COVID-19 Spotlights 3 Payer Telehealth Expansion Challenges

Coverage for different sites of telehealth care

Covering telehealth services conducted at locations other than the typical care sites, including a patient’s home and rural healthcare facilities, can yield some challenges.

In an effort to keep patients in their homes, remote patient monitoring utilization saw an uptick. As a result, federal and state regulators have had to contend with how to reimburse for services delivered to a patient in his home from a provider who is in her own home.

In April 2020, CMS paved the way toward coverage for home healthcare as a viable site for telehealth reimbursement.

“Providers can bill for telehealth visits at the same rate as in-person visits,” CMS said. “Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth. New as well as established patients now may stay at home and have a telehealth visit with their provider.”

The agency also deemed that Medicare payers should cover virtual care conducted while the patient is in her own home as fulfilling the face-to-face requirement that attends many conditions requiring inpatient rehabilitation, hospice, and home healthcare.

Telehealth coverage for rural healthcare sites, such as rural health clinics, has improved as a result of the coronavirus pandemic. CMS has already finalized telehealth expansion for rural areas in Medicare Advantage by relaxing requirements for how many patients must live within a certain geographic range to qualify for Medicare Advantage plan.

By increasing the number of patients that can participate in Medicare Advantage, CMS also opened a door for these patients to have greater access to telehealth care under such plans.

Coverage for different telehealth technologies

Determining coverage for the many different forms of telehealth has also been a challenge.

During the coronavirus pandemic and even now as states reopen, many have been demanding more widespread coverage for audio-only services, specifically for Medicare Advantage plans. While many health plans covered the cost for audio-visual telehealth services—such as video calls— fewer plans were covering telehealth encounters in which the providers solely interacted with the patient via a phone call and never saw the patient’s face. Plans cannot submit hierarchical condition category (HCC) coding for reimbursement for these visits.

“Prior to COVID-19, the rule was that an HCC code or diagnosis could only be entered on a patient encounter or face-to-face visit. During the crisis, it has been liberalized to include tele-video,” Steven Green, MD, chief medical officer Sharp Rees-Stealy Medical Group (SRSMG) told HealthPayerIntelligence. “But it’s been a problem for us that is not allowing us to get credit for HCC codes that we entered during an audio-only visit.”

Green said that this incentivizes providers to have senior patients come into the office in order to receive Medicare Advantage reimbursement, which still may not be advisable even as many restrictions lift.

State and federal regulations and waivers

Since both public and private payer coverage relies on state and federal regulation to set the coverage requirements, one of the main challenges overarching both site of care and tool-specific coverage is answering the question: what will the state and federal governments allow?

States largely set the standards for reimbursement and licensure in telehealth for private payers. This leads to a lot of variety within telehealth guidelines for payers to consider.

As of October 2019, a few months ahead of the coronavirus outbreak in the US, 42 of the 50 states and Washington, D.C. had a private payer telehealth statute, according to a 50-state survey by Foley & Lardner LLP. That being said, four of the states that do have statutes do not mandate that payers cover telehealth.

These statutes could include a coverage provision, a reimbursement provision, patient origin or site-of-care restrictions, member cost-shifting protections, size of provider network guidelines, remote patient monitoring coverage requirements, or store and forward telehealth coverage.

Payers will have to move their telehealth strategies forward in step with state and federal policymakers. Fortunately for them, CMS has demonstrated a willingness to make many of the telehealth coronavirus-era flexibilities permanent.

“I can’t imagine going back,” CMS Administrator Seema Verma told STAT at a virtual event as reported by the Upper Midwest Telehealth Resource Center. “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.”

On the state level, she called out the need for states to reconsider licensure restrictions, while federally she said that Congress should permanently expand telemedicine coverage.