more than direct revenue, but every clinician deserves to be paid fairly for their services. Build your telemedicine program now, reduce healthcare costs, and position yourself for the even brighter financial future that’s coming. Learn more.