Telehealth Reimbursement Trends and Opportunities: What Physicians Need to Know

Oct 02, 2019

New legislation concerning telemedicine will soon provide new opportunities for physicians. 

For years, telehealth reimbursement fears dogged physician practices. In fact, according to the American Well Telehealth Index: 2019 Physician Survey, uncertainty over reimbursement was flagged by 77 percent of providers as a key barrier to telehealth adoption.

But for physician practices who currently use a telehealth platform – and especially those who are eager to implement telehealth -- the surge in legislation expanding telemedicine coverage is welcome news.

In 2018, the passage of the CHRONIC Care Act broke down significant barriers to reimbursement. And in April 2019, the Centers for Medicare & Medicaid Services (CMS) released a Final Rule that will allow Medicare Advantage (MA) plans to offer “additional telehealth services” as part of their basic benefit package - not just a supplemental benefit - beginning in 2020. Meanwhile, several Medicare Physician Fee Schedule changes in telehealth have also taken effect, including the allowance for five-minute virtual check-ins.  

These are just a few developments that will fuel the use of telemedicine technology in helping more patients receive care easily and quickly.

But in order to effectively move past reimbursement fears and confusion, physicians will need to acquaint themselves with Medicare’s coverage changes. Knowing what’s covered and what isn’t can help physicians and the organizations they work for navigate the best ways to incorporate telehealth into their daily workflows.

Changes to Medicare Advantage (MA)

For providers, the changes to MA offer an opportunity to appeal to new patients who are approaching enrollment in MA plans by emphasizing the convenience of accessing high-quality care from any location-whether that’s their home, the physician’s office or another originating site.

Previously, MA plans tended to only offer telehealth services as a supplemental benefit. With the Final Rule, MA plans will offer additional telehealth benefits as part of patients’ regular coverage, which opens the door for providers to offer more telehealth services without fear of going broke.  

As private payers nearly always follow Medicare’s precedent, it’s likely physician practices will have to worry less about whether they’ll be reimbursed for telehealth consultations with private-pay patients. 

Medicare Physician Fee Schedule’s Virtual Check-in Code

The 2019 Medicare Physician Fee Schedule changes offer providers an opportunity to provide better care to patients through the use of telehealth. Specifically, CMS will now pay separately for two “newly defined” physicians’ services furnished using communication technology:

·       Brief communication through a technology-based service (HCPCS code G2012); and

·       remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010).

This allowance expands on CMS’ existing Chronic Care Management (CCM) benefit, which reimburses physicians for non-face-to-face visits with patients who have two or more chronic conditions. 

And the timeliness of this new provision is ideal: Chronic disease expenditures account for 90 percent of the U.S. health system’s costs, according to the Centers for Disease Control and Prevention (CDC). With 52 percent of Medicare beneficiaries willing to use telehealth, according to a 2019 Senior Consumer survey from American Well, offering virtual-check ins can help a practice differentiate itself by offering immediate access to expert advice. When patients can avoid unnecessary visits to doctor offices, urgent care or the emergency department, everyone wins.

However, it’s important to note that the virtual check-in benefit has a few restrictions in its initial rollout: Check-ins are meant to be for current patients concerning chronic care issues and for overall health management/wellness. They can only be provided to established patients who have seen the provider they are checking in with at least once in the preceding three years. Additionally, virtual check-ins may not be related to a service provided within the past seven days, nor may they lead to a service or procedure within the next 24 hours or during the soonest available appointment.

For healthcare providers already using a telehealth platform, make sure your vendor’s most current software update enables easy code mapping and documentation of the virtual experience within the EHR.

Remote Patient Monitoring

Physicians hoping to extend care management into the home will welcome CMS’ expanded coverage for remote patient monitoring (also under the 2019 Medicare Physician Fee Schedule), which includes coverage for initial set-up of a remote patient monitoring device and the patient education associated with using the device at home.

The change could also enable physician practices to get reimbursed for serving patients at the precise time they need care - and avoid hospital admissions and other adverse events.

For example, researchers at Stanford University School of Medicine studied the use of an Apple Watch and an iPhone to identify heartrate irregularities that could signify atrial fibrillation, a leading cause of stroke. Eighty-four percent of those who received notification of an irregular pulse were found to be in atrial fibrillation at the time of the notification. If an irregular pulse was detected, the participant received a notification and was instructed to immediately schedule a telemedicine consultation with a physician in the study. Fifty-seven percent of those who received irregular pulse notifications sought medical attention. While seeking medical attention for heart rate irregularities doesn’t directly prevent hospitalization, identifying patients at risk for atrial fibrillation can lead to important lifestyle changes that ultimately prevent stroke or heart disease.

Understanding the benefits and applications of telehealth tools can help physicians build or expand their existing telehealth programs. With emerging opportunities for telehealth reimbursement, physicians may benefit from developing patient-facing strategies and looking for new ways to incorporate telehealth into their workflows. By adopting - and adapting to - telehealth now, providers will be ahead of the game as reimbursement continues to expand for Medicare beneficiaries and commercial health plans.

Mike Baird is the President of Customer Solutions at American Well. Prior to this, Mike was co-founder and CEO of Avizia. He launched Avizia in 2013 with the goal of improving access to telehealth by eliminating barriers to adoption for health systems and delivering on the triple aim of reducing cost, expanding the reach, and improving the quality of healthcare. American Well acquired Avizia in 2018, expanding the capabilities of the American Well platform.