This phrase, if it does not ring an immediate “bell”, is a nod to the famous reply in the New York Sun from 1897. In response to a question from an inquisitive 8-year-old regarding the existence of Santa Claus, the responding editor replied: “Yes, Virginia, there is a Santa Claus”.

Similarly, I’d like to spread some well-founded hope about the reimbursement for telehealth albeit grounded in more evidence than said editor. To you, I say: “Yes, Virginia, there is Telehealth Imbursement.” (and there will be plenty even after the health crisis is over).

Telehealth Reimbursement, B.C. (Before Covid)

Most organizations and clinicians that have done telehealth in 2020 have done so for the first time this year. Telehealth presented a safe and efficient and oftentimes effective way to care for patients at their home to protect them from the coronavirus and to also protect clinical staff from avoidable exposure.

It is true that Medicare, many Medicaid programs, and the majority of private payors quickly “updated” or changed their reimbursement rules to pay for telehealth. But what was touted in the media as a landslide of changes, actually was built on an ever growing reimbursement for telehealth services.

Before Covid, all 50 states were already paying for video visits under Medicaid. Over the past years, in many states, Medicaid telehealth reimbursement was expanding to allow payment for services in the home, in schools, and to other sites.

What also helped reimbursement, even before any of the emergency legislation was passed, is that the majority of states already had coverage parity. The coverage parity meant that commercial payors had to pay for telehealth visits, if they would have paid for an in-person visit. I.e., reimbursement was independent of the type of service or the service location and based on the usual pre-authorization rules. A few states even passed laws requiring payment parity, thus requiring payors to pay the same reimbursement for telemedicine as for in-person visits.

Medicare Telehealth Reimbursement, B.C.

With regard to Medicare, over 100 CPT codes were reimbursed when delivered via telehealth, already covering a big portion of “traditional” healthcare delivery.

The biggest impediment to growth, however, had been Medicare’s limitations based on statutes from over 20 years ago that limit reimbursement of telehealth services to patients in designated rural counties (about 20% of the population) and for services provided in an approved clinic site (i.e., excludes the home).

Over time, and especially in recent years, CMS even found innovative ways circumventing the limitations established by the 2001 statutes by implementing payment policies for other communication technology-based services such as eVisits, brief check-ins, and RPM.

Emergency Exceptions
Emergency Exceptions

One of the key allowances made in the wake of COVID-19 health crisis was the lifting of the Medicare origination requirements, i.e., the requirement for patients having to be in a designated non-metropolitan county and presenting in a clinic setting such as a rural clinic or nursing home.

Other Medicare additions included additional CPT codes (such as for Physical Therapy), paying for telephonic-only care, expanding the types of providers who could bill for telehealth services, etc.

Other payors (and states with less than stellar telehealth reimbursement rules) soon followed suit and especially reimbursement for telephonic “telehealth” services were utilized a million times over across the country.

But it was mainly the lifting of the 2001 statutes that paved the way for a very broad adoption of telehealth, given that about only 20% of the Medicare population lives in counties designated as “non-metropolitan”.

Before and After

As I laid above, though, even “before covid”, reimbursement was already pretty good for commercial payors and Medicaid patients. The problem for a wider adoption of telehealth was not finding a suitable, financially sustainable business model – it was more of a common resistance to the adoption of telehealth, not the reimbursement limitations.

Therefore I’m surprised to hear repeatedly that providers are “wondering” whether they could keep offering telehealth services due to the “ambiguity” of many emergency exceptions being put back in place. Granted, that’s true for Medicare, but for commercial payors and Medicaid, the reimbursement was already acceptable in many areas.

From my vantage point, I would not mind if the widespread use of telephonic-only care delivery would be limited once again. What I am hopeful about though, is that the ridiculous limitations for Medicare recipients to receive care at home (the statutes from 2001) will stay lifted for good. Because in my experience, it is especially those patients in rural counties (but still belonging to a metropolitan area) that have transportation and care access issues would benefit the most from having access to care via telehealth.

And that’s a future I’m looking forward to!

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Christian Milaster optimizes Telehealth Services for health systems and physician practices as Interim Telehealth Program Director. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.

Contact Christian by phone or text at 657-464-3648, via email, or video chat.

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