When analysts enthusiastically described telehealth as a money-saver over the last several decades, they were not referring to the financial impact on traditional payers and health systems. They also could not have anticipated that these powerful institutions would initiate telehealth coverage rollbacks prior to the end of a Public Health Emergency (PHE) to offset their losses. Many payers and healthcare systems are now struggling for a variety of reasons, not the least of which are the popularity and efficacy of telehealth. The American Hospital Association estimates that the country’s health care systems are losing an average of $50.7 billion per month.
It is no wonder then, that reports of telehealth coverage rollbacks started circulating prior to June 4, when Aetna, United Healthcare, and Anthem ended no-cost coverage of non-COVID telehealth for commercially insured members. The Florida Daily Post summarized the issue with these words: “Now, due to the financial strain on health care systems and insurers, the increase in telehealth use may be forced to shrink even though the public health crisis remains.” On the other hand, large brick-and-mortar institutions and their payment systems form the backbone of the US healthcare system. They cannot be expected to shift their revenue streams overnight.
Given the continuance of the Public Health Emergency until January 30, 2021, companies such as UnitedHealthcare (UHC) have again been in the news over the last few weeks with yet more announcements. For instance, STAT News reported that UBH has stopped waiving telehealth copays as of October 1 for some plans, while the UBH company website explains that such telehealth coverage rollbacks are only in effect for specified markets. UBH has also stated that in other cases, telehealth coverage is expanding. The Aetna website has announced a similar process, which is set to take effect on December 31, 2020.
Complications abound, however. Private insurance plans differ not only from one another within a state but also from each other across states. A Blue Cross in one state can operate quite differently from a Blue Cross in another state. Similarly, many state-funded Medicaid plans operate with different rules and dates for how they handle coverage – but such differences are nothing new. Now that telehealth coverage is the topic of discussion, these pre-existing complications and contradictions are compounded from one state to another. STAT News summarizes the problem:
However, patients who do learn of the costs before scheduling such a visit will likely face one of three scenarios, depending on costs… A patient may decide to go through with the virtual visit, with the patient either paying any outstanding costs him or herself, or the hospital or clinic shouldering all or part of that cost; a patient may opt for an in-person visit, or a patient may choose to skip the appointment altogether. There’s also the possibility—if the patient only learns after the fact that his or her visit wasn’t covered—that he or she may “get hit with a surprise bill,” STAT News reports.
What about Medicare and Medicaid?
Interestingly, the Centers for Medicare and Medicaid Services (CMS) is taking the exact opposite tack. Perhaps the telehealth financial analysts were right after all? Government payers seem to be working to retain current waivers, and CMS has made repeated statements about making its waivers permanent until COVID-19 is no longer a public health emergency. It has already proposed codifying many of them long-term, and more than a dozen laws are awaiting 2021 to be finalized. For details of recent CMS positions and a succinct summary of other laws scheduled to be given attention in January-February, see TBHI’s: October 2020 Telehealth Reimbursement News Update.
Which States Have Passed Laws to Prevent Telehealth Coverage Rollbacks?
Several states have already passed laws to stop private insurers from telehealth coverage rollbacks, and more are on the way. In California, the Department of Managed Health Care, which regulates health plans covering the majority of the state’s insured residents, required both commercial plans and Medi-Cal managed care plans to pay providers for telehealth at parity with regular appointments during the pandemic’s public health emergency (PHE). It also limited a patient’s out-of-pocket, “cost-sharing” to the traditional amount owed for an in-person healthcare visit. Starting Jan. 1, a new California state law AB-744, will make that requirement permanent for all commercial plans in the state.
Six other states have pay-parity laws against the telehealth coverage rollbacks already in effect, according to Mei Wa Kwong, executive director of the Center for Connected Health Policy. These states are Delaware, Georgia, Hawaii, Minnesota, and New Mexico. Washington state’s law will go into effect on Jan. 1, 2021, for a total of seven states to date. To learn more about your state’s plans to require telehealth payment past the PHE, visit your state’s insurance commissioner website, or contact the Center for Connected Health Policy.
What Else Can Providers Do?
Now that consumers have experienced the power and convenience of telehealth, we are likely to see continued pressure on payers to cover telehealth long term. If the pushback we are already witnessing from state legislators for telehealth coverage rollbacks is a predictor of the future, telehealth is here to stay, regardless of the financial strain on insurer’s wallets. In the words of an 11/10/2020 announcement by HIMSS entitled, Billing Medicare and Private Payers for Telehealth Visits: What to Expect Post-Public Health Emergency:
It can be expected that post-PHE, payers will enact policies to limit the scope of telehealth coverage. Many patients appreciate the convenience of telehealth and it is likely the number of telehealth visits will continue to increase post-PHE. As patients use telehealth to interact with their physicians more often, payers will be expected to reimburse more visits, negatively impacting their financial performance.
Here’s a short list of other actions to consider:
- Understanding telehealth billing basics and following telemedicine billing and coding guidelines have never been more important. TBHI recommends that providers contact payer websites to review policy announcements, and if asking questions, get information in writing.
- If uncertain about appropriate telehealth billing and reimbursement coding or other practices, register for TBHI’s Maximizing Reimbursement Strategies in Telehealth to get your questions answered.
- Write to your legislators to encourage them to take an active role in telehealth expansion legislation. Your voice counts. Exercise it by being the pebble in the shoe of your legislators, reminding them of your wish for them to vote for the many bills that will soon be heard in legislative offices across the land.
- Join your professional association(s) to help them advocate on behalf of your profession. Voices are louder when spoken through organized associations with strong legislative action agendas.
Current Telebehavioral Health Trends?
Most recently, TBHI has been consulting with health systems seeking to develop new revenue streams through telebehavioral interventions. Telebehavioral interventions are the least vulnerable to telehealth coverage rollbacks long term when compared to traditional in-office medical specialties such as oncology, pulmonology, cardiology, etc. In addition to historically high user satisfaction rates, telebehavioral health makes it easy for professionals to consider permanently expanding their practices with telehealth because it:
- Allows the user to avoid the often embarrassing stigma of going to a mental health or drug treatment facility,
- Affords the privacy and comfort of being helped in one’s own home for weekly sessions that can take a toll on one’s work hours when employed,
- Provides safety during the pandemic as well as other illness-prone times of the year such as flu season, and
- Offers the ability for a well-trained teletherapist to establish rapport and a therapeutic relationship through video and other specialized technologies.
Many of TBHI’s more recent consulting clients are shifting their payer mix to government payers, and planning to gradually shift away from full caseloads of clients or patients from third-party, private carriers.