The national Medicare Chronic Care Management Program (CCM), which went into effect January 1, 2015, reimburses for telemedicine services provided by licensed professionals to patients with two or more chronic conditions. It is the first time the national government has made an exception to the originating site rule rule which mandates medicare patients must live in rural and physician shortage areas. Visit our Medicare Chronic Care Management page to learn more about incorporating it into your care delivery.
With the exceptions of services provided through the Medicare CCM program, videoconferencing is the only service that is reimbursable through Medicare. Store-and-forward technologies, such as email, will not be reimbursed by Medicare unless delivered to patients through the Medicare CCM program.
CMS currently decides to approve a submitted Current Procedural Terminology (CPT) code based on the type of service that was provided over telehealth. There are certain services for which they will reimburse and others for which they will not. Essentially, Medicare attempts to determine two things:
In addition to limiting services and methods of telemedicine care delivery, Medicare has several other requirements that patients and providers must meet in order to be reimbursed through Medicare for telemedicine. To learn more about these specific requirements, visit our Medicare reimbursement page.
Currently, 30 states have parity laws that mandate private payer reimbursement for telemedicine services. Typically, these mandates only cover real-time videoconferencing, but there are few states that cover store-and-forward technology. Visit our private payer reimbursement page to learn more about the patient and provider requirements that determine reimbursement. Additionally, the Center for Connected Health Policy provides in-depth information on legislation for both public and private healthcare programs and is a fantastic resource for those looking to dive deep into individual state policy.
CCHP’s most recent fifty-state survey of state telehealth laws and Medicaid program policies was completed in August 2016. The full PDF report is available, as is an interactive map of existing and pending telehealth-related policies by state. Below are some key findings:
Only those practitioners who are allowed to provide telemedicine care as outlined in the state legislation will be reimbursed for these services.
Currently, 48 states have some form of reimbursement legislation outline in their public healthcare program. The two states that contain absolutely no mention of telemedicine or telehealth in their public program are and Rhode Island.
Each state’s public program determines the services that may or may not qualify as reimbursable. For example, one public program may reimburse for store-and-forward while another state’s program may only reimburse for videoconferencing.
Per state telemedicine reimbursement through the public program is extremely nuanced. Programs may place certain patient location requirements, specifically prohibiting reimbursement for services provided to a patient who is not at an established medical site when receiving telemedicine care. They may require practitioners to document that a patient has a barrier to receiving in-person care in order to receive reimbursement for delivery remote care.
Although each state may define telehealth separately, the federalHealth Resources and Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”
Although most states define telemedicine slightly differently through their own legislation, most agree any use of technology for the purpose of delivering healthcare qualifies as such. What began as hub-and-spoke models linking disparate hospitals in rural areas has become a ubiquitous tool for follow-up care.
Store-and-forward services differ from live video because they are not real-time. Store-and-forward is defined on a per state basis, but it is broadly defined as the electronic exchange of medical information through secure email communications. It can include imaging data, videos, photos or other patient information.
The most commonly reimbursed form of telemedicine is videoconferencing. In order to qualify as “live video” across all states, real-time video and audio must be present, and the quality must be similar to that of an in-person encounter.
Remote patient monitoring refers to monitoring a patient’s physical state outside of the conventional office setting. It most often involves technology that records physiological data that is then sent to a provider through wireless communication at a distant site.
The distant site is a term used by CMS to refer to the location where a practitioner is providing care to a patient at another location. Aside form physician reimbursement, facility fees most now be reimbursed by both federal and private payers.
CMS uses the term “originating site” when referring to the location of a patient who is receiving telemedicine care. Both Medicare and Medicaid place restrictions on the originating site when determining whether the encounter is eligible for reimbursement.
The American Medical Association defines an established medical site as a patient-location that has an on-duty medical professional. Oftentimes, Medicaid will require patients to be at an established medical site in order for practitioners to qualify for reimbursement of telemedicine services.