Billing Medicare and Private Payers for Telehealth Visits: What to Expect Post-Public Health Emergency

Prepare Now for Anticipated Changes to Medicare and Private Payer Rules
01:40 PM

By Tyler Williams, Directory of Strategy, AR Optimization, ZOLL Data Systems

Prepare Now for Anticipated Changes to Medicare and Private Payer Rules

“The expansion of telehealth and the offering of new telehealth services that were not previously covered really enabled physicians to care for their patients in the midst of this crisis,” said Todd Askew, the AMA’s senior vice president of advocacy, during a recent “AMA COVID-19 Update.”[i]“We have moved forward a decade in the use of telemedicine in this country, and it’s going to become and will remain an increasingly important part of physician practices going forward.” While the AMA and many others are advocating for continued support of telehealth post-pandemic, healthcare providers and practice leaders should anticipate and prepare for a return to more standardized regulation after the public health emergency (PHE).

Anticipated New CMS Rules for Telehealth

The Centers for Medicare and Medicaid Services (CMS) is expected to issue new rules for telehealth in the release 2021 Physician Fee Schedule later this year. Today, Medicare reimburses for specific services when delivered via live video. These new rules are expected to specify what Medicare will cover regarding telehealth services, how those services must be billed going forward, and what documentation is required to be reimbursed. It is highly probable that private payers will adopt the Medicare rules, but it is unknown how quickly they may follow suit.

All providers need to review these new Medicare telehealth billing rules, as well as any state-specific legislative or regulatory requirements. While the Office of Inspector General (OIG) has deferred random audits during the PHE, expect them to resume at the end of the emergency. As a best practice, to understand state-specific policies, providers can check the Center for Connected Health Policy State Telehealth Laws and Reimbursement Policies Report.[ii]

It is also recommended to review individual payer websites for any changes in telehealth policies for 2021. It can be expected that post-PHE, payers will enact policies to limit the scope of telehealth coverage. Many patients appreciate the convenience of telehealth and it is likely the number of telehealth visits will continue to increase post-PHE. As patients use telehealth to interact with their physicians more often, payers will be expected to reimburse more visits, negatively impacting their financial performance.

Provider Considerations

When it comes to telehealth reimbursement, an important consideration for providers is whether they have a set of CMS-approved telehealth CPT codes for reimbursement. CMS publishes a list of currently approved telehealth codes. The American Medical Association (AMA) compiles the CPT handbook, in which the “starred appendix” includes those codes that are telehealth eligible. Post-PHE, providers will also want to check that the telehealth service is a covered benefit under a patient’s insurance policy. It is also important for providers to understand their state’s parity regulations. In some states, parity regulations require that the payer reimburse the same amount for a telehealth visit as an in-person visit.

Staying Ahead of Change

How can telehealth providers prepare for the changes expected to come at the end of the public health emergency? Now is the time to be thinking about what changes need to be made to manage an increased volume of telehealth visits post-PHE. Proactively review strategic plans and ensure the ability to meet the pre-PHE telehealth requirements, as well as the most-probable changes. This includes meeting all state-level telehealth, licensing, and credentialling requirements. Also, check which payers require providers to be registered in-network to be covered and take steps to become a member of those networks that make sense for your organization.

Advocate for the right changes. Comment on rules during the open comment period. Use technology to make the reimbursement process more effective. For example, make sure the same frontend registration processes are in place for telehealth patients as in-person patients. Use patient demographics verification and insurance coverage discovery and eligibility software to maximize reimbursement.

Tips for Moving Forward Post-PHE

Use this time to prepare for future telehealth requirements. Follow these tips to position for success post-PHE:

  1. Put a process in place to capture patient consent up front
  2. Thoroughly review national and state-level policies impacting telehealth practice and reimbursement
  3. Ensure licensing and credentialling is in proper order for all providers
  4. Make sure a practice or emergency physician group is set up correctly to succeed with telehealth once the PHE has lifted
  5. Evaluate how technology solutions can help optimize reimbursement
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