Telehealth Reimbursement

How do telehealth services work?

Telehealth services revolutionize healthcare delivery by allowing medical care, health education, and public health services to be accessed remotely via telecommunications technology. This care delivery method typically involves a range of communication technology-based services, such as video conferencing, mobile health apps, "store-and-forward" technology, and remote patient monitoring. Telehealth enables healthcare providers to conduct patient consultations through video calls and offer diagnosis and tracking without the patient needing to travel and manage prescriptions online.

The process usually begins with scheduling an appointment, similar to in-person visits. Once scheduled, the patient will receive a link to a secure platform for the consultation. During the appointment, practitioners can review medical history, discuss symptoms, assess the patient visually, and provide a diagnosis and treatment plan. This can include prescribing medications, recommending follow-up care, or referring to specialists.

Telehealth not only increases accessibility to healthcare services but also enhances patient engagement and continuity of care by bridging geographical and mobility gaps.

Different types of telehealth services

Building on the foundational understanding of how telehealth services function, it's essential to recognize the various types that cater to different healthcare needs and preferences. Telehealth can be broadly categorized into four main types:

• Live video conferencing: This synchronous form of telehealth allows real-time interaction between the patient and healthcare provider. It is commonly used for consultations, follow-up visits, and initial assessments where a face-to-face interaction is necessary but not feasible physically.
• Store-and-forward: Unlike live video, this asynchronous telehealth service involves transmitting recorded health information (such as radiographs, photos, video, and bio-signals) to a healthcare provider at a convenient time. It is beneficial in specialties like dermatology, radiology, and pathology, where physical examination through live interaction is not required.
• Remote patient monitoring (RPM): RPM enables healthcare providers to monitor patients remotely using various technological devices. This method is beneficial for managing chronic conditions, post-operation recovery, and primary care, enhancing personalized care plans.
• Mobile health: Utilizing mobile devices such as smartphones and tablets, mHealth applications empower patients to manage their health more actively. They include medication reminders, fitness tracking apps, and direct communication with healthcare providers.

These diverse telehealth services offer flexible, accessible, and efficient healthcare solutions, helping to cater to patients' individual needs while maintaining high standards of healthcare throughout.

Telehealth Reimbursement guidelines

Understanding the specific reimbursement guidelines is crucial for healthcare providers as telehealth services expand. These guidelines vary significantly across different payers, including federal programs like Medicare, state-dependent Medicaid plans, and private insurers, each with its own rules and coverage options.

Medicare

Following the extensions granted by the Consolidated Appropriations Act of 2023 (GovInfo, 2022), Medicare has significantly enhanced telehealth access, effective through December 31, 2024. This expansion includes the removal of geographic restrictions, allowing Medicare beneficiaries to receive telehealth services regardless of their location. Now, any healthcare provider who can bill Medicare, including Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), is authorized to provide and bill for telehealth services. This broadened provider eligibility is crucial for increasing patient access to care.

Medicare now covers a comprehensive list of services delivered via telehealth, which includes but is not limited to office visits, psychotherapy, and consultations. Providers must use specific billing modifiers, such as GT or 95, to denote a service delivered via a telehealth program. Additionally, they need to employ the correct Place of Service (POS) codes:

• POS 02 for telehealth services not delivered in the patient's home
• POS 10 for services delivered in the patient's home. The accurate application of these codes and modifiers is vital for securing appropriate reimbursement.

For a complete list of covered services and more detailed billing instructions for eligible services, providers should consult the latest updates on the CMS website.

Medicaid

Each state sets its own Medicaid telehealth reimbursement policies, creating a patchwork of guidelines for providers. As of January 2024, all states, including the District of Columbia, had mandated payment and coverage parity for Medicaid telehealth services, mirroring in-person service reimbursement. However, the extent of covered services, eligible providers, and allowable technology platforms can differ significantly between states (Centers for Medicare & Medicaid Services, 2023).

Providers must familiarize themselves with their state’s Medicaid rules to understand which services are reimbursable under telehealth provisions and any pertinent billing procedures. Depending on the state's telehealth policy, this might include synchronous video calls, asynchronous store-and-forward services, or remote patient monitoring.

It is also essential for healthcare providers to stay informed about any state-specific changes that could affect billing, such as updates during public health emergencies or regulatory revisions.

Private practices

In the private insurance sector, telehealth coverage is also subject to variability depending on the insurer and the state regulation. While many private insurers have followed federal leads in expanding telehealth coverage, especially in response to the COVID-19 pandemic, the details regarding covered services and billing requirements can vary widely.

Providers should proactively communicate with each insurance carrier to clarify the specific telehealth services covered, any special billing codes or modifiers required, and the reimbursement rates for telehealth versus in-person services. This direct engagement helps prevent billing errors and ensures that providers can maximize reimbursement opportunities while adhering to insurer-specific guidelines.

For healthcare providers, staying updated with the continuously evolving landscape of telehealth reimbursement is essential. This ensures compliance with current regulations and maximizes reimbursement opportunities, thereby supporting the sustained integration of telehealth into regular healthcare practice.

How to be eligible for Telehealth Reimbursement

Gaining eligibility for telehealth reimbursement involves understanding and adhering to specific criteria laid out by various reimbursement entities such as Medicare, Medicaid, and private insurers. Here are the general steps and requirements providers must follow to ensure they meet the eligibility criteria for telehealth reimbursement.

1. Provider qualifications

First, healthcare providers must be eligible to bill the respective insurance entity, whether Medicare, Medicaid, or a private insurer. This typically means the provider must be licensed in the state where the patient is receiving services and must be enrolled as a provider with the payer.

