For the first time, patients during COVID could meet with their healthcare providers without sitting in waiting rooms with potentially distressingly ill patients. Routine and follow-up care were relegated mainly to audio-only telehealth visits, followed by video-based telehealth in utilization rates. Acceptance and reimbursement for previously disallowed audio-only telehealth visits have since increased. Audio-only reimbursement allows health professionals to connect with hard-to-reach people, those who don’t have computers, older people who lack computer literacy skills, live in remote areas, or have other health disparities. For instance, bi-lingual patients have reportedly been one of the more significant groups aided by telehealth phone calls. There are also are a fair number of people who need healthcare and prefer to use the telephone.1,2,3
In the American Medical Association’s recent Telehealth use: Physician survey of 2,232 physicians, 69% reported their continued use of audio-only visits. RAND, a leading non-profit research organization, conducted a study of 45 Federally Qualified Health Centers that provide care for lower-income people, many of whom are located in rural areas of California. It reported:
We found that 18 months after the start of the pandemic, many safety-net clinics were still relying on audio-only telehealth for many of their services.” Lori Uscher-Pines, lead author of the study and a senior policy researcher at RAND. She continued, “More effort is needed to understand the ideal mix of in-person, video, and audio-only visits for different conditions to support quality health care.
What is the Physician’s Fee Schedule?
The 2022 Medicare Physician Fee Schedule (PFS) covers updates to physician payment and other regulations regarding Medicare’s Merit-Based Incentive Payment System (MIPS) each year. The Medicare PFS is updated each year to adjust Medicare payment and quality provisions for the upcoming calendar year. The PFS governing payment for audio-only telehealth for Medicare was published in the Federal Register on November 19, 2021, and went into effect on January 1, 2022.
In the 2022 Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) expanded the definition of telehealth services that qualify for reimbursement under the Medicare program through 2023. Those services now include audio-only services under specific circumstances. The patient:
- Is already “established,”
- Has a mental illness/substance use disorder (SUDs), and
- Is unable or unwilling to use video technology.
The expansion of telehealth to include audio-only services applies only to mental illness/SUDs. These services had been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency, beginning with the presidential emergency declaration in March 2020 (Psychiatric News). In December 2020, Congress approved the Consolidated Appropriations Act (CAA) of 2021, a $1.4 trillion package that—among many other provisions—permanently expanded mental health services provided via telehealth by easing geographic and site-of-service restrictions under the Medicare program (Psychiatric News). The rule is a substantial victory for patients and the behavioral professionals who work with them.
In July 2021, CMS proposed a controversial requirement that in-person visits for telehealth, in general, take place every six months for all patients—whether new or established patients—after the initial telehealth encounter. However, in the final rule, the administration extended this provision to every 12 months for established patients, with exceptions at the discretion of the treating professional. As mandated by the CAA, there is no exception for new patients. The practitioner must see them in an in-person visit within six months before initiating mental health services via telehealth. Additionally, CMS expanded the patient’s home residence definition to include locations beyond the home, such as a homeless shelter or places a patient may need to go for privacy.
Need for Documentation about Audio-Only Telehealth Visits
Importantly, clinicians need to document the reason for audio-only telehealth in the patient record, which includes patient refusal to use audio-video, inability to use audio-video, or lack of access. Practitioners must also document that the patient can obtain any needed point-of-care testing, including vital sign monitoring and laboratory studies.
Legislative Support for Audio-Only Telehealth
Now that supportive research is mounting, and legislators have heard from stakeholders about their preferences regarding telehealth, a steady flow of weekly concessions are also being made to pass pro-telehealth laws at the state and federal levels. A remarkable 1,000+ proposals have been introduced in state and federal legislatures to expand telehealth beyond the Public Health Emergency (PHE). Over half of all states in the United States have enacted legislation to maintain audio-only telehealth access for their citizens.
