The medical coding and reimbursement process from payers is notoriously confusing and complex, with many healthcare organizations dedicating entire teams to navigating the ever-changing landscape of rules and regulations. Telehealth reimbursement is even more confusing with laws constantly changing by state and reimbursement varying on your organization’s state, practice, services, and third-party payer.
How does a healthcare organization bill for telemedicine to Medicare, Medicaid, and private payers? What differences in reimbursement are at the state-level? What types of telemedicine are covered? Let’s navigate these questions and more in our newest blog post.
Establish Your Use Case(s)
In order to successfully understand what services will be covered or not, it’s important to first establish a few key points of information on the telemedicine services:
1. Determine the type of telemedicine service you are looking to reimburse. Are you performing live video consultations? Are you managing chronic conditions or outpatient conditions with remote patient monitoring?
2. Establish a use case. Who will be administering the telemedicine? What treatment(s) will you be providing via telemedicine? Having answers to these questions through a use case will help determine reimbursement.
Medicare Reimbursement Regulations
Medicare has a complicated, nuanced reimbursement system for telehealth and telemedicine services with many regulations and stipulations. Make sure you’re up-to-date on the rules and limitations for reimbursement. Let’s break them down below:
Defining Distant Site: Medicare reimburses telehealth services offered by a healthcare provider at a Distant Site, to the patient at the Originating Site. The only medical professionals who are eligible to provide telemedicine services to Medicare patients for reimbursement are:
- Nurse Practitioner
- Physician Assistant
- Nurse Midwives
- Clinical Nurse Specialists
- Clinical Psychologists and Social Worker
- Registered Dieticians or Nutrition Professionals
Defining Originating Site & Geographic Limitations: Another stipulation Medicare applies to reimbursement is the patient’s location, or Originating Site. Medicare sees telemedicine as needed services for rural or remote patients that wouldn’t normally have access to care. Under current law, an Originating Site is eligible for reimbursement if:
- The address of the Originating Site does not fall in a Metropolitan Statistical Area (MSA) or;
- If the address falls in a MSA, the address must then be in a rural area and be in a Primary Care or Mental Health geographic Health Professional Shortage Area (HPSA)
Want to know if your location is eligible for Medicare telemedicine reimbursement? Check out this originating site search tool on HRSA’s website.
Additionally, eligible Originating Sites much be one of the following medical facilities:
- Offices of Physician or Practitioner
- Critical Access Hospitals
- Community Mental Health Centers
- Skilled Nursing Facilities
- Rural Health Clinics
- Federally Qualified Health Centers
- Hospital-Based or Critical Access Hospital (CAH)-Based Renal Dialysis Centers (including satellites)
Telemedicine Modality Limitations: Medicare only reimburses for certain Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for telemedicine. In order to successfully bill for telemedicine services, you must submit the proper HCPCS or CPT code along with the telemedicine GT modifier. To download the full list of eligible telehealth services and their corresponding codes, visit this page from CMS.
Here’s a breakdown of eligible services by telemedicine modality/type:
- Videoconferencing sessions: Live, two-way video conferencing in real-time is the most popular and “gold standard” for telemedicine. Currently, Medicare reimburses for telehealth services delivered over video conferencing in all states except Alaska and Hawaii which are currently conducting pilot programs.
- Store-and-Forward: Medicare does not reimburse for telehealth services delivered via store-and-forward methods, i.e. email and fax.
- Remote Patient Monitoring (RPM): Earlier this year, CMS announced it would start reimbursing provider for RPM services. Effective January 1, 2018, Medicare will pay providers for RPM services billed under CPT code 99091. The service is defined as the “collected and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digital stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” For an in-depth look in the new RPM codes, check out this blog post from Health Care Law Today.
- mHealth: At this time, Medicare does not reimburse for any use of mobile devices to deliver care to patients.
Medicare will pay the originating site a facility fee to reimburse for hosting the telemedicine session which helps cover the cost of the technology and the supervision costs on the client side. For details on this fee, look up HCPCS code Q3014 or visit this blog post dedicated to the facility fee payment.
Medicare reimburses telemedicine services based on the current Medicare physician fee schedule which is updated every year. This means telemedicine services are reimbursed at the same rate as comparable in-person medical services. Still have questions about telehealth reimbursement from Medicare? Check out this Telehealth Services in-depth guide from the Medicare Learning Center.
Medicare Chronic Care Management Program: While traditional Medicare reimbursement plans for telemedicine services have strict limitations on patient location, services provided via telemedicine, and the facilities and health professionals which can receive these payments, there’s another Medicare program that has fewer limitations called the Medicare Chronic Care Management Program. This national policy program was adopted to help heath professional provide monthly care to patients with two or more chronic conditions through telemedicine services. Patients can be located anywhere, even in metropolitan/urban areas, and receive services from any health facility, their home, or office. For more information on this program, read through the Medicare Chronic Care Management Services brochure.
Medicaid Reimbursement Regulations
While almost all state Medicaid programs offer some or partial coverage for live video telemedicine sessions, Medicaid reimbursement varies state by state for the exact telemedicine services and use cases. While we can’t list the rules and regulations for every state, here are a few state-by-state guides that should get you started on your state-specific questions and research:
- Center for Connected Health Policy: Telehealth Medicaid & State Policy Guide
- American Telemedicine Association: State Policy Resource Center
- Center for Telehealth & e-Health Law: Medicaid Reimbursement
- E-Visit: Does Medicaid Reimburse for Telehealth in My State?
Private Payer Reimbursement
While each private payer covers telemedicine reimbursement differently, many of the larger insurance companies are providing more coverage after seeing the benefits provided from telemedicine. The big issuers such as Aetna, Cigna, United Healthcare and BCBS do cover telemedicine based on the patient’s policy. Some policies may cover telemedicine services and others may not. The best method is to call your major insurance players for your healthcare organization and ask detailed questions about their reimbursement policies.
Telehealth Resource Centers
If you’re looking for a dedicated resource to help with the nitty gritty of reimbursement policies and more, connect with your local telehealth resource center. For a complete list of regional telehealth centers, visit this interactive map from the National Consortium of Telehealth Resource Centers.
**Update: On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed historic changes that would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare.
For the full release, fact sheets, statements, and more, visit here. For additional reading, see these articles:
- Fierce Healthcare: CMS physician payment proposal nudges open the door for telehealth
- mHealth Intelligence: CMS Proposes More Medicare Reimbursement For Telehealth, RPM
- mHealth Intelligence: CMS Makes a ‘Landmark Change’ in RPM, Telehealth Reimbursement
Does your organization bill for telemedicine reimbursement? What methods and strategies has your organization developed to tackle the ever-changing reimbursement landscape? Tell us your thoughts below in the comments!