How to Get Reimbursed for Telemedicine

Telemedicine Reimbursement

Medicare

Medicare reimburses for telemedicine nationwide, but doesn’t allow telemedicine from the patient’s home.

Medicaid

48 state Medicaid programs cover telemedicine (CT & RI do not).

Private

The big 5 (United Healthcare, Aetna, Cigna, Humana, BCBS) all cover telemedicine, but coverage is policy-dependent.

The 3 Types of Payers

Medicare

• Medicare is a national program run CMS to provide government-funded healthcare for Americans 65 and older (and youger adults with disabilities)

• Medicare lags behind the other payers for telemedicine reimbursement

• Medicare guidelines are still mostly based on traditional model of telemedicine, where the patient would come into a small, rural health clinic to do an online visit with a far away specialist

• This is where the terms “originating site” and “distant site” come in

• Legislation is in the works to expand Medicare coverage of telemedicine soon

Main Points

Navigating Medicare

• Originating Site – the location of the patient at the time of the telemedicine visit

• Distant site – location of the provider at the time of the telemedicine visit

• Eligible providers – healthcare providers that can get reimbursed for telemedicine under Medicare

• Facility fee – fee that can be charged by the originating site as payment for “hosting” the patient for the telemedicine visit

• HPSA– Health Professional Shortage Area

Terms you need to know

Navigating Medicare

1. You must be doing live video telemedicine

• Medicare only covers telemedicine via live video

• The only exception is for AK and HI, where store-and-forward is covered as well

• Live video telemedicine means you can see and hear the patient in real-time, like an in-person visit

• Store-and-forward (also called asynchronous) telemedicine is where you’re sending medical data or diagnosis remotely and not talking to the patient in real-time

How to Get Reimbursed

Navigating Medicare

2. Patient must be at an eligible Originating Site• The originating site must meet 2 conditions:

1) It must be in a Health Professional Shortage Area (HPSA)• To find out if it’s in a HPSA, type address into here

2) It must fall into one of these categories:

• At this time, Medicare does not recognize the patient home as an originating site

How to Get Reimbursed

• Physicians or practitioner offices

• Hospitals• Critical Access

Hospitals (CAH)

• Rural Health Clinics• Federally Qualified

Health Centers• Hospital-based or CAH-

based Renal Dialysis

Centers• Skilled Nursing

Facilities (SNF)• Community Mental

Health Centers (CMHC)

Navigating Medicare

• July 7th, 2015 - House representatives introduced the Medicare Telehealth Parity Act of 2015

• If passed, the bill will get rid of some of the limitations on what qualifies as an originating site

When will Medicare recognize the patient home as an eligible site?

Navigating Medicare

3.Telemedicine needs to be delivered by an eligible healthcare provider:

• Physicians• Nurse practitioners• Physician assistants• Nurse-midwives• Clinical nurse specialists• Certified registered nurse anesthetists• Clinical psychologists • Clinical social workers • CPs and CSWs • Registered dietitians or nutrition professionals

How to Get Reimbursed

Navigating Medicare

4. The medical procedure needs to be on the list of covered services

• Here’s the complete list of medical services eligible for telemedicine reimbursement

• Check for CMS updates to the list of covered telehealth services here

How to Get Reimbursed

Navigating Medicare

• Use the appropriate CPT/HCPCS code

• Add the “GT” modifier to show the service was delivered via telemedicine

• If you’re an originating site, use HCPCS code Q3014 to bill a facility fee as payment for hosting the visit

How to Bill

Navigating Medicare

• Medicare reimburses telemedicine at the same rate as in-person visits

• Just check the CY Medicare physician fee schedule for the appropriate CPT/HCPCS code to see rate

• You can also get a 10% bonus for delivering services to a HPSA

• To see if it’s in a HPSA, type address here

Reimbursement Rates

Next Payer up…..

MEDICAID

Navigating Medicaid

• Originating (Spoke) Site – the location of the patient at the time of the telemedicine visit

• Distant (Hub) site – location of the provider at the time of the telemedicine visit

• Eligible providers – healthcare providers that can get reimbursed for telemedicine under Medicare

• Facility fee – fee that can be charged by the originating site as payment for “hosting” the patient for the telemedicine visit

• Referring provider – the healthcare provider at the originating or spoke site. This provider is acting as the host.

• Consulting provider – the healthcare provider at the distant or hub site. This is the provider who’s actually delivering the medical service.

• Telepresenter– professional at the originating (or spoke) site who helps patient get set-up for the telemedicine visit.

Terms you need to know

Navigating Medicaid

• Since every state has its own Medicaid program, every Medicaid program has different rules for telemedicine

• Always read your state Medicaid telemedicine guide• Go to your Medicaid website• Search for your provider manual on telemedicine• For instance, here’s Georgia’s telemedicine manual

• And talk to your state Medicaid department• You can also get help from your

regional telehealth resource center

Main Points

Navigating Medicaid

• 48 state Medicaid programs offer some form of coverage for telemedicine (except CT & RI)

• 24 states cover telehealth under their state employee plans• 24 states plus DC don’t require a specific patient location as a condition for

coverage• 25 states recognize the home as an originating site• 82% of U.S. states cover telemedicine state-wide, with no restrictions on distance

between provider and patient• 15 states plus DC don’t specify type of healthcare provider as condition of payment• 28 states plus DC don’t require a telepresenter

