Telehealth Reimbursement Continues to Evolve
The sudden growth of telehealth “will upend financial dynamics across the healthcare continuum,” predicts Anton Arbatov, MHA, FACHE.
Ultimately, patient visits probably will generate less revenue for hospitals. That is because telehealth generally is reimbursed at a lower rate than in-person care, and with more restrictions on what is covered.
“Telehealth will likely reduce the frequency of emergency department visits and reduce revenue from procedural billing,” says Arbatov, vice president of revenue cycle management and compliance at SOC Telemed, a Reston, VA-based provider of acute care telemedicine services.
For patients, coverage limitations for telehealth mean high out-of-pocket costs. “This will also impact provider revenue due to historically low patient payment collection rates,” Arbatov says.
For the field of patient access, the telehealth boom carries some broader implications. “As more patients become familiar with using telehealth, they are demonstrating a desire for additional digital interactions with providers,” says Bill Krause, vice president of connected consumer health at Nashville, TN-based Change Healthcare.
After receiving virtual care for the first time, people are going to expect more of the same. They will be looking for self-serve scheduling, registration, check-in, and payment, according to Kraus. “Creating a more retail-style digital experience for consumers will help hospitals compete with nontraditional providers,” he says. Those include urgent care centers and clinics located in retail stores. “Care is moving to the lowest-cost setting,” Kraus adds. “Telehealth is just one more competitor in this arena.”
There are two main questions for revenue cycle departments: Are health plans going to pay for virtual visits? If so, how much? “As telehealth expands its scope of services, reimbursement policy will continue to struggle to keep pace,” Arbatov observes.
Patient access departments can maximize telehealth reimbursement in these ways:
• Keep up with federal, state, and payer policies. “For example, consent laws are state-specific,” Arbatov notes.
In most states, the standard consent form obtained during registration is adequate for telehealth. In other states, telehealth-specific consent is required at the point of care. “Pay close attention to evolving policy,” Arbatov cautions.
• Ensure telehealth services meet billing compliance requirements. For instance, in consultative services, providers at the originating site must document the order for a telehealth consultation. “At the distant site, providers must document the duration of the encounter, among other elements,” Arbatov explains.
• Work with health plans to understand eligible billing codes and required modifiers. “Ensure that these codes are part of contracted fee schedules,” Arbatov stresses. For the duration of the national emergency declaration, the Centers for Medicare & Medicaid Services (CMS) made more than 80 new CPT codes eligible for telehealth reimbursement.1 “However, that does not mean that all payers followed suit,” Arbatov says. For example, emergency department (ED) visits are now eligible telehealth codes for Medicare. Yet not all commercial health plans are paying for telehealth ED visits.
• Obtain specifics from health plans on how long telehealth reimbursement will continue. “Uncertainty, coupled with chaotic policy changes, creates risk,” Arbatov says. To avoid lost revenue, patient access leadership must press health plans for specific time frames. Expecting frontline staff to keep track of it is not realistic. “It is up to the providers to ensure that appropriate eligibility-filtering workflows are in place to avoid denied claims,” Arbatov says.
Many registrars never handled a single telehealth appointment before the pandemic. Other hospitals already had some experience with it. “The places that have done best with telemedicine are those who were doing it in some way in the past and could rapidly bring it up,” says Lorraine Possanza, DPM, JD, MBE, program director of ECRI Institute Partnership for Health IT Patient Safety. Logistically, the switch to telehealth generally is simpler for everybody. When it comes to reimbursement, the situation is a bit more complex. “Everybody has a mistaken impression that it’s so much easier, and that it is possible to rapidly get patients in and out. But there are many things that have to be done to complete the visit,” Possanza says.
None of the waived requirements from the federal government, states, and commercial health plans are permanent or foolproof. All come with limitations. “Those kinds of things are going to be important moving forward, or people aren’t going to get paid for care,” Possanza says. For each payer, these specifics are needed: Who can provide the care? What type of care is covered? What type of technology is acceptable? Does there need to be a video component in the visit? Does a secure application need to be used, or is FaceTime OK?
Nailing down these details could determine if hospitals end up with much-needed revenue or mountains of bad debt. “This is something to be mindful of, moving forward,” Possanza says.
- CMS.gov. Covered telehealth services for PHE for COVID-19 pandemic, effective March 1, 2020. Updated April 30, 2020.
For patient access, the telehealth boom carries some broad implications. As more patients become familiar with using telehealth, they are demonstrating a desire for additional digital interactions with providers.
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