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Telemedicine Reimbursement by Public Payers

telemedicine reimbursement for medicareWe’re not going to lie. At this time there is really nothing simple about providers getting reimbursed for clinical visits conducted via telemedicine. (That’s why we had to invent sophisticated software to help make sure providers get paid.) The private payer landscape is tricky mostly due to inconsistant and changing state laws and payer policies. Medicare complicates the approach with regulations that limit which visits count for reimbursement. There is also a new Chronic Care Management program that differs from standard Medicare practices. Let’s have a look at the details.

Standard Medicare

Ok, “standard Medicare” isn’t really a thing, but we’re calling it that to differentiate it from the Chronic Care Management Program (CCM), which will talk about in a minute. This section refers to patients who are not part of the CCM program.

Geographic Requirements

Medicare’s coverage of video visits targets people in remote and rural areas. Patients must reside in a Health Professional Shortage Area (HPSA) outside of a metropolitan area, or in a rural census tract or a county that is outside of a Metropolitan Statistical Area.

Originating Site Requirements

In addition to the general geography limitations, Medicare also restricts the specific places where patients must go for video visits. Mediare will not reimburse providers who treat patients remotely from their home or office even if the patient lives in an eligible county. The patient must be at one of the following types of facilities:

  • Provider office
  • Hospital
  • Critical access hospital
  • Rural health clinic
  • Federally qualified health center
  • Skilled nursing facility
  • Community mental health center
  • Hospital-based or critical access hospital-based renal dialysis center

The provider, on the other hand, can be anywhere.

Additional Requirements

The type of service guides Medicare reimbursement decisions based on the Current Procedural Terminology (CPT) code. Some codes are eligible for reimbursement, while others are not. (Here is a list of eligible codes.)

Chronic Care Management (CCM) Program

The Chronic Care Management Program is designed to compensate healthcare providers who coordinate the care of people who have two or more chronic conditions. It does not contain the geographical limitations of standard Medicare. Even patients in large metropolitan areas can enroll. Providers earn $42 per month for these services. Payments received under CCM do not impact reimbursement for other types of services. However, in order to claim reimbursement providers must spend at least 20 minutes per month in non-face-to-face care of eligible patients.

The most difficult obstacle to reimbursement under the program is the documentation of the 20 minutes or more spent by staff providing non-face-to-face care. Telemedicine encounters are the ideal approach for providing and accounting for the service. In this case, there is no originating site requirement. The patient can be anywhere.

Some providers harbor the false believe that Medicare doesn’t pay for telehealth. While there are limits on reimbursement for many patients because of location and facility type, the CCM program represents a significant revenue opportunity for participating practices.