Doc bills for patient portal messages are a rare occurrence

Patient portal messages represent just a drop in the bucket of overall evaluation and management (E&M) services, according to new Michigan Medicine data, findings that may help temper industry anxieties about the increased workload these messages can cause.

Indeed, during the height of the pandemic, patient portal messages represented just around 1 percent of all E&M billing codes for Medicare, according to the study published in Health Affairs Scholar. By 2021, patient portal messaging plateaued, representing just 0.05 percent of all E&M billing codes.

Patient portal messaging has been at the center of healthcare’s digital patient engagement strategy for some time. While the patient portal gives users a look into their medical records and other health data, the secure direct messaging function serves as a lifeline for patients trying to get in touch with their doctors between visits.

As the pandemic accelerated healthcare’s digital transformation, industry leaders had to grapple with an unintended consequence of the patient portal: answering those messages takes time for clinicians when they’re already hard-pressed for it.

In 2020, Medicare created an E&M code allowing healthcare providers to bill for the time it took them to answer a patient portal message when it took them at least five minutes to do so.

Those charges for patient portal messages have gained moderate media attention, with some experts fearing the charges would trickle down to patients and discourage them from connecting with their providers.

This latest data provides some insights into billed patient portal messages, potentially putting some of those fears to rest.

Overall, billing codes for patient portal messages are a drop in the bucket of all E&M codes, the team said after assessing codes from between January 2020 and December 2022.

Billed patient portal messages were more common during the onset of the pandemic when providers fielded 728 monthly messages per 100,000 Medicare beneficiaries. During this time, patient portal messages represented 0.9 percent of E&M codes.

Patient portal messaging volumes leveled out after that first COVID-19 peak to 90 monthly messages per 100,000 beneficiaries. Patient portal messaging codes represented 0.05 percent of E&M services in 2021 and 2022.

“These 2 findings can help alleviate concerns regarding the potential 3 overuse of portal message and e-visit billing,” the researchers said in the study’s discussion section.

Still, it would be prudent to examine how patient portal messaging affects workflows for primary care providers seeing as 50 percent of all patient portal messaging codes were from PCPs and 30 percent were billed at the highest level of clinician time (at least 21 minutes).

“Patient portal messages can be a great tool for chronic disease management, which is the bread and butter of primary care,” Terrence Liu, MD, lead study author, National Clinician Scholar at U-M’s Institute for Healthcare Policy and Innovation, and clinical instructor in internal medicine at U-M, said in a statement.

“For example, if we’re adjusting medication doses in response to a patient’s log of their self-measured blood pressure or blood sugar trends, we don’t necessarily need an in-person or virtual visit for that specific issue,” added Liu. “Patients don’t have to wait on the phone to schedule an appointment, and then wait for the appointment. We need to match the type of question to the right modality for clinical care.”

Triage could be helpful in this area. Healthcare organizations could appoint a nurse manager to field and answer questions or triage them to healthcare providers when their expertise is necessary. Some organizations are also looking into how generative AI could help triage patient portal messages.

Of note, patients aren’t really footing the bill for patient portal messages, at least as of right now. The U-M data showed that 0.8 percent of patients were billed for at least one e-visit.

In March 2024, the Peterson-KFF Health System Tracker reported that 82 percent of patients for whom their portal message was billed saw their healthcare payer cover the total cost of the bill. Said otherwise, 82 percent of patients saw a $0 bill for a patient portal message.

When patients did carry financial responsibility for a patient portal message, the bill was $25.

Liu indicated that understanding the patient financial responsibility for patient portal messages, plus other implications for increased use of the patient portal, are key areas for future research.

“We need to understand more about how this type of care can be most effectively used by both patients and providers, and what it means for clinic operations, provider burnout and patient behavior and outcomes,” Liu noted.

“Patient portal messages are being used as a routine form of telehealth, but there is very little research to date on it. We hope these data will help inform efforts to support providers as they handle these types of visits.”