Increased Scope of Telemedicine
Telemedicine and telehealth describe the use of telecommunication tools including the Internet, video, and email to exchange information in the context of health care between patients, providers, consultants, and content for the purpose of education, evaluation, decision-making, and treatment. Prior to the COVID-19 pandemic, telemedicine applications had evolved to broadly cover care for chronic and emergent conditions. Psychiatry broadly utilized telemedicine psychiatric ‘office’ visits in addition to emergency care. Primary care and internal medicine demonstrated the value and utility of telemedicine across venues and across credentials from intensivists running command and control centers remotely for multiple ICU stations to physician assistants on video phone chats to a patient’s home. Telemedicine’s historical role has been to increase access to health care for remote or sequestered populations like inhabitants of rural areas. In this article, let’s understand telemedicine coverage and reimbursement in the year 2022 and how it evolved prior to and during Public Health Emergency (PHE).
Telemedicine Coverage and Reimbursement
Prior to the pandemic fee-for-service, Medicare reimbursement for telemedicine was restricted to remote or very specific chronic care but CMS was liberalizing its implementation in alternative payment models such as accountable care organizations (ACOs). At the start of 2020, traditional Medicare and Medicare Advantage plans expanded telehealth coverage, limiting restrictions on patient location requirements and expanding coverage for more diagnosis.
Prior to the pandemic, private payers were increasingly covering telemedicine either by law or by choice. During some or all of the public health emergency period, most major private payers have provided telemedicine reimbursement across the entire nation. Large gaps still exist in telemedicine reimbursement, but nonetheless, almost all states provided Medicaid coverage for telemedicine prior to the PHE and that coverage has improved since. With the emergence of the COVID-19 public health emergency (PHE) in early 2020, almost overnight the adoption of telemedicine leaped several years forward. As of March 1, 2020, during the PHE, traditional Medicare has radically liberalized access to telemedicine across effectively all locations and all conditions.
Prior to the PHE, reimbursement was the largest obstacle to the widespread adoption of telemedicine. Prior to the PHE, 29 states and Washington DC had parity laws requiring private payers to reimburse telemedicine services on par with in-person services. Three additional states provided partial coverage. Blue Cross Blue Shield, Aetna, United Health, and Cigna were the top payers, but the majority of state employee plans covered some degree of telemedicine services. During the PHE, private payers almost universally have provided reimbursement for telemedicine services, usually with parity to in-office visits, although it is unclear the extent to which this practice will be maintained post-pandemic.
Hospitals themselves will provide reimbursement for telemedicine coverage in instances where a specialty is not otherwise available but is necessary for the hospital’s overall provision of services. All states but Rhode Island provide Medicaid reimbursement for some level of telemedicine services, but the degree of coverage varies greatly. Requirements vary for qualifying distances to providers, eligible providers, and technologies. In some states, the patient must be in a physician’s office or a federally qualified health center. In half of the states, there is no qualification regarding the location of the patient. Currently, sixteen states have restrictions on what type of facility qualifies as an originating site. Store and forward is covered in eighteen states (one more than Medicare), including Alaska, Arizona, California, Illinois, Minnesota, Mississippi, New Mexico, Oklahoma, and Virginia.
Prior to the PHE, Medicare was the most restrictive payer regarding telemedicine services. Fee-for-service Medicare reimbursement was typically available only for patients in remote locations that lack providers or in certain restrictive long-term care scenarios. During the PHE, CMS dramatically liberalized reimbursement for telemedicine services. Audio-visual, as well as audio-only, are reimbursed effectively at parity to in-office encounters regardless of the site of service. Virtual check-ins are reimbursed as well. During the PHE the list of covered telehealth services was expanded significantly. Some of these are set to expire after the PHE while others were added to the permanently covered services.
To Summarize
For the time being, many of the restrictions associated with originating sites will revert back to pre-PHE rules when PHE expires. This means that services covered on the PHE list, including E&M codes, will be restricted to those in rural areas (health shortage regions) and at approved facilities. Legislation is expected to bring positive change in this regard, as there is a strong push to permanently eliminate originating site restrictions.
We referred American Urology Association’s telemedicine guidance page to discuss telemedicine coverage and reimbursement in 2022. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We can assist you in receiving accurate insurance reimbursement for telemedicine services from government and private payers. To know more about our telemedicine billing services, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.
FAQs
1. What types of telemedicine services are covered by Medicare during the Public Health Emergency (PHE)?
During the PHE, Medicare significantly expanded coverage for telemedicine, including services delivered via audio-visual and audio-only formats. It also allowed reimbursement for virtual check-ins and added many new services to the telehealth coverage list, such as evaluation and management (E&M) codes.
2. How does telemedicine reimbursement differ between private payers and Medicare?
Private payers often reimbursed telemedicine services at parity with in-person visits during the PHE, though practices vary by state and insurer. Before the PHE, Medicare had stricter limitations, primarily covering telemedicine in rural areas or certain long-term care settings. During the PHE, Medicare relaxed these restrictions, offering broader coverage.
3. Are there location-based restrictions for telemedicine reimbursement?
Before the PHE, Medicare required patients to be in rural or health shortage areas for telemedicine reimbursement. Most states have similar rules, but many lifted these restrictions during the PHE. However, these rules are likely to revert after the PHE unless legislative changes make them permanent.
4. Do Medicaid programs cover telemedicine services?
Yes, all states provide some level of Medicaid coverage for telemedicine. Coverage varies by state, with differences in eligible providers, technologies, and originating site requirements. For example, some states require patients to be at specific facilities, while others have no such restrictions.
5. What are “store-and-forward” telemedicine services, and are they reimbursable?
Store-and-forward telemedicine involves transmitting patient information, such as medical images or data, to a provider for evaluation at a later time. While Medicare generally does not cover these services, 18 states, including California, Minnesota, and Virginia, reimburse for them under Medicaid programs.
