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Why Private Payer Reimbursement for Telemedicine Isn’t as Hard as You Think

Every day telemedicine receives more and more attention from the media. From the amount of buzz the topic generates, you’d think that most physicians in the US have already implemented a telemedicine solution. The reality is that the adoption of video-based telemedicine is still modest among physician practices. Video visits are convenient for patients and even more efficient for practices than in-person appointments, but still, adoption has remained fairly low. But why do so few practices use telemedicine? The root of this trend (or anti-trend) centers around regulatory complexities and challenging rules associated with private payer reimbursement for telemedicine.

This in spite of the fact that in about 30 states, private insurers are required to cover telemedicine appointments, in many cases at the same rates as in-person services. However, it comes as no surprise that payers have been slow to recognize this legislation, and even slower to put formal policies in place around telemedicine reimbursement. The variation between states, payers, and even specific plans is simply too complex for an average practice to handle on their own.

An interesting case study that illustrates the complexity of private payer reimbursement is the telemedicine law in Texas that has garnered attention from national media including articles in the New York Times.

At first glance, the legislation in Texas appears straight forward – “A health benefit plan may not exclude a telemedicine medical service or a telehealth service from coverage under the plan solely provided through a face-to-face consultation.”

However, the law is much more nuanced than it appears. Even more nuanced is the variation from payer to payer on how they treat telemedicine reimbursement.
First, there is a long list of exceptions to the mandate. For example, certain small employer plans are exempt. Further, some plans in Texas have specific exceptions for telemedicine. Often the only accurate way to determine if a plan specifically excludes telemedicine is to call the payer directly.

Some payers require a modifier code in addition to the appropriate CPT code in order to pay a telemedicine claim; but some payers only require modifiers only for certain types of appointments – for example a visit linking a provider with a patient at a remote healthcare facility. Since telemedicine is just now emerging as a prevalent standard of care, many payers do not have clearly defined policies. It’s impractical for practices to take on this complexity with their own staff.

Chiron Health built a robust insurance rules database specifically designed to streamline the process of telemedicine reimbursement. This database powers a proprietary telemedicine insurance rules engine, which automates the process in a scalable way. Armed with this intelligence, Chiron Health clients find it easy to be reimbursed via private insurance in states that mandate coverage – or Chiron will pay the claim themselves.

To learn more about private payer reimbursement in your state, and the Chiron Health Reimbursement guarantee, contact one of our knowledgeable consultants today.