Telehealth Reimbursement Just for Value-Based Providers Post-COVID?

The Medicare Payment Advisory Commission (MedPAC) is the latest group to weigh telehealth reimbursement expansions after the COVID-19 pandemic.

In a meeting held virtually last week, MedPAC analysts Ariel Winter and Ledia Tabor floated some policy ideas for keeping telehealth coverage and reimbursement expansions after the pandemic now that providers across the country are robustly leveraging telephonic and virtual services to prevent the spread of the virus.

One of their ideas was to allow clinicians participating in Advanced Alternative Payment Models (A-APMs) to continuing providing telehealth services to patients outside of rural areas and to patients in their homes.

Under this policy option, clinicians in A-APMs that include financial risk for total Medicare spending and quality of care would be able to leverage most telehealth expansions, including higher payment rates for telehealth services and the delivery of telehealth to patients in non-rural areas and in patient homes.

Reimbursement for telehealth would also encourage participation in the alternative payment models, which is the ultimate goal of the Quality Payment Program.

Providers participating in the general Medicare fee-for-service system would not get the same telehealth flexibility in this post-pandemic world though.

“Giving the same flexibility to clinicians who do not participate in an A-APM poses a risk of overuse,” said Winter according to an official transcript of the meeting.

Allowing telehealth reimbursement expansions to continue throughout Medicare after the pandemic would require guardrails considering large healthcare fraud cases involving fraudulent billing of services ordered via telehealth.

One such case involving telehealth companies and the ordering of durable medical equipment and lab tests resulted in $3.3 billion in losses for Medicare, Tabor reported.

Providers in A-APMs do not face the same incentives to overuse telehealth services, the analysts explained.

Overuse or inappropriate use limited in A-APMs because of value-based incentives. Providers can either use telehealth services appropriately and save money or risk inappropriate utilization and fail to add value, thereby jeopardizing value-based payment.

Providers in A-APMs would strive to control telehealth use like they control utilization, the analysts added.

Winter and Tabor recommended that providers who are not in A-APMs be granted a limited set of telehealth services, which will be subject to guardrails.

Fee-for-service providers, for example, may be restricted to a number of specific types of telehealth services that can be billed for a given Medicare beneficiary. Or CMS could require providers to deliver a face-to-face visit with a beneficiary to order DME or lab tests above a certain dollar amount, the analysts suggested.

To decide what telehealth coverage and reimbursement expansions would be on the list from general providers, CMS should consider access, cost, and quality, the analysts added.

Mental health services could be a good candidate for telehealth reimbursement expansions after the pandemic, they suggested, considering historical access issues.

But telehealth reimbursement rates should not be on par with those used for in-person visits, which has been allowed during the COVID-19 public health emergency.

“The issue is that services delivered via telehealth probably do not have the same practice costs as services provided in a physical office,” Winter said. “Therefore, continuing to set rates for telehealth services that are the same as rates for in-office services could distort prices and could lead clinicians to favor telehealth over comparable in-person services.”

CMS and policymakers also should consider not covering audio-only services allowed during the public health emergency.

“Because clinicians are unable to visually examine patients during audio-only visits, it is possible that they will lead to new services instead of substituting for existing ones and, therefore, could increase program spending. Therefore, policymakers might want to consider not covering audio-only services after the PHE, even when provided by clinicians who are in A-APMs,” Winter stated.

Providers have been calling on CMS to continue telehealth reimbursement parity beyond the public health emergency to support virtual care efforts.

“[C]hanges in payment policy address some of the biggest issues facing physicians as they struggle to make up for lost revenue and provide appropriate care to patients,” the American College of Physicians wrote in a June 4th letter to CMS Administrator Seema Verma.

The College recommended that CMS maintain payment parity between audio-only evaluation and management (E/M) claims and their in-person equivalents, as well as between all telehealth and in-person visits after the public health emergency has ended.

“This extension should last at least through the end of 2021, or until such a time when effective vaccines and treatments are widely available, with an option to extend it even further, or consider making permanent, based on the experience and learnings of patients and physicians who are utilizing these visits,” the letter stated.

Administrator Verma later said in a Health Affairs blog post that the agency is assessing telehealth reimbursement rates post-pandemic. But officials have similar concerns as MedPAC – telehealth visits require different resources than an in-person visit even though new processes and workflows do have associated costs.

“We are monitoring program integrity implications such as practitioners who may be offering shorter telehealth visits with patients to maximize payment, or billing more visits than are possible in a day,” Verma wrote. “We know the path forward to expanding telehealth relies on CMS addressing the potential for fraud and abuse in telehealth, as we do with all services,” Verma wrote.