Editor’s note: The ACR has telehealth guidance specific to rheumatology practices, including some of the codes to use for billing purposes.
Reimbursement Challenges
The 41 states that have passed laws aimed at improving the provision of telemedicine services have also sought to increase reimbursement for such services. Parity laws account for most of these reforms, which require both private payers and government payers providing Medicaid services to cover or reimburse telemedicine services at the same rate for the same services that would be provided in-person to a patient in an office setting. Coverage rates still vary by policy, as do the covered telemedicine services under each state’s insurance laws and Medicaid regulations.
Private Payer
Currently, 36 states and Washington, D.C., have existing laws that require private insurance companies cover patients’ telemedicine services at equivalent rates to appointments held in person at physician offices, hospitals or other clinical locations.
Sixteen states also have parity laws that require providers be reimbursed for telemedicine services at rates equivalent to services provided in person.
Thirteen states have not adopted parity policies, but telemedicine is nonetheless covered to some degree by primary health insurance companies, including Aetna, Blue Cross Blue Shield, Cigna, Humana and UnitedHealthcare.
Medicaid
Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements for efficiency, economy and quality of care. Medicaid covers some forms of telemedicine service in every state and offers coverage and reimbursement parity in the majority of states.
Since 2018, the CMS has increased the telehealth services that are eligible for provider reimbursement beyond traditional consultation or inpatient and outpatient visits to include preventive services, education and counseling sessions, and even care management or virtual check-ins.
Like Medicare, Medicaid in some states has an originating site requirement, and 12 states actually consider a patient’s home to be an originating site for payment purposes. Nineteen states have not yet adopted Medicaid parity policies, so changes to the regulations in those states are anticipated at some point.
In addition, many states, such as Ohio, generally don’t consider telephone services to be a reimbursable medium for the provision of telemedicine.
Note: On March 17, the CMS released Medicaid telehealth guidance to the states to help states better understand policy options for paying Medicaid providers using telehealth to deliver patient services in combating the coronavirus. The CMS encouraged providers to use telehealth services due to the benefit of increasing access to care while reducing both the risks for spread of infection and exposure to vulnerable populations.
