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.
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:
“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.
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:
If Medicare is part of your reimbursement mix, get the Medicare healthcare provider fact sheet here.
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)
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.
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.
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