One of the big advantages of telemedicine for healthcare providers, especially for small and solo practices is that it is a great way to boost practice revenue. The approach allows you to see more patients per day, and even to add weekend or evening appointments. Of course, your telemedicine program won’t boost your bottom line unless you are reimbursed for each visit. The answer to the simple question, “Will payers cover video visits,” is not so simple. Getting compensated is possible, but there are a few things you need to know.
Most states have laws regarding reimbursement for telemedicine
State legislatures across the country have come to recognize the value of telemedicine for improving the quality of care and expanding patient access to providers. That’s why more than 38 states have passed some form of legislation requiring . Many states have so-called “parity” laws that require compensation that is the same as that for an in-office visit. Each state has different requirements, with some covering store-and-forward type telehealth, and others requiring the use of live video.
Some insurers offer reimbursement even when they don’t have to
Why would an insurance company cover a service if the law doesn’t require it? Because they’ve learned that telehealth improves patient outcomes, reduces hospital readmissions, and simplifies the treatment of chronic conditions. UnitedHealthCare, for example, is happy to pay out claims across the US for video visits for its more than 21 million members on
Your telemedicine platform should validate eligibility and guarantee reimbursement
Because the rules vary from state to state and payer to payer, it can be a challenge for a practice to determine which patients are eligible for reimbursement for telemedicine visits and which should be seen in person. That’s why most modern telemedicine platforms for practices have a built-in rules engine and eligibility verification algorithm. When a video visit is scheduled, the system pulls in the necessary patient information from your EHR and checks eligibility. The best solutions even offer a reimbursement guarantee. If the claim is denied, they will work on your behalf with the payer to be sure it is covered. If it ultimately isn’t, they’ll reimburse you themselves. With a reimbursement guarantee, you can be confident that you’ll be paid for every video encounter you perform.
Medicaid plans vary by state
Each state is responsible for administering its own Medicaid programs, and therefore, coverage for telehealth for Medicaid patients varies. However, the trend is clearly moving toward covering this type of care. Last year, for example, Delaware, Colorado, Maryland, Michigan, Minnesota, Missouri, New York, Texas, Washington, and Wyoming moved to allow reimbursement for visits that occur when the patient is at home, rather than a designated medical facility. This variation and changing landscape make edibility verification even more essential.
Medicare – It’s complicated
Generally, Medicare only covers video visits under a spoke-and-hub model. That means that the patient must go to a designated healthcare site, like a physician’s office or hospital, where they meet with a healthcare provider who initiates a remote visit with a provider at another location. This is a good solution for bringing in specialists, but not ideally flexible.
There are a couple of exceptions to the spoke-and-hub requirement. One is for patients located in what is referred to as a Health Professional Shortage Area (HPSA) outside of a Metropolitan Statistical Area (MSA) or; those in a rural census
The other exception is something called the Medicare Chronic Care Management Program (CMC). This is a national policy that eliminates the originating site restrictions on the practice of telemedicine. The program was adopted to help practitioners better provide monthly care to patients with two or more chronic conditions through telehealth services. Patients can be located anywhere, even in the middle of a metropolitan city, and they may receive services from any facility, including their home or office. This creates an opportunity for practices to generate additional revenue and provide enhanced care to people suffering from multiple chronic conditions.
Although the current situation regarding reimbursement for telemedicine, there are three pieces of good news. First, it is possible in almost every state to be reimbursed for video visits under some circumstances. Next, if you select the right technology platform for telemedicine, you will be able to verify eligibility for each visit. Finally, all of the trends are pointing in the direction of simplifying the rules around telemedicine and expanding its use. The benefits for providers, patients, payers, and the healthcare system as a whole are just too great to disregard.