The healthcare payment landscape has never been easy to navigate. Various insurers, different copayments, pre-authorization, long payment delays… it can be a time-consuming and frustrating endeavor just to keep up, especially for independent private practices.
Healthcare delivery has now shifted to telehealth and regulations have changed. Government and insurance organizations are making rapid adjustments in response to the COVID-19 crisis, and practices must stay informed. For healthcare providers to confidently promote telehealth services and deliver virtual care, knowing what to expect from the Centers for Medicare & Medicaid Services (CMS) and commercial insurance payers is paramount.
We created the following guide to give practices information that can help ease the way into regular telehealth care delivery and answer some common questions.
Introduction to telehealth services
As with in-person visits, reimbursements and requirements for telehealth can vary depending on your insurance payer, the services you deliver, and your state.
In response to the COVID-19 outbreak, the CMS and commercial payers have relaxed or removed many telehealth requirements. This gives patients expanded access to care while they maintain isolation from others during the crisis.
To ensure you have the most timely telehealth information for your state and services, these initial steps are strongly recommended:
- Check in with your state board or association to understand any laws or requirements
- Contact the benefits and eligibility departments of your private payers to inquire about coding and documentation that’s required when billing
Coding for telehealth services
“Common billing codes for telehealth care” is a quick reference guide with information from the AMA. Medicare and major commercial payers have waived usual restrictions that define when a virtual visit is warranted and recognized — for now, during the national public health emergency, all patients are eligible for telehealth visits, not just those in particular situations. Therefore, codes for typical E&M visits are now widely available for telehealth billing use. A video connection with a patient will suffice, and the patient most certainly can be at home.
Updated (04.27.2020): In April, CMS changed their guidance on coding for typical E&M visits. Instead of including “02 – Telehealth” as the “place of service” (POS), healthcare practices should include the POS where the visit would have normally occurred (usually “11 – Office”) and then add the modifier “95” to denote that telehealth was utilized. Some private payers may follow the same requirements.
For Medicare telehealth payments
As mentioned above, CMS has expanded rules so healthcare providers can deliver virtual care to all Medicare patients. Previously, this was limited to patients who lacked access to care in rural areas or were receiving telehealth care while at a healthcare facility.
Two types of patient visits are most relevant for virtual care delivery by private practices today:
- Medicare telehealth visit: Audio and video visit. Applies to most providers including social workers, dietitians, and nutritionists. Cost-sharing (deductibles and co-insurance) can be waived. For the duration of the public health emergency, payment is the same as the rate for an in-person visit.
Relevant CPT codes
New patients: 99201, 99202, 99203, 99204, 99205
Established patients: 99211, 99212, 99213, 99214, 99215
- Online digital visits / check-ins: Brief connections, usually initiated by the patient, for a quick conversation, or to share a video or image. This can be done via video or live phone call, and doctors may respond to concerns via text messaging and patient portal messaging. CMS has waived the requirement that virtual check-ins be conducted with established patients only.
Relevant CPT codes
99421, 99422, 99423
98970, 98971, 98972 (non-physician healthcare professional)
If Medicare is part of your reimbursement mix, get the Medicare healthcare provider fact sheet here.
For private insurance
Contact your payers to understand telehealth reimbursements for your services, as well as coding and billing requirements — just as you would when adding any new care service. For efficiency, start with the payer that covers the highest percentage of your patients.
The following summarizes changes commercial payers are making to expand access to telehealth care during the COVID-19 emergency. For complete, updated details, please click through to each payer’s website from the links provided.
Major private payers (updated 4.27.2020)
- aetna: All patient costs for 27 types of telehealth visits are waived through June 4, 2020, when patients see an in-network provider delivering virtual care via Teladoc.See current aetna information on telehealth.
- Blue Cross Blue Shield: Coverage for telehealth services has been expanded to all members for 90 days, beginning March 19, 2020. This includes waiving cost-sharing for fully insured members seeing network telehealth providers. Prior authorizations have also been waived.See BCBS information related to COVID-19.
- Humana: Claims will be reimbursed for services delivered via telehealth for as long as the national health emergency is in effect. Patient cost-sharing has been waived for all telehealth visits, including routine primary and specialty care, for 90 days beginning March 10. Applies to in-network providers using video conferencing (synchronous care like PatientPop Telehealth) as well as audio-only phone calls. Prescription medicines can be refilled early for an extra 30- or 90-day supply.See details on access to telehealth care from Humana.
- UnitedHealthcare: Claims will be reimbursed for 46 types of telehealth services, and patient cost-sharing has been waived for all in-network telehealth visits, through June 18, 2020. This applies to members of Medicare Advantage, Medicaid, and commercial plans. Eligible care providers can bill for interactive audio-video visits as well as audio only.
The Center for Connected Healthcare Policy has an interactive map with the state laws and reimbursement policies for all 50 states, including regulation on Medicaid and private payer law, as of Fall 2019. This information is also available state by state in a complete report from the CCHP.
To help providers keep up with evolving regulatory changes during the COVID-19 crisis, the CCHP has two regularly updated sources: telehealth coverage policies in response to COVID-19 and state actions in response to COVID-19. It’s strongly recommended that healthcare providers check both to see current waivers or requirements in their state.
Parity laws for private payers
Most states (36 as of this writing) have some type of “parity laws,” which require private payers to consider telehealth care in ways comparable to in-person care. Currently, only 16 states address reimbursement specifically, and only 10 have true reimbursement parity, paying the same rates for virtual and in-person care.
Because of the differences, it’s important to understand how each state’s laws affect your services and reimbursements.
For Medicaid telehealth payments
As of Fall 2019, all 50 states have Medicaid reimbursement for live video telehealth visits. Fourteen states provide Medicaid reimbursement to practices using telehealth for store-and-forward activity: Alaska, Arizona, California, Connecticut, Georgia, Maryland, Minnesota, Nevada, New Mexico, New York, Tennessee, Texas, Virginia, Washington.
State plans are now encouraged to consider telehealth as a mode of care delivery in response to COVID-19. States are not required to amend their plan (with a State Plan Amendment, or SPA) if they choose to reimburse telehealth visits just as they would for in-person visits or consultations.
As with any reimbursement program that has state-by-state requirements or guidelines, it’s always recommended to contact your state Medicaid program for telehealth details, both now and after the COVID-19 crisis.
For more information on delivering telehealth care, see “Your quick reference guide to billing and reimbursements for telehealth,” and details about the PatientPop Telehealth platform.