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Telemedicine Reimbursement Checklist for California

telemedicine reimbursement in CaliforniaIn its current state, California offers some of the most favorable telemedicine reimbursement laws in the US. However, it still varies widely from payer to payer, plan to plan, even patient to patient. Chiron Health clients have the benefit of a proprietary telemedicine reimbursement rules engine, providing up to date intelligence on reimbursement across all payers.

For those researching telemedicine for their practice, here is a high level checklist for telemedicine reimbursement in California.

Medicare

If you’re billing traditional Medicare, you need to know that Medicare restricts the location of the patient, eligible services, the location of the provider and who can provide services.

Originating Sites:

An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs.

  • Authorized originating sites: The offices of physicians or practitioners; Hospitals; Critical Access Hospitals (CAH); Rural Health Clinics; Federally Qualified Health Centers; Hospital-based or CAH-based Renal Dialysis Centers (including satellites); Skilled Nursing Facilities (SNF); and Community Mental Health Centers (CMHC).
Location of originating site:
  • The originating site must be in a Health Professional Shortage Area (HPSA) as defined by HRSA; OR in a county outside any Metropolitan Statistical Area
  • Here’s a useful tool to determine eligibility for traditional Medicare reimbursement based on location of originating site
Eligible Services:
  • Office or other outpatient visits | CPT codes 99201–99215
  • Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs  |  HCPCS codes G0406–G0408
  • Another resource that details the above and many more services can be found here.
Billing and Payment
  • Providers should bill using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT)
  • Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. You should bill the MAC for the originating site facility fee, which is a separately billable Part B payment (80 percent of the lesser, of the actual charge, or $24.43)
Medi-Cal:

Medi-Cal is California’s state Medicaid program. Here’s what you need to know:

  • Medi-Cal only reimburses for synchronous videoconferencing. Store-and-forward, RPM and telephone care delivery are not reimbursable services through Medi-Cal.
  • Medi-Cal does not limit the patient site or patient geographic location, and it also does not require documenting a barrier to in-person care.

Essentially, providers may provide remote care through videoconferencing to a patient at any location and be reimbursed for that service.

Medicare Advantage

In general, plans administered by commercial payers follow the private payer regulations to follow.

Private Insurance

Section 1374.13 of the California Health & Safety Code mandates that private payers reimburse practitioners for synchronous videoconferencing. However, they are not required to reimburse for any other forms of care delivery, such as RPM or store-and-forward.

This legislation provides a strong foundation for requiring private payer reimbursement in California, however, since telemedicine is an emerging form of care delivery, every payer treats reimbursement differently. Some plans have specific exclusions, some require specific CPT codes or modifiers and others do not.

Chiron Health strips the burden of navigating the complexities of telemedicine reimbursement away from practices. Its proprietary telemedicine insurance rules engine will determine eligibility of every patient for a telemedicine visit. That check takes into account all of the nuance and variability across private payers in California.

Contact a telemedicine consultant to learn more about Chiron Health’s reimbursement guarantee in California.