Reimbursement Resources

Reimbursement Resources

Telemedicine is on the rise, with some sources forecasting a 20-fold increase in the number of patients accessing care remotely over the period between 2013 and 2018.1

Despite this, reimbursement policies for telehealth encounters often seem unclear and are a common barrier to adoption for many care providers. The good news, however, is that there are a range of situations in which telemedicine is clearly eligible for reimbursement, and a small amount of investigation may reveal that telehealth is a viable option for many of your patients.

In general, private payers are most apt to reimburse telemedicine encounters, especially if your state has a "parity" law that obligates them to do so, as more than half of all states currently do. Medicare, on the other hand, is often the most restrictive payer, encumbering providers with many requirements for patient eligibility. State Medicaid programs typically fall somewhere in between these two groups, with many reimbursing for at least some types of video visits. Specific policy varies greatly by state for all payers except Medicare, and criteria for eligibility often include such factors as patient or provider geographic location, site of service, type of telehealth technology used, and nature of medical service provided. The majority of states now have an environment in which at least some type of telemedicine will be reimbursable for most types of providers and practice situations.

Medicare

The Centers for Medicare & Medicaid Services have very strict guidelines for telemedicine reimbursement for Medicare fee-for-service patients, essentially limiting coverage to patients in rural settings, where the patient and provider are interacting by live video and the patient is situated at a medical facility (as distinct from in the home).2

Synchronous (live video)

Patients must be in an "originating site" that is in a county outside of a Metropolitan Statistical Area (MSA) or in a rural Health Professional Shortage Area (HPSA) located either outside of an MSA or in a rural census tract. Additionally, the patient must be in a medical clinic, hospital, nursing facility, or other similar location (specifically not their home or other non-medical facility).

Medicare will only reimburse a subset of possible procedural codes; though, these do include standard office or other outpatient visit codes, 99201–99215.

Services are reported using the standard CPT or HCPCS code with the GT modifier added.

Asynchronous (store and forward)

Asynchronous "store and forward" technology is permitted only in Federal telemedicine demonstration programs conducted in Alaska or Hawaii.

Medicaid

Medicaid provides for reimbursement of telemedicine encounters in practically all states (with MA, RI, UT and CT being the exceptions) for synchronous (live video) visits. Roughly half of the states will only reimburse for synchronous visits where the patient is located in a medical facility. Asynchronous forms of telemedicine are reimbursed in a subset of states and typically apply to select specialties only. Billing codes and reimbursement requirements differ on a state-by-state basis and the best source for these are state Medicaid provider manuals.

Medicaid, being in large part state-based, is quite variable in its reimbursement of telemedicine services. The American Telemedicine Association (ATA) and the Center for Connected Health Policy (CCHP) produce yearly reports that include state-by-state analyses of the reimbursement climate for both synchronous and asynchronous telemedicine.3,4

Medicaid is overall much more progressive in its telemedicine reimbursement than is Medicare. According to CCHP, "Forty-seven states have some form of reimbursement for telehealth in their public program," with the exceptions being Massachusetts, Rhode Island, and Utah. In the ATA's calculation, "Forty-eight state Medicaid programs have some type of coverage for telemedicine," with Connecticut and Rhode Island being the exceptions. The CCHP and ATA reports differ on states like Connecticut and Utah because coverage is either so slight that one agency doesn't count it (Connecticut) or coverage policies are unclear enough that one agency doesn't count it (Utah).

Barriers such as requirements on patient location still exist in many state Medicaid policies. Per the ATA, "Twenty-six states and D.C. do not specify a patient setting as a condition for payment of telemedicine."

Each state produces an equivalent of a Medicaid provider manual, and this document typically has a telemedicine section that describes requirements, limitations, and billing/reporting procedures. Billin of a Medicaid provider manual, and this document typically has a telemedicine sectiog and reporting is typically done using standard CPT codes in combination with the HCPCS GT and GQ modifier codes or with one of the CPT telemedicine codes (e.g., 99444).

Synchronous (live video)

According to CCHP, forty-seven states reimburse at least some amount of synchronous telemedicine, but there are often restrictions on type of provider, type of service, and patient and/or provider location at time of service.

Asynchronous (store and forward)

Per CCHP, states that reimburse for asynchronous telemedicine include Alaska, Arizona, California, Illinois, Minnesota, Mississippi, New Mexico, Virginia, and Washington. Reimbursement is typically only available for some specialties or types of services (e.g., California only reimburses for teledermatology, teleophthalmology, and teledentistry). Per ATA, Alaska, Minnesota, Mississippi, Nebraska, Texas, California, Illinois, New York (law passed, may not be implemented yet), Oregon, Tennessee, and Virginia all reimburse some amount of asynchronous telemedicine. Most often, services are limited to fields such as dermatology or ophthalmology (e.g., diabetic retinopathy screening).

Private Payers

Private payers are the most open to reimbursement for telemedicine. For patients covered by private payers, there are two paths to reimbursement. First, state “parity” laws, which exist in approximately half of the states. Second, payer-specific private policies which are typically generous toward reimbursement for synchronous telemedicine, but ultimately depend on the specific policy details of individual patients.

Many states have passed "parity" laws that require private health insurers to reimburse for services provided via telemedicine, so long as they reimburse for those same services when provided in person. Per the ATA, "Twenty-eight states and the District of Columbia have enacted full parity laws." Some parity laws fail to mandate equivalent reimbursement, or they impose restrictions on provider type, service type, or originating site (although those imposing originating site requirements are the minority).

Many private payers have also independently begun to reimburse for telemedicine services, regardless of any legal requirement to do so. The situation is complex, and likely the best strategy is to contact any payer with which you are credentialed and discuss their policy in the state for telemedicine reimbursement. They can also tell you how they prefer to have services reported (typically CPT codes with GT/GQ modifiers or, seemingly less often, specific telemedicine CPT codes).

References

  1. Daniel, H., Sulmasy, L. S. & ACP Health and Public Policy Committee. Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Ann. Intern. Med. (2015). doi:10.7326/M15-0498
  2. Medicare Learning Network. Telehealth Services (calendar year 2016). (Centers for Medicare & Medicaid Services (CMS), 2015).
  3. Thomas, L. & Capistrant, G. State Telemedicine Gaps Analysis: Coverage and Reimbursement (2016). (American Telemedicine Association (ATA), 2016).
  4. Gutierrez, M. & Center for Connected Health Policy (CCHP). State Telehealth Laws and Medicaid Program Policies (March 2016). (Center for Connected Health Policy (CCHP), 2016).

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