States Given Flexibility on Medicaid Audio-Only Telehealth Visits
On December 7, the Centers for Medicare and Medicaid Services (CMS) released an updated State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, Supplement #1 that confirmed that states might continue to cover audio-only telehealth visits for Medicaid enrollees after the end of the federal public health emergency (PHE) and continue to receive federal financial participation at the state’s matching rate. This action bolsters recent efforts by many states since mid-2020 to make Medicaid telehealth policies permanent. At this point, states are given free rein to make their own rules.
In the absence of legislation in the remaining states, existing telehealth limitations have or will be reinstated; some will expire when the federal PHE ends, while others have established clear deadlines. Much of the argument about continuing audio-only telehealth reimbursement also centers on what is practical and what isn’t. Connectivity issues, otherwise known as broadband, also play a role in pushing the boundary between good clinical care and any clinical care. In some situations, telehealth phone calls may be the only contact form possible, particularly for follow-up.
Several states have acknowledged the potential of audio-only telehealth visits and are profiting from its current relevance. Other states are taking a cautious approach, implementing a “wait-and-see” policy concerning telehealth phone calls.
- Maryland is implementing payment parity in HB 123 through June 2023 to assess and offer suggestions for the future.
- Connecticut – Between now and June 2023, Connecticut is proposing payment parity with HB 5596 for many professional groups. These groups include alcohol and drug counselors, professional counselors, art therapists, music therapists, behavior analysts, registered nurses or advanced practice registered nurses, psychologists, marital and family therapists, clinical social workers, and master social workers. Other groups include dietitians and nutritionists, and speech and language therapists.
- Arizona is the pack leader, with telehealth progressive bills in many areas. HB 2454 was approved by Governor Ducey on May 5, 2021. HB 2454 permits audio-only telehealth interactions between a client and a health care provider when an audio-visual telehealth interaction is not reasonably possible. For mental health or substance use disorder, audio-only without a pre-established relationship is also permitted.
- Colorado is modifying its definition of telehealth with HB 1190 by removing references to interactive audio, video, or data connections. Instead, it defines telehealth as “the delivery of medical services using HIPAA-compliant telecommunications networks.”
Expiration of Audio-Only Telehealth Policies
Not all states are taking steps to expand telehealth, and telehealth coverage policies are also changing. For example, Medicare agreed to provide coverage for audio-only telehealth visits for mental and behavioral health treatment through 2023. But some private insurers have already stopped reimbursing coverage for audio-only telehealth visits. The lack of reimbursable telehealth services means decreased telehealth appointment availability and, most likely telehealth phone calls to be cut first. This leaves many older adults and Black, American Indian, and non-English speaking patients who cannot attend in-person appointments and now rely on audio-only visits.
The Florida Senate voted unanimously to approve a bill (SB 312) that allows telehealth to be used to prescribe Schedule III, IV, and V substances. However, the legislation did not authorize the use of telehealth phone calls as an option. The House had unanimously voted on February 24 to pass the bill.
The Future of Audio-Only Telehealth Policies
The argument about the future of audio-only telehealth visits hinges on whether it is effective and, if so, for which situations. Audio-only isn’t helpful when the client, patient, or clinician feels the need for visual or tactile interaction. The question needs further refinement for behavioral health, as behavioral health patients have traditionally always been “seen” and rarely touched. Because behavioral issues run the gambit and are present in all populations, a one-size-fits-all approach to therapeutic interventions would be short-sighted. The promise and the challenge of healthcare technology are that many more people can be helped using various interventions. That promise can be fulfilled with competency-based care and the ability to match the service to the client’s or patient’s needs. As technology gets closer to the goal, the informed professional would do well to carefully consider which technology will best serve which patient or client at various points in the treatment process.
The report, “Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator,” is available at www.rand.org.
As for the future of audio-only telehealth, the proliferation of audio-only telehealth protocols since the start of COVID, available professional training to help clinicians be aware of needed competencies for this form of intervention, and strong consumer demand shows promise for many groups, including diverse and underprivileged populations. The next task for the professional is to make sure they are competent to deliver the services being promised.
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