For Medicare, this includes doctors, nurse practitioners, physician assistants, and certain other healthcare providers, including FQHCs and RHCs, as authorized under recent legislation.

2. Service type and delivery method

The type of telehealth services offered must fall within the scope of the fee for service deemed reimbursable by the payer. Commonly covered services include consultations, mental health counseling, and chronic disease monitoring. The delivery method—whether synchronous (real-time audio and video) or asynchronous (store-and-forward technology)—must also align with what is covered.

For example, Medicare typically reimburses for live video interactions but has specific stipulations about asynchronous services, mainly limited to certain regions like Alaska and Hawaii.

3. Technology and privacy compliance

Providers must use telecommunication systems that comply with HIPAA requirements to ensure the privacy and security of patient data. The technology used should provide a clear, real-time audio and video connection if required by the hospital or payer’s policy. Additionally, any digital communication tools employed for asynchronous services should meet federal and state standards for data security.

4. Coding and billing compliance

Correct coding is crucial for telehealth reimbursement. Providers must use appropriate CPT/HCPCS codes, modifiers, and place of service codes. For Medicare, this includes using POS 02 for telehealth services provided outside the patient's home and POS 10 when services are rendered in the patient's home.

Accurate documentation and adherence to coding guidelines prevent delays in reimbursement and potential audits.

5. State-specific Medicaid policies

Since the states administer Medicaid, providers must know their state’s specific telehealth policies. This includes understanding which services are covered by connected health policy, unique billing procedures, and eligibility criteria for patients and providers within the state.

By meeting these criteria, healthcare providers can establish eligibility for telehealth reimbursement, ensuring they can continue providing accessible, high-quality healthcare services remotely while maintaining financial viability.

Tips on how to reimburse for telehealth

Navigating the complexities of telehealth reimbursement requires precise attention to several key areas to ensure services are appropriately compensated. Here are some essential tips to help healthcare providers optimize their reimbursement processes for telehealth services:

1. Stay updated on reimbursement policies

Regularly check for updates in telehealth reimbursement policies from Medicare, Medicaid, and private insurers. Policies can change frequently, mainly as temporary measures introduced during the COVID-19 pandemic are evaluated for permanence. Keeping abreast of these changes ensures that providers always comply with the latest guidelines and can adapt their billing practices accordingly.

2. Understand and use correct coding

Proper coding is crucial for telehealth reimbursement. Providers must familiarize themselves with the specific CPT, HCPCS codes, and modifiers applicable to telehealth services. For example, Medicare requires POS code 02 for telehealth services rendered outside the patient’s home and POS 10 for services provided in the patient's home.

Additionally, understanding which services are eligible for audio-only telehealth and which require interactive audio or video can impact how services are coded and billed.

3. Document thoroughly

Ensure that all telehealth sessions are documented with the same level of detail as in-person visits. Documentation should include the duration of the visit, the technology used, the nature of the service provided, and patient consent for the telehealth encounter. Thorough documentation supports billing claims and is crucial in the case of audits.

4. Verify patient eligibility and coverage

Before providing telehealth services, verify the patient’s eligibility and coverage for telehealth under their specific health plan. This includes checking whether the patient’s insurance covers the particular type of telehealth service provided and any applicable co-payments or deductibles.

5. Utilize technology that complies with regulatory standards

Employ telehealth platforms and technologies that comply with HIPAA and other relevant privacy and security regulations to protect patient information. Using non-compliant technology can lead to denied claims or potential legal issues.

6. Engage in continuous education

Participate in webinars, workshops, and training sessions offered by professional associations, payer organizations, or legal experts specializing in telehealth. These educational resources and professional services can provide valuable insights into best billing and coding practices and updates on regulatory changes.

7. Seek expert advice when needed

Consider consulting with a healthcare attorney or billing specialist with telehealth expertise. These professionals can offer guidance management services tailored to your practice and help you navigate complex reimbursement scenarios.

By following these tips, healthcare providers can enhance their proficiency in telehealth billing, reduce the likelihood of claim rejections, and ensure they are compensated fairly for their remote services. This supports the practice's financial health and promotes the sustainability of telehealth as a valuable mode of delivering patient care.

For a deeper dive into patient billing, explore our Ultimate Guide to Patient Billing.

Why use Carepatron as your telehealth software?

Carepatron stands out as a premier telehealth software designed to streamline the seamless management of healthcare services. It offers a robust platform integrating advanced telehealth functionalities with easy-to-use features, enhancing provider efficiency and patient satisfaction. With Carepatron, healthcare providers can access video consultations, appointment scheduling, and automated reminder tools within a secure, HIPAA-compliant environment. This protects patient information while facilitating smooth and practical virtual care sessions.

Choosing Carepatron for your telehealth needs also means gaining access to exceptional support and continuous updates that keep your practice ahead in a rapidly evolving digital healthcare landscape. Whether you want to expand your telehealth offerings or optimize current practices, Carepatron provides the necessary tools to enhance your operations and improve patient outcomes.

Ready to elevate your telehealth capabilities? Try Carepatron today and experience the difference in streamlined healthcare delivery.

References

Centers for Medicare & Medicaid Services. (2023). Medicare and medicaid programs; CY 2024 payment policies under the physician fee schedule and other changes to part B payment and coverage policies; medicare shared savings program requirements; medicare advantage; medicare and medicaid provider and supplier enrollment policies; and basic health program. Federal Register. https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other

GovInfo. (2022). H.R. 2617 (ENR) - Consolidated Appropriations Act, 2023. https://www.govinfo.gov/app/details/BILLS-117hr2617enr/summary