telehealth reimbursementAnticipated Changes to Medicare and Private Payer Telehealth Reimbursement Rules

Telehealth reimbursement is undergoing change at the federal as well as state levels. “The expansion of telehealth and the offering of new services that were not previously covered really enabled physicians to care for their patients in the midst of this crisis,” said Todd Askew, the AMA’s senior vice president of advocacy, during a recent AMA COVID-19 Update. We have moved forward a decade in the use of telemedicine in this country, and it’s going to become and will remain an increasingly important part of physician practices going forward.” While the AMA and many others are advocating for the continued support of telehealth reimbursement post-pandemic, healthcare providers and practice leaders should anticipate and prepare for a return to more standardized regulation after the public health emergency (PHE).

Telehealth Medicare Reimbursement Finds Support in Congress

US Congressional support for permanently expanding reimbursement and other forms of telehealth access seems to be rising, though challenging questions persist around payment, timing and which flexibilities should be retained after the COVID-19 PHE expires (see here).

Anticipated New CMS Rules

The Centers for Medicare and Medicaid Services (CMS) is expected to issue new rules for telehealth in the release 2021 Physician Fee Schedule in the autumn of this year. Today, Medicare reimburses for specific services when delivered via live video (see here). These new rules are expected to specify what Medicare will cover regarding telehealth services, details of telehealth billing going forward, and which documentation will be required for telehealth reimbursement. It is highly probable that private payers will adopt the Medicare rules, but how quickly they will follow suit is unknown, can differ by state as well as by carrier.

All providers may want to review these new Medicare billing rules as well as any state-specific legislative or regulatory telehealth reimbursement requirements (see here). While the Office of Inspector General (OIG) has deferred random audits during the PHE, expect them to resume at the end of the emergency. 

It is also recommended to review individual payer websites for any changes in telehealth policies for 2021. It can be expected that post-PHE, payers will enact policies to limit the scope of coverage (see here‎). 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.

Provider Considerations

When it comes to telehealth reimbursement, an important consideration for providers is whether they use the CMS-approved CPT codes for reimbursement. CMS publishes a list of currently approved telehealth codes. The American Medical Association (AMA) compiles the CPT handbook, in which the “starred appendix” includes those codes that are telehealth eligible. Post-PHE, providers will also want to check that the telehealth service is a covered benefit under a patient’s insurance policy. It is also important for providers to understand their state’s parity regulations. In some states, parity regulations require that the payer reimburse the same amount for a telehealth visit as an in-person visit (see here).

Staying Ahead of Change

How can telehealth providers prepare for the changes expected to come post public health emergency? Now is the time to be thinking about what changes need to be made to manage an increased volume of telehealth visits. These suggestions may be worth considering:

  • Proactively review strategic plans and ensure the ability to meet the pre-PHE telehealth requirements, as well as the most-probable changes. This includes meeting all state-level telehealth, licensing, and credentialing requirements.
  • Check which payers require providers to be registered in-network to be covered and take steps to become a member of those networks that make sense for your organization to be successful at telehealth billing.

Also, advocate for the right changes.

  • Comment on rules during all open comment periods.
  • Use technology to make the reimbursement process more effective. For example, make sure the same front-end registration processes are in place for telehealth patients as in-person patients.
  • Use patient demographics verification and insurance coverage discovery and eligibility software to maximize reimbursement.

Tips for Telehealth Billing Moving Forward Post-PHE

Use this time to prepare for future telehealth billing requirements. Follow these tips to position your service for success post-PHE:

  • Put a process in place to capture patient informed consent upfront (see here‎)
  • Thoroughly review national and state-level policies impacting telehealth practice and reimbursement
  • Ensure licensing and credentialing is in proper order for all providers
  • Make sure a practice or emergency physician group is set up correctly to succeed with telehealth once the PHE has lifted
  • Evaluate how technology solutions can help optimize reimbursement