*based on recent report by the American Telemedicine Association (ATA)

Medicaid Telemedicine Trends

Navigating Medicaid

1. Lookup the Medicaid telemedicine reimbursement rules for your state

• The National Telehealth Policy Resource Center has an interactive map of telehealth policy, state-by-state

• Visit your state Medicaid agency website & read your Medicaid handbook

• Read this policy analysis from American Telemedicine Association

How to Get Reimbursed Through Medicaid

Navigating Medicaid

2.Know what to researchHere are some of the common restrictions and guidelines that may affect your telemedicine reimbursement through your state Medicaid program:

How to Get Reimbursed Through Medicaid

• Type of Telemedicine (Live video, store-and-forward, remote patient monitoring)

• Health Services covered & Applicable CPT Codes

• Eligible providers (Physicians, NPs, PAs etc)

• Distance or Geographic restrictions (Does patient need to be located in certain region, or distance from provider)

• Is a Pre-existing relationship with patient required?

• Location restrictions on patient or provider

(what defines an eligible originating site? Eligible distant site?)

• Informed Patient consent (do you need to get patient’s consent before the visit?)

• Type of fee reimbursed (transmission, facility, or both)

• GT Modifier (do you to use the GT modifier when coding?)

Navigating Medicaid

3. Record your research and think about how it affects your use case

• Download our Medicaid state policy worksheet here

4. Contact your Medicaid department or Rep with questions

How to Get Reimbursed Through Medicaid

Next Payer up…..

Private Payers

Navigating Private Payers

Telemedicine Parity Laws• State telemedicine parity laws require private payers to reimburse for telemedicine

the same way they would for in-person medical services• 29 States + DC currently have parity laws (9/2015)• Check if your state is covered here

Things to Know

Map created by the American Telemedicine Association2015 Source

Navigating Private Payers

• The Big Five commercial insurance carriers cover telemedicine

• BCBS• Aetna• Cigna• United Healthcare,• Humana

BUT……• Coverage by private payers is policy-

dependent • A patient with a BCBS gold policy in North

Carolina might have telemedicine listed as a covered service for their policy

• A patient in same state with BCBS silver, may not have it

Things to Know

Navigating Private Payers

• So how to you ensure a patient’s private insurance will reimburse for telemedicine?

• You have to verify before the visit• Verify insurance coverage for each patient• ALWAYS record that call with a verification

form• Use our example verification form

Things to Know

Navigating Private Payers

• Like with Medicaid, private payers in your state are influenced by state policy

• Plus, each private payer has their own telemedicine guidelines

• The best way to check their telemedicine reimbursement requirement? Call them and ask questions

Check with your payers

Navigating Private Payers

• Pick your top 3-5 private payers and call their eligibility & verification department

• Ask the right questions:• Which CPT and HCPCS codes can be completed via telemedicine?• Do I need to use the GT modifier?• Do I need prior authorization?• Are there any restrictions on the location of the patient or provider?• Does the reimbursement rate match the in-person rate?• Which providers are eligible (physician, NP, PA)?• Are there any specific notes that need to be included in the visit documentation?• Do you have a handout or guide you could send me on your telemedicine guidelines?

Calling your private payers

Navigating Private Payers

Billing Trends

• Private payers tend to follow Medicare on billing

• Generally you would use the appropriate E/M CPT code plus the GT modifier

• But, some payers accept the telemedicine-specific code 99444

• Again, always check coding guidelines with your payers. These are just trends we’ve seen for context.

Our Recommendations• Consider starting with one payer, or one use case

• For instance, offer telemedicine only to patients with a Medicaid plan• Or, only offer telemedicine visits to patients with a chronic condition• Once you figure out the workflow for that payer or use case, grow from there

• Always call your private payers and verify their guidelines

• Connect with your state Medicaid department and your regional telehealth resource center to verify guidelines and get questions answered

• Always verify a patient’s insurance covers telemedicine using the example verification form we provided

• Yes, you’ll need to do it for each patient, but only for the first visit!

If all else fails…

• Patients love the convenience of telemedicine

• Many of our clients simply charge a convenience fee

• You can charge a fee in place of reimbursement, or on top of

• Fees can range anywhere from $30 to $125 per visit depending on the length of the visit

Charge Your Patients Directly!

Review of the Steps

1. Determine the type of telemedicine (live video)

2. Define your use case (you can also narrow down your payers at this point and skip a couple of the next steps if not relevant)

3. Review Medicare guidelines and see if your use case is eligible for reimbursement

4. Research your state Medicaid guidelines and see if your use case is eligible for reimbursement

5. Call your private payers and ask for their telemedicine guidelines

6. Decide which payers you’ll go through, if not all

7. Call eVisit or connect with your local telehealth resource center for questions

8. Train your staff on the workflow

9. Verify that your patient's insurance will cover telemedicine before you start

10. Charge a convenience fee (in place of, or in addition to your reimbursement)

Here are the key steps for figuring out telemedicine reimbursement for your practice:

Other Reimbursement Resources

• List of state Medicaid websites• Medicare Telemedicine Guide• List of Medicare telemedicine CPT codes• ATA state policy matrix• Telehealth Resource Center State Policy Map

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Sept 2015Follow us@eVisitevisit.com/blog/

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