Private payer reimbursement for telemedicine

Parity laws

Currently, 37 states have telehealth parity laws that require private insurance companies to reimburse providers for care delivered remotely via telemedicine. Additionally, 2 states have proposed or pending parity laws.

Patient location

In most states, these parity laws prevent health plans from withholding reimbursement for telehealth services based on a patient’s location. This means that patients can do telehealth appointments from their home or office, and don’t need to travel to a qualified originating site (a cumbersome requirement for Medicare reimbursement).

Reimbursable services

All states with parity laws mandate private payer reimbursement for real-time videoconferencing, while only some states require reimbursement for store-and-forward telemedicine. To determine if a state reimburses for both services, review the state’s definition of both telemedicine and telehealth. Certain legislation will define “telehealth” or “telemedicine” as services provided in “real-time,” thereby excluding store-and-forward.

Eligible providers

Each state determines which licensed professionals may practice telemedicine – this is often determined by the state medical board. For reimbursement purposes, the general rule is any provider that can bill for an in-office visit can also bill for remote telemedicine encounters.

Reimbursement levels

The amount providers are reimbursed for telemedicine will vary depending on a state’s legislation. Some states specifically mandate that private payers reimburse the same amount for telemedicine as if the service was provided in-person. However, most states with reimbursement mandates leave this determination up to the payers. We have found the majority of private payers still reimburse at levels equivalent to in-person visits.

Exceptions

Many state reimbursement mandates do have exceptions for certain types of insurance plans. For example, small group plans and worker’s comp plans sometimes have the option to opt out of telemedicine coverage. It simply depends on the state’s legislation and the specific insurance plan.

Billing for telemedicine with private payers is slightly different than billing for telemedicine with Medicare or Medicaid. The Centers for Medicare and Medicaid Services (CMS) requires that practitioners use a GT modifier code (or a GQ modifier code in Alaska and Hawaii). However, state legislation does not necessarily require the use of modifier codes when billing for telemedicine.

Given that billing requirements for private payers are constantly changing, it’s important to select a telemedicine service that provides insurance eligibility checks specially for telemedicine reimbursement. Visit our telemedicine software page to learn how we do it.