Providers Must Take Steps to Stay Abreast of Evolving Telehealth Reimbursement Policies

Portrait of a sick patient coughing into tissue being helped via tele medicine by a male doctor wearing blue scrubs uniform using laptop

September 3, 2020

Jon Giuliani
Vice President of Operations
Healthcare Financial Resources, LLC

As the use of telehealth skyrockets due to the COVID-19 pandemic, financially hard-hit providers must consider new revenue cycle management protocols to ensure the best chance for full reimbursement.

In March 2020, telehealth utilization exploded 4,300% from a year earlier as patients and providers sought alternatives to office visits for routine care. Yet long-term uncertainty about Medicare reimbursement and wide disparities in the way commercial payers and Medicaid programs reimburse for telehealth mean providers must be extra-vigilant to limit denials and underpayments.[1]

Key steps like ensuring complete documentation of services, including the audio and/or visual functionality used to deliver the care, as well as close scrutiny of telehealth claims, are essential to maximize reimbursement, revenue cycle experts with Healthcare Financial Resources (HFRI) say.

“With telehealth services accounting for an ever-larger percentage of care, making sure you’re collecting every telehealth dollar you’re entitled to will be critical to sustaining cash flow in the months and years to come, particularly amid the lingering downturn triggered by COVID-19,” said Dan Low, HFRI’s director of operations.

As defined by the American Medical Association, telehealth services generally fall into one of four modalities:

  • Real-time, audio-visual communications that link physicians and patients
  • Store-and-forward technologies that collect images and data to be transmitted and interpreted later
  • Remote patient-monitoring tools such as wearable devices, blood pressure monitors and other devices that record and communicate biometric data
  • Verbal and text virtual check-ins made through patient portals and messaging apps.[2]

Telehealth can be administered by a range of clinicians, including physicians, nurse practitioners, physician assistants, clinical nurse specialists and psychologists.

Economic pressure mounting

Physician offices and hospitals have been slammed economically by sharp drops in office visits and elective procedures as a result of the pandemic. Although volume has begun to recover, the American Hospital Association is predicting hospitals and health systems could still lose $120.5 billion between July 2020 and the end of the year, or about $20 billion a month.[3] Primary care doctors, meanwhile, may lose approximately $15 billion in 2020.[4]

Permanent changes sought

At the outset of the pandemic, statutes preventing expanded access to telehealth for Medicare beneficiaries were waived by Congress as part of the declaration of a public health emergency. The temporary move allowed a wider range of providers to deliver more telehealth services with a greater variety of technology and without geographic or originating site limitations. This flexibility helped accelerate the expansion of telehealth across the care continuum, with over nine million Medicare beneficiaries participating from mid-March through mid-June, according to internal Centers for Medicare and Medicaid Services (CMS) analysis.[5]

Although the initial telehealth waivers were initially set to expire on July 25, 2020, the U.S. Department of Health and Human Services (HHS) extended the federal public health emergency on July 24 through October 23, 2020, thus ensuring continued telehealth coverage through the ongoing public emergency. This waiver must be renewed every 90 days.[6]

Separately, the CMS 2021 Physician Fee Schedule Draft has proposed nine new telehealth CPT codes. The agency also has developed a new Category 3 for codes that will be covered during the COVID-19 emergency only. This category contains approximately 50 codes created during the COVID-19 pandemic, as well as 13 new codes and other changes.[7] Several telehealth bills likewise have been introduced to help expand the service and ensure telehealth regulations remain intact beyond the pandemic.[8]

Commercial, Medicaid payer confusion

The increased statutory flexibility has made it easier to be reimbursed for Medicare telehealth services. But at least for now, inconsistent and conflicting policies across the commercial landscape have created major payment hurtles for some providers. Although many insurance companies have asserted that, like Medicare, they will reimbursement at 100% of the in-person rate for a range of virtual visits, the reality is far less straightforward.

Clinicians say some insurance companies are unable to provide updated information about telehealth payment policies and much uncertainty exists about what companies will pay for and what they won’t. Medicaid reimbursement, meanwhile, varies from state to state, with telehealth payment policies clearly defined in some states but not in others.

Revenue Cycle safeguards

Regardless of the payer, providers should make a point to include all pertinent information on telehealth claims to limit the risk of denials. Specifically, claims should incorporate:

  • Date, time and location of service
  • Appropriate use of GT (telehealth) modifiers
  • Emergency room or outpatient consultation
  • Recommendations and scheduled follow-ups
  • Type of technology used
  • Proof of patient consent with systems that are not privacy protected (e.g. Skype)

Providers also should conduct ongoing audits to be sure telehealth claims are being coded, documented and filed accurately. Close monitoring of, and communications with, payers of all types likewise are important to maintain an up-to-date understanding of telehealth policies.

“Consistent monitoring of telehealth CARC AND RARC reason codes from the insurance carrier will help you to identify what rejections the payers are applying to your telehealth services,” Low said.

The new normal

Most observers expect the waivers granted for Medicare telehealth will be made permanent and that commercial payment policies eventually will become more coherent and consistent. Assuming providers remain vigilant about reimbursement policies, the telehealth wave unleashed by COVID-19 ultimately could support a new paradigm for providing health-quality, cost-efficient care, not only for outpatient services but inpatient and remote patient monitoring as well.

HFRI can help

Staying abreast of the latest coding directives regarding telehealth reimbursement and denials can be a challenge. This is especially true when coverage varies between government and commercial payers and from state to state. Healthcare Financial Resources has a large footprint across the U.S. Our experts have a thorough knowledge of each state’s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

[1] Heather Landi, “More than 300 organization, physician groups push Congress to take action on telehealth policies,” Fierce Healthcare, June, 30, 2020.
[2] “AMA Telehealth quick guide,” American Medical Association, updated July 6, 2020.
[3] Robert King, “AHA: Hospitals could lose $20B a month for the rest of 2020 due to COVID-19 impact,” Fierce Healthcare, June 30, 2020.
[4] Robert King, “Study: Primary care practices could lose $15B in 2020 due to COVID-19,” Fierce Healthcare, June 26, 2020.
[5] Seema Verma, “Early Impact of CMS Expansion of Medicare Telehealth During COVID-19,” Health Affairs, July 15, 2020.
[6] “Renewal of Determination that a Public Health Emergency Exists,” Kaiser Family Foundation, July 1, 2017.
[7] Eric Wicklund, “How CMS Changes, Trump’s Executive Order Affect Telehealth Coverage,” mHEALTH INTELLIGENCE, August 6, 2020.
[8] Eric Wicklund, “The COVID-19 Telehealth Expansion Bills Are Starting to Pile Up,,” mHEALTH INTELLIGENCE, July 31, 2020